Sample: T ' R F A 6-18
Sample: T ' R F A 6-18
Sample: T ' R F A 6-18
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
III. How much time does he/she spend in your class or service per week?
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. ____________________
2. ____________________
3. ____________________
4. ____________________
5. ____________________
6. ____________________
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
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
E
0 1 2 6. Defiant, talks back to staff 0 1 2 39. Hangs around with others who get in trouble
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
15. Fidgets
PL
___________________________________
10. Can’t sit still, restless, or hyperactive
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
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 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
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):
__________________________________
__________________________________
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