FORMS
EVESHAM TOWNSHIP SCHOOL DISTRICT
ACCIDENT REPORT
This report is to be completed at the time of the accident. All information must be printed or written clearly.
School Grade Date of Accident Time
Student’s Name Age Male Female
Address Phone #
(please include area code)
Location of Accident
Who was in attendance or may have observed accident/incident?
Nature of Accident Part of Body Injured
Abrasion Bruise/bump Burn Cut Abdomen Ankle Arm Back Chest
Convulsion Dislocation Fall Head injury Elbow Eye Face Finger Foot
Fracture Laceration Puncture Shock Hand Head Knee Leg Teeth
Sprain Other Wrist Other
Fight (describe on back/must include the name of all students involved or who may have witnessed the incident)
Give full description of accident:
Nurse’s Report and/or action taken:
Treatment and disposition:
Was parent/guardian notified? Yes No What time: Spoke With: Left Message
………………………………………………………………………………………………………………..
Follow-up information:
Time lost from school? Yes No Amount of time lost:
………………………………………………………………………………………………………………..
Principal’s Report and/or action taken:
Signature of Nurse Signature of Teacher Signature of Principal
Was parent/guardian advised of student accident insurance? Yes No
Copy was also sent to: Curriculum Supervisor Business Office Principal
EVESHAM TOWNSHIP SCHOOLS
MARLTON, NEW JERSEY
OPENING DAY REPORT
SCHOOL _________________________
TEACHER _________________________ GRADE __________ DATE
1. Number Assigned
2. Number Not Reporting (Listed, but did not report.)
3. Number Added (Reporting, but not listed on Assignment Sheet)
4. Total Number Enrolled
The following pupils are on the Assignment Sheet, but have not reported:
Name Birthdate Parent *Reason for not reporting
(if known)
*Inquire of other teachers or pupils
The following pupils are not on the Assignment Sheet, but have reported:
Name Birthdate Parent
Please attach one copy of corrected Class Assignment Sheet to this report. Children not
reporting should be red lined on the Assignment sheet and those reporting who are not on the
sheet should be added at the bottom.
EVESHAM TOWNSHIP SCHOOLS
MARLTON, NEW JERSEY
SUPPLIES REQUISITION FORM
SCHOOL TEACHER
ROOM NO. DATE
Quantity Items Ordered Sent Quantity Items Ordered Sent
OPTION #1
EVESHAM TOWNSHIP SCHOOLS
MARLTON, NEW JERSEY
ELEMENTARY SCHOOL WEEKLY PROGRAM
School Year
NOTE: Schedule must provide a detailed breakdown of total number of minutes of the student day, including beginning times of each period. List the classes/subjects
taught, number of students and locations, if applicable. Include all duties, special periods, supervised play periods, team meetings, prep periods, and lunch
periods.
TEACHER GRADE SCHOOL
TIME MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
Related arts teachers, instructional assistants, reading specialists, media specialists, etc. should indicate the number of students, grade level, and house.
Staff members whose schedule changes each cycle or marking period or semester, updated schedule must be sent no more than one week after that period begins.
forms:week sch option1
OPTION #2
EVESHAM TOWNSHIP SCHOOLS
MARLTON, NEW JERSEY
ELEMENTARY SCHOOL WEEKLY PROGRAM
School Year
NOTE: Schedule must provide a detailed breakdown of total number of minutes of the student day, including beginning times of each period. List the
classes/subjects taught, number of students and locations, if applicable. Include all duties, special periods, supervised play periods, team
meetings, prep periods, and lunch periods.
TEACHER GRADE SCHOOL
Time MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
Related arts teachers, instructional assistants, reading specialists, media specialists, etc. should indicate the number of students, grade level, and house.
