Sample: T ' R F A 6-18

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Please print TEACHER’S REPORT FORM FOR AGES 6-18 For office use only

ID #

Your answers will be used to compare the pupil with other pupils whose teachers have completed similar forms. The information from this
form will also be used for comparison with other information about this pupil. Please answer as well as you can, even if you lack full
information. Scores on individual items will be combined to identify general patterns of behavior. Feel free to print additional comments
beside each item and in the spaces provided on page 2. Please print, and answer all items.
PUPIL’S First Middle LastPARENTS’ USUAL TYPE OF WORK, even if not working now.
FULL (Please be specific —for example, auto mechanic, high school teacher,
NAME homemaker, laborer, lathe operator, shoe salesman, army sergeant.)
PARENT 1 (or father)
PUPIL’S GENDER PUPIL’S AGE PUPIL’S ETHNIC GROUP
TYPE OF WORK _________________________________________
OR RACE
Boy Girl PARENT 2 (or mother)
TYPE OF WORK _________________________________________
TODAY’S DATE PUPIL’S BIRTHDATE (if known)
THIS FORM FILLED OUT BY: (print your full name)
Mo.____ Date____ Year____ Mo.____ Date____ Year____
____________________________________________________

E
GRADE IN NAME AND ADDRESS OF SCHOOL
Your gender: Man Woman Other (specify)
SCHOOL _____________________________
Your role at the school:
_____________________________
Classroom Teacher Counselor Teacher’s Aide
___________ _____________________________ Special Educator Administrator Other (specify):

I.

1.

PL
For how many months have you known this pupil? ______ months

II. How well do you know him/her? Not Well 2.

III. How much time does he/she spend in your class or service per week?

Don’t know 0. No 1. Yes — what kind and when?


Moderately Well 3. Very Well

IV. What kind of class or service is it? (Please be specific, e.g., regular 5th grade, 7th grade math, learning disability,
counseling, etc.)

V. Has he/she ever been referred for special class placement, services, or tutoring?
M
VI. Has he/she ever repeated any grades? Don’t Know 0. No 1. Yes - grades and reasons:

VII. Current academic performance — list academic subjects and check box that indicates pupil’s performance for each subject:

1. Far below 2. Somewhat 3. At grade 4. Somewhat 5. Far above


SA

Academic subject grade below grade level above grade grade

1. ____________________

2. ____________________

3. ____________________

4. ____________________

5. ____________________

6. ____________________

Be sure you answered all items. Then see other side.


Copyright 2001 T. Achenbach UNAUTHORIZED COPYING IS ILLEGAL 07-02-18 - 301
ASEBA, University of Vermont
1 South Prospect St., Burlington, VT
05401-3456 www.ASEBA.org PAGE 1
Please print. Be sure to answer all items.
VIII. Compared to typical pupils 1. Much 2. Somewhat 3. Slightly 4. About 5. Slightly 6. Somewhat 7. Much
of the same age: less less less average more more more

1. How hard is he/she working?

2. How appropriately is he/she


behaving?

3. How much is he/she learning?

4. How happy is he/she?

IX. Most recent achievement test scores (optional): Percentile or


Name of test Subject Date grade level obtained

E
X. IQ, readiness, or aptitude tests (optional):
Name of test
PL Date IQ or equivalent scores
M
Does this pupil have any illness or disability (either physical or mental)? No Yes — please describe:
SA

What concerns you most about this pupil?

Please describe the best things about this pupil:

Please feel free to write any comments about this pupil’s work, behavior, or potential, using extra pages if necessary.

PAGE 2
Please print. Be sure to answer all items.
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.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True

0 1 2 1. Acts too young for his/her age 0 1 2 34. Feels others are out to get him/her
0 1 2 2. Hums or makes other odd noises in class 0 1 2 35. Feels worthless or inferior

0 1 2 3. Argues a lot 0 1 2 36. Gets hurt a lot, accident-prone


0 1 2 4. Fails to finish things he/she starts 0 1 2 37. Gets in many fights

0 1 2 5. There is very little he/she enjoys 0 1 2 38. Gets teased a lot

E
0 1 2 6. Defiant, talks back to staff 0 1 2 39. Hangs around with others who get in trouble

0 1 2 7. Bragging, boasting 0 1 2 40. Hears sound or voices that aren’t there


0 1 2 8. Can’t concentrate, can’t pay attention for long (describe): _________________________
__________________________________
0 1 2 9. Can’t get his/her mind off certain thoughts;
0 1 2 41. Impulsive or acts without thinking
obsessions (describe):_________________

