AMERIGO A. ANASTASIA ELEMENTARY SCHOOL STUDENT SELF ASSESSMENT FORM Teacher____________________________ Date __________ Time ____________ 1. Which school rule(s) did you break? (circle one) Be Respectful Be Responsible Be Ready What did you want? I wanted attention from an adult I wanted attention from another child I wanted to make an adult become angry I wanted to let someone know that I am angry with them I wanted to avoid doing my school work I wanted to be in control of the situation I wanted to cause others problems because I don’t think they like me I wanted something that someone else has I wanted __________________________________________________ This is what happened: 4. This is what I could have done to make a better choice: This is how I will solve the problem: TEACHER COMMENTS: Student Signature_________________________________________________________
AMERIGO A. ANASTASIA ELEMENTARY SCHOOL STUDENT SELF ASSESSMENT FORM Teacher____________________________ Date __________ Time ____________ 1. Which school rule(s) did you break? (circle one) Be Respectful Be Responsible Be Ready What did you want? I wanted attention from an adult I wanted attention from another child I wanted to make an adult become angry I wanted to let someone know that I am angry with them I wanted to avoid doing my school work I wanted to be in control of the situation I wanted to cause others problems because I don’t think they like me I wanted something that someone else has I wanted __________________________________________________ This is what happened: 4. This is what I could have done to make a better choice: This is how I will solve the problem: TEACHER COMMENTS: Student Signature_________________________________________________________