Staff members whose schedule changes each cycle or marking period or semester, updated schedule must be sent no more than one week after that
period begins.
forms:week sch option2
EVESHAM TOWNSHIP SCHOOLS
MARLTON, NEW JERSEY
MIDDLE SCHOOL WEEKLY PROGRAM
MIDDLE SCHOOL
School Year
NOTE: Schedule must provide a detailed breakdown of total number of minutes of the student day, including beginning times of each period. List the classes/subjects
taught, number of students and locations, if applicable. Include all duties, special periods, supervised play periods, team meetings, prep periods, and lunch
periods.
TEACHER GRADE/SUBJECT SCHOOL
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6
Time
Related arts teachers, instructional assistants, reading specialists, media specialists, etc. should indicate the number of students, grade level, and house.
Staff members whose schedule changes each cycle or marking period or semester, updated schedule must be sent no more than one week after that period begins.
forms:week sched middle
EVESHAM TOWNSHIP SCHOOLS
Marlton, New Jersey
SUBSTITUTE TEACHER REPORT FORM
NAME_______________________________________________________________DATE____________________________
SCHOOL______________________________________________________________________________________________
SUBSTITUTED FOR____________________________________________________________________________________
GRADE AND/OR SUBJECT______________________________________________________________________________
1. DESCRIPTION OF WORK COVERED
In order to provide information for the teacher on work accomplished, please complete the following:
PERIOD/CLASS REPORT OF WORK ACCOMPLISHED/ASSIGNED
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
2. PLEASE CHECK
A. Lesson Plans Available Yes_____ No_____
B. Seating charts and name tags available Yes_____ No_____
C. Supplies and materials available Yes_____ No_____
D. Schedules available Yes_____ No_____
E. Information on building’s procedures Available Yes_____ No_____
F. Assistance from Staff Available Yes_____ No_____
G. The teacher is most interested in the behavior of his/her children. Please comment or give names and infractions if
necessary.
SUBSTITUTE TEACHER’S COMMENTS
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
PLEASE RETURN THIS REPORT AND THE TEACHER’S KEY TO THE
PRINCIPAL AT THE END OF THE DAY.
3. CLASSROOM TEACHER’S COMMENTS
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
10 month = 22 pays 12 month = 26 pays
PAYROLL SCHEDULE 2008 - 2009 SCHOOL YEAR
Pay Date Time Slips Due Dates Included (hourly)
12mo July 3, 2008 Contract Emp. Only
12mo July 18, 2008 July 11, 2008 07/01 to 07/11
12mo Aug. 1, 2008 July 25, 2008 07/12 to 07/25
12mo Aug. 15, 2008 Aug. 08, 2008 07/26 to 08/08
12mo Aug. 29, 2008 Aug. 22, 2008 08/09 to 08/22
Sept. 12, 2008 Sept. 05, 2008 08/23 to 09/05
Sept. 26, 2008 Sept. 19, 2008 09/06 to 09/19
Oct. 10, 2008 Oct. 2, 2008 09/20 to 10/02
Oct. 24, 2008 Oct. 17, 2008 10/03 to 10/17
+ Nov. 05, 2008 * Oct. 29, 2008 10/18 to 10/29
~ Nov. 21, 2008 Nov. 14, 2008 10/30 to 11/14
#' Dec. 05, 2008 * Nov. 26, 2008 11/15 to 11/26
$ Dec. 19, 2008 Dec. 12, 2008 11/27 to 12/12
Dec. 23, 2008 ** Dec. 16, 2008 12/13 to 12/16
Jan. 16, 2009 Jan. 09, 2009 12/17 to 01/09
~ Jan. 30, 2009 Jan. 23, 2009 01/10 to 01/23
Feb. 13, 2009 Feb. 6, 2009 01/24 to 02/06
# Feb. 27, 2009 Feb. 20, 2009 02/07 to 02/20
+ Mar. 13, 2009 Mar. 6, 2009 02/21 to 03/06
Mar. 27, 2009 Mar. 20, 2009 03/07 to 03/20
~ Apr. 09, 2009 Apr. 2, 2009 03/21 to 04/02
Apr. 24, 2009 * Apr. 09, 2009 04/03 to 04/09
May 08, 2009 May 1, 2009 04/10 to 05/01
May 22, 2009 May 15, 2009 05/02 to 05/15
