Total Points: ______/100 Enhancing Personal Responsibility—Feedback Form and Rubric Record-keeping Identification Number: ________________ Instructions: The person who has asked you to fill out the following questionnaire is attempting to gauge how well he or she demonstrates behaviors that lead to success in all aspects of his or her life. It is important that you honestly answer these questions so that this person can use the results of this questionnaire, in addition to other mechanisms for assessing these behaviors, to evaluate his or her progress in these areas. Please use the chart below to choose the appropriate number to assess each behavior. Then write the appropriate number is the space below each behavior category. Please use the space below the chart to add any additional comments that may be useful in explaining the scores. Please circle the description that best indicates your relationship to this person. Work Personal Academic BEHAVIORS THAT LEAD TO SUCCESS—A Rubric BEHAVIOR 4--Outstanding 3--Good 2—Needs 1--unsatisfactory CATEGORIES Improvement Almost perfect Rare excused Absences and/or Absences and/or Attendance attendance; never absences; tardy tardiness are affecting tardiness are tardy; makes rarely; makes others and are excessive. Score: ______ arrangements for arrangements for inhibiting this absences in advance absences in advance to person’s ability if possible if possible successfully accomplish his/her goals. Preparation Well-prepared for Is usually prepared Sometimes is Is rarely prepared. the occasion or for the occasion or prepared, but not on a situation in dress, situation, but not as regular basis. Score: _______ manner, and much attention to materials.; detail and minor and rarely lapses in quality. misses deadlines. Attitude and Takes responsibility Usually takes Sometimes take Unwilling to take
Total Points: ______/100 Enhancing Personal Responsibility—Feedback Form and Rubric Record-keeping Identification Number: ________________ Instructions: The person who has asked you to fill out the following questionnaire is attempting to gauge how well he or she demonstrates behaviors that lead to success in all aspects of his or her life. It is important that you honestly answer these questions so that this person can use the results of this questionnaire, in addition to other mechanisms for assessing these behaviors, to evaluate his or her progress in these areas. Please use the chart below to choose the appropriate number to assess each behavior. Then write the appropriate number is the space below each behavior category. Please use the space below the chart to add any additional comments that may be useful in explaining the scores. Please circle the description that best indicates your relationship to this person. Work Personal Academic BEHAVIORS THAT LEAD TO SUCCESS—A Rubric BEHAVIOR CATEGORIES 4--Outstanding 3--Good 2—Needs Improvement 1--unsatisfactory Attendance Score: ______ Almost perfect attendance; never tardy; makes arrangements for absences in advance if possible Rare excused absences; tardy rarely; makes arrangements for absences in advance if possible Absences and/or tardiness are affecting others and are inhibiting this person’s ability to successfully accomplish his/her goals. Absences and/or tardiness are excessive. Preparation Score: _______ Well-prepared for the occasion or situation in dress, manner, and materials.; and rarely misses deadlines. Is usually prepared for the occasion or situation, but not as much attention to detail and minor lapses in quality. Sometimes is prepared, but not on a regular basis. Is rarely prepared. Attitude and Takes responsibility Usually takes Sometimes take Unwilling to take