SAP Behavioral Checklist

You have been asked to provide feedback regarding a student has been referred to the SAP team for further assessment. Please complete the following questions to the best of your knowledge of the student. SAP teacher input is confidential and will not be shared directly with the student and/or student's family. However, the information and insight gained from your input will be summarized to compile a complete SAP report if necessary. In short, the information you provide could be communicated to the student and family, but who provided the information will be maintained confidential.

Please complete the form below. Required fields marked with an asterisk *

Name of Person Completing this form

Answer Required

Referred Student Information

Student's Last Name

Answer Required

Student's First Name

Answer Required

Grade

Answer Required

Academic Performance

Answer Required

Drop in grades/lower achievement

Decrease in class participation

Failure to complete assignments

Short attention span/easily distracted

Poor short term memory

Other:

Class Attendance

Answer Required

Tardiness to class

Absent from school

Skipping class

Frequent visits to nurse's office

Frequent visits to guidance office

Frequent visits to restroom

Other:

Additional comments or concerns regarding this student:

Answer Required