#' June 05, 2009 May 29, 2009 05/16 to 05/29
~ June 19, 2009 June 12, 2009 05/30 to 06/12
June 30, 2009 10 mo & hrly June 23, 2009 06/13 to 06/30
* Time Slips are due early due to Holiday $ Longevity paid in this pay period
# Clubs / Activities paid in this pay period ' Opt out paid in this pay period
** Early due to Winter Recess + Lane changes
Club Rate = $20.66 Professional Rate = $27.23
~ Workshops paid in this pay period
July 18, 2008 from 6/07 to 7/03 Due to Curriculum 07/03 - 10:00 AM
August 29, 2008 from 07/04 to 08/15 Due to Curriculum 08/15 - 10:00 AM
Sept 26, 2008 from 8/16 to 9/12 Due to Curriculum 09/12
Nov. 21, 2008 from 09/13 to 11/05 Due to Curriculum 11/05
Jan. 30, 2009 from 11/06 to 01/16 Due to Curriculum 01/16
Apr. 09, 2009 from 01/17 to 03/27 Due to Curriculum 03/27
June 19, 2009 from 03/28 to 06/05 Due to Curriculum 06/05
@ July 17, 2009 from 06/06 to 07/03 Due to Curriculum 07/03 - 10:00 AM
@ Aug. 28, 2009 from 07/04 to 08/14 Due to Curriculum 08/14 - 10:00 AM
Non-Tenured Teacher S – Satisfactory
CLASSROOM OBSERVATION FORM N – Needs
Improvement
U – Unsatisfactory
Teaching Staff Member: Observer:
School: Assignment:
Date Observed: Class Observed:
Status: Year 1 2 3
Rating Comment Rating Comment
I. Objectives of lesson III. Student-Teacher
Interaction
II. Instructional IV. Classroom
Strategies Management
COMMENTS:
COMMENDATIONS:
RECOMMENDATIONS:
TEACHER'S COMMENTS:
Teacher's Signature* Observer's Signature Date
Title
*This signature indicates that the teaching staff member and the evaluator together discussed this
report. It does not necessarily denote agreement with all factors of the evaluation.
EVESHAM TOWNSHIP PUBLIC SCHOOLS
25 South Maple Avenue
Marlton, New Jersey 08053
TENURED TEACHER OBSERVATION REPORT
Teacher: _____________________________School: ________________________________
Assignment: ____________________ Date: ___________ Observer: ____________________
Lesson Observed: ______________________________________________________________
Lesson Summary:
(Satisfactory, Needs Improvement, Unsatisfactory, Not Applicable) S N U N/A
Checks in the N or U columns will be accompanied by a comment in the
recommendation section.
Classroom Environment
Creates a safe, student-centered environment organized for student
learning
Considers students’ physical, emotional, intellectual and social needs.
Physical space reflects evidence of student learning
Displays student generated charts, projects, centers, etc. that reflect
student individuality.
Establishes a climate of respect and rapport
Demonstrates a respectful give and take between and among all
members of the classroom community.
Manages the classroom in developmentally appropriate ways
Employs proactive, positive management of physical space,
organization of activities and student behavior.
Facilitates a joyful and rigorous culture of learning
Creates a climate where students demonstrate active learning and
purposeful engagement, including meaningful problem-solving, student
generated inquiry and positive social interactions.
Ensures special needs students are well-integrated in the classroom
Reflects Evesham Township Schools In-Class Support model. Meets
students’ various needs without calling undue attention to limitations or
extraordinary abilities.
Planning and Preparation
Lesson design and structure reflects district curriculum
Indicates clear, observable objectives, procedures and assessment(s).
(Satisfactory, Needs Improvement, Unsatisfactory, Not Applicable) S N U N/A
Checks in the N or U columns will be accompanied by a comment in the
recommendation section.
Demonstrates knowledge of content/pedagogy