Teacher Report Form FOR AGES 6-18

Full Name *
Gender * Age *
Today's Date Child's Birth date
Ethnic Group Or Race
Name and Address of School Grade in school *

PARENTS’ USUAL TYPE OF WORK, even if not working now. (Please be specific — for example, auto mechanic, high school teacher, homemaker, laborer, lathe operator, shoe salesman, army sergeant.)

PARENT 1 (or father)

PARENT 2 (or mother)

Please list the sports you most like to take part in Compare to others of the same age,about how much time does he/she spen in each? Compare to others of the same age,about how well does he/she do each one?
THIS FORM FILLED OUT BY: (print your full name) .) None Male Female Classroom Teacher Counselor Teacher’s Aide Other
your Gender
Your role at the school
For how many months have you known this pupil?
How well do you know him/her?
How much time does he/she spend in your class or service per week?
regular 5th grade 7th grade math learning disability counseling Other
What kind of class or service is it?
Don’t know No Yes If Yes — what kind and when?
Has he/she ever been referred for special class placement, services, or tutoring?
Has he/she ever repeated any grades?
8. Current academic performance
Academic subject 1. Far below grade 2. Somewhat below grade 3. At grade level 4. Somewhat above grade 5. Far above grade
VIII. Compared to typical pupils of the same age: Much less Somewhat less Slightly less About average Slightly more Somewhat more Much more
How hard is he/she working?
How appropriately is he/she behaving?
How much is he/she learning?
How happy is he/she?
IX. Most recent achievement test scores (optional):
Name of test Subject Date
X. IQ, readiness, or aptitude tests (optional):
Name of test Date IQ or equivalent scores
Does this pupil have any illness or disability (either physical or mental)? Yes No Describe
What concerns you most about this pupil? Describe
Please describe the best things about this pupil: Describe

Below is a list of items that describe pupils. For each item that describes the pupil now or within the past 2 months, please circle the 2 if the item is very true or often true of the pupil. Circle the 1 if the item is somewhat or sometimes true of the pupil. If the item is not true of the pupil, circle the 0. Please answer all items as well as you can, even if some do not seem to apply to this pupil.

Not True Somewhat or Sometimes True Very True or Often True
1. I acts too young for My age
2.Hums or makes other odd noises in class:
3.I argues a lot
4.I fails to finish things that i starts
5.There is very little he/she enjoys
6.Defiant, talks back to staff
8.Can't concentrate, can't pay attention for long
9.Can't get his/her mind off certain thoughts; obessions(describes:)
10. Can,t sit still,restless,or hyperactive
11.Clings to adults or too dependent
12.Complains of loneliness
13.Confused or seems to be in a fog
14.Cries a lot
16.Cruelty,bullying,or meanness to others
17.Daydreams or gets lost in his/her thoughts
18.Delibertaly harms self or attempts suicide
19.Demands a lot attention
20.Destorys his/her own things
21.Destroys things belonging to his/her family or others
22.Difficulty following directions.
23.Disobedient at school
24.Disturbs other pupils
25.Does'nt get along with other kids
26.Does'nt seem to feel guilty after misbehaving
27.Easily jealous
28.Breaks rules at home, school, or elsewhere
29.Fears certain animals,situations,or places, other than school(describe):
30.Fears going to school
31.Fears he/she might think or do something bad
32.Feel he/she has to be perfect
33.Feels or complains that no one loves him/her
34.Feels others are out to get him/her
35.Feels worthless or inferior
36.Gets hurt a lot, accident-prone
37.Gets in many fights
38.Gets teased alot
39.Hangs around with others who get in trouble
40.Hears sound or voices that aren't there (describe):
41.Impulsive or acts without thinking
42.Would rather be alone than with others
43.Lying or cheating
44.Bites fingernails
45.Nervous,highstrung,or tense
46.Nervous movements or twitching(describe):
47.Overconforms to rules
48.Not liked by other pupils
49.Constipated,doesn't move bowels
50.Too fearful or anxious
51.Feels dizzy or lightheaded
52.Feels to guilty
53.Talks out of turn
54.Overtired without good reason
56.Physical problems without known medial cause:
A.Aches or pains (not stomach or headaches)
B. Headaches
C. Nausea, feels sick
D.Eye problems (not if corrected by glasses)
E.Rashes or other skin problems
G.Vomiting, throwing up
57.Physically attacks people
58.Picks nose,skin,or other parts of body(describe):
59.Sleeps in class.
60.Apathetic or unmotivated.
61.Poor school work
62.Poorly coordinated or clumsy
63.Prefers being with older kids
64.Prefers being with younger kids
65.Refuses to talk
66.Repeats certain acts over and over, compulsions(describe):
67.Disrupts class discipline
68.Sreams a lot
69.Secretive, keeps things to self
70.Sees things that aren't there (describe):
71.Self-conscious or easily embarrassed
72.Messy work
73.Behaves irresponsibly (describe):
74.Showing off or cloning
75.Too shy or timid
76.Explosive or unpredictable behavior
77.Demands must be met immediately, easily frustrated :
78.Inattentive or easily distracted
79.Speech problem(describe):
80.Stares blankly.
81.Steals at home
82.Steals outside the home
83.Stores up too many things he/she doesn't need (describe):
84.Strange behaviour(describe):
85.Strange ideas(describe):
86.Stubborn,sullen, or irritable
87.Sudden changes in mood or feelings
88.Sulks a lot
90.Swearing or obscene language
91.Talks about killing self
92.Underachieving, not working up to potential
93.Talks too much
94.Teases a lot
95.Temper tantrums or hot temper
96.Seems preoccupied with sex
97.Threaten people
98.Tardy to school or class
99.Smokes,chews,or sniffs tobacco
100.Fails to carry out assigned tasks:
101.Trauncy ,skips school
102.Underactive,slow moving, or lacks energy
103.Unhappy, sad,or depressed
104.Unusually loud
105.Uses drugs for nonmedical purposes(don't include acohol or tobacco)(describe):
106.Overly anxious to please
107.Dislikes school
108.Is afraid of making mistakes
110.Unclean personal appearance
111.Withdrawn,does'nt get involved with others
113.Please write in any problems the pupil has that were not listed above: :