Appendix A: Social/Emotional Worksheet Instructions: Classroom teachers or counselors should complete this checklist to aid in the collection of information to determine if student is in need of Tier II or Tier III behavioral interventions NOTE: This worksheet is not a behavioral screener. For behavioral screening resources, visit . STUDENT IS DISRUPTIVE IN CLASS: STUDENT IS ANXIOUS: fidgets appears depressed is overly active rarely smiles does not remain in seat appears to be tense talks out of turn appears frightened or worried disturbs others when they are working easily constantly attention does not trust others overly aggressive with others (i.e., physical fights) reports fears or phobias (such as fear of coming to school) belligerent towards teachers and others in authority defiant or stubborn SOCIAL/EMOTIONAL BEHAVIORS: impulsive lacks self-confidence can’t wait his/her turn says do” even before attempting “can’t acts without thinking of the consequences reacts poorly to disappointment is overly sensitive to disappointment STUDENT IS WITHDRAWN: depends on others shy, timid clings to adults has difficulty making friends pretends to be ill sits alone in cafeteria has poor grooming or personal hygiene does not join in classroom group activities overly conforms to STUDENT HAS: appears to daydream or be out of touch with the class been on runaway status has difficulty expressing feelings been caught stealing at school left class without permission cursed school personnel threatened to harm school personnel or wished school personnel harm been suspended for fighting attempted suicide received tobacco violations at school received drug/alcohol violations at school CLASSROOM INTEREST: High Average Low Other, Please Specify MOTIVATION: CLASSROOM PARTICIPATION: completes homework almost always completes about half of the assignment frequently tends to give up easily occasionally has difficulty getting started on assignments seldom TO THE BEST OF YOUR KNOWLEDGE: CLASSROOM PREPAREDNESS: This student is involved with the court system. always brings necessary supplies This student is in counseling. usually brings supplies This student is on medication. seldom comes to class with supplies never comes to class with supplies Appendix B: Language Service Plan (for Students Instructions: This form should be completed by the individual and the classroom teacher.
Appendix A: Social/Emotional Worksheet Instructions: Classroom teachers or counselors should complete this checklist to aid in the collection of information to determine if student is in need of Tier II or Tier III behavioral interventions NOTE: This worksheet is not a behavioral screener. For behavioral screening resources, visit . STUDENT IS DISRUPTIVE IN CLASS: fidgets is overly active does not remain in seat talks out of turn disturbs others when they are working constantly attention overly aggressive with others (i.e., physical fights) belligerent towards teachers and others in authority defiant or stubborn impulsive can’t wait his/her turn acts without thinking of the consequences STUDENT IS WITHDRAWN: shy, timid has difficulty making friends sits alone in cafeteria does not join in classroom group activities overly conforms to appears to daydream or be out of touch with the class has difficulty expressing feelings STUDENT IS ANXIOUS: appears depressed rarely smiles appears to be tense appears frightened or worried easily does not trust others reports fears or phobias (such as fear of coming to school) SOCIAL/EMOTIONAL BEHAVIORS: lacks self-confidence says “can’t do” even before attempting reacts poorly to disappointment is overly sensitive to disappointment depends on others clings to adults pretends to be ill has poor grooming or personal hygiene STUDENT HAS: been on runaway status been caught stealing at school left class without permission cursed school personnel threatened to harm school personnel or wished school personnel harm been suspended for fighting attempted suicide received tobacco violations at school received drug/alcohol violations at school CLASSROOM INTEREST: High Average Low Other, Please Specify CLASSROOM PARTICIPATION: almost always frequently occasionally seldom CLASSROOM PREPAREDNESS: always brings necessary supplies usually brings supplies seldom comes to class with supplies never comes to class with supplies MOTIVATION: completes homework completes about half of the assignment tends to give up easily has difficulty getting started on assignments TO THE BEST OF YOUR KNOWLEDGE: This student is involved with the court system. This student is in counseling. This student is on medication. Appendix B: Language Service Plan (for Students Instructions: This form should be completed by the individual and the classroom teacher.
11.4.16%20JPS%20MDE%20Multi-Tiered%20System%20of%20Supports%20Documentation%20Packet.docx