Behavior Checklist
Student ____________________________________________________ Grade ____________
Check only those behaviors you have personally observed.
Return to <504 coordinator> by ________________________.
Academic Performance:
Significant change in grades
Academic Failure
Lack of Motivation—apathy
School Attendance:
Frequent absenteeism (excused or
not)
Frequent tardiness
Frequent counselor visits
Frequent nurse visits
Frequent schedule changes
Suspension from school and/or
class
Extracurricular Activities:
Loss of eligibility
Increasing non-involvement
Dropped out
Ignores activity rules
Physical Symptoms:
Poor hygiene
Smelling of alcohol, smoke or
marijuana
Vomiting
Glassy, bloodshot eyes
Coordination problems
Slurred speech
Changes in appearance
Noticeable weight gain or loss
Shakiness
Listless—drowsy
Physical Injuries
Behavior—Disruptive:
Defiance of rules—constant
discipline
Irresponsibility, blaming, denying,
lying
Fighting
Cheating
Sudden outbursts—verbal abuse
Obscene language—gestures
Dramatic attention getting
Frequent need to leave classroom
Extreme negativism
Hyperactivity, nervousness
Indicate below any interventions
tried (E = effective, I = Ineffective):
Behavior Management
Conference with parent
Conference with student
Conference with resource
personnel
If so, who?
_______________________
Sent note home
Called home
Kept student before/after school
Positive reinforcement
verbal written
Modified assignments
Other
Behavior–Atypical:
Talks freely about drug/alcohol use
Erratic behavior—mood swings
Paranoid (feels persecuted, picked
on)
Change of friends—usually
negative
Alibi, elaborate excuses
Excessive crying
Tine disorientation
Inappropriate responses
Defensive
Unusual eating behaviors
Promiscuity
Withdrawn, secluded, loner
Job problems
Displays of inappropriate affection
with
peers
Behavior—Criminal—Legal:
Selling drugs—exchange of money
Possession of drugs and
paraphernalia
Vandalism
Smoking or chewing
Alcohol or drug use
Bringing alcohol/drugs to school
Carrying weapons
Home Problems:
Run away
Speaks angrily of parents
Unusual sibling problems
Suffered recent loss (move,
divorce,
death, etc.)
Troubles in family (health,
financial,
emotional)
Other (please specify)
Check all behaviors that apply:
Short attention span
Difficulty concentrating
Disturbs other students
Doesn’t respect the property of
others
and/or self
Difficulty following instructions
verbal written
Low frustration level
Sad
Oversensitive
Disruptive
Withdrawn
Disorganized
Day dreams
Temper outbursts
Excitable
Destructive
Aggressive
Quarrelsome
Selfish
Overly serious
Attitude toward authority:
Excessive demands for teacher
attention
Overly anxious to please
Submissive
Stubborn
Defiant
Cooperative
Rude
Fearful
Teacher ___________________________________________________
Resource provided by AEA 267 © 2009
Archdiocese of Dubuque September 2013