0
0

0
0

0
0
1

1
1

1
1

1
1
2

2
2

2
2

2
2
11. Clings to adults or too dependent
12. Complains of loneliness

13. Confused or seems to be in a fog


14. Cries a lot

15. Fidgets
PL
___________________________________
10. Can’t sit still, restless, or hyperactive

16. Cruelty, bullying, or meanness to others


0
0

0
0

0
1
1

1
1

1
2
2

2
2

2
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


M
0 1 2 17. Daydreams or gets lost in his/her thoughts
0 1 2 49. Has difficulty learning
0 1 2 18. Deliberately harms self or attempts suicide
0 1 2 50. Too fearful or anxious
0 1 2 19. Demands a lot of attention
0 1 2 51. Feels dizzy or lightheaded
0 1 2 20. Destroys his/her own things
0 1 2 52. Feels too guilty
0 1 2 21. Destroys property belonging to others
0 1 2 53. Talks out of turn
0 1 2 22. Difficulty following directions
SA

0 1 2 54. Overtired without good reason


0 1 2 23. Disobedient at school
0 1 2 55. Overweight
0 1 2 24. Disturbs other pupils
56. Physical problems without known medical
0 1 2 25. Doesn’t get along with other pupils
cause:
0 1 2_ 26. Doesn’t seem to feel guilty after misbehaving
0 1 2 a. Aches or pains (not stomach or headaches)
0 1 2 27. Easily jealous 0 1 2 b. Headaches
0 1 2 28. Breaks school rules 0 1 2 c. Nausea, feels sick
0 1 2 d. Eye problems (not if corrected by glasses)
0 1 2 29. Fears certain animals, situations, or places, (describe): _________________________
other than school (describe): ____________ __________________________________
___________________________________ 0 1 2 e. Rashes or other skin problems
0 1 2 30. Fears going to school 0 1 2 f. Stomachaches
0 1 2 g. Vomiting, throwing up
0 1 2 31. Fears he/she might think or do something bad
0 1 2 h. Other (describe): ____________________
0 1 2 32. Feels he/she has to be perfect
__________________________________
0 1 2 33. Feels or complains that no one loves him/her
__________________________________

PAGE 3 Be sure you answered all items. Then see other side.
Please print. Be sure to answer all items.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True

0 1 2 57. Physically attacks people 0 1 2 84. Strange behavior (describe): ___________


0 1 2 58. Picks nose, skin, or other parts of body __________________________________
(describe): ___________________________ 0 1 2 85. Strange ideas (describe): ______________
____________________________________ __________________________________

0 1 2 59. Sleeps in class 0 1 2 86. Stubborn, sullen, or irritable


0 1 2 60. Apathetic or unmotivated 0 1 2 87. Sudden changes in mood or feelings

0 1 2 61. Poor school work 0 1 2 88. Sulks a lot


0 1 2 62. Poorly coordinated or clumsy 0 1 2 89. Suspicious

0 1 2 63. Prefers being with older children or youths 0 1 2 90. Swearing or obscene language

E
0 1 2 64. Prefers being with younger children 0 1 2 91. Talks about killing self

0 1 2 65. Refuses to talk 0 1 2 92. Underachieving, not working up to potential


0 1 2 66. Repeats certain acts over and over; 0 1 2 93. Talks too much
compulsions (describe):_________________
0 1 2 94. Teases a lot
____________________________________

0
0

0
0

0
0
1
1

1
1

1
1
2
2

2
2

2
2
67. Disrupts class discipline
68. Screams a lot

69.
70.
Secretive, keeps things to self

PL
Sees things that aren’t there (describe):
__________________________________
__________________________________

71. Self-conscious or easily embarrassed


72. Messy work
0

0
0

0
0

0
0

0
0
1

1
1

1
1

1
1

1
1
2

2
2

2
2

2
2

2
2
95. Temper tantrums or hot temper

96. Seems preoccupied with sex


97. Threatens people

98. Tardy to school or class


99. Smokes, chews, or sniffs tobacco

100. Fails to carry out assigned tasks


101. Truancy or unexplained absence

102. Underactive, slow moving, or lacks energy


103. Unhappy, sad, or depressed
M
0 1 2 73. Behaves irresponsibly (describe): ________
__________________________________ 0 1 2 104. Unusually loud
__________________________________ 0 1 2 105. Uses drugs for nonmedical purposes
0 1 2 74. Showing off or clowning
(don't include tobacco) (describe):
0 1 2 75. Too shy or timid
0 1 2 76. Explosive or unpredictable behavior
0 1 2 106. Overly anxious to please
SA

0 1 2 77. Demands must be met immediately, easily


0 1 2 107. Dislikes school
frustrated
0 1 2 78. Inattentive or easily distracted 0 1 2 108. Is afraid of making mistakes
0 1 2 109. Whining
0 1 2 79. Speech problem (describe): ____________
__________________________________ 0 1 2 110. Unclean personal appearance
0 1 2 80. Stares blankly 0 1 2 111. Withdrawn, doesn’t get involved with others
0 1 2 81. Feels hurt when criticized 0 1 2 112. Worries
0 1 2 82. Steals 113. Please write in any problems the pupil has
that were not listed above:
0 1 2 83. Stores up too many things he/she doesn't
0 1 2 _______________________________________
need (describe): _____________________
0 1 2 _______________________________________
__________________________________
0 1 2 _______________________________________
__________________________________

PAGE 4 Please be sure you answered all items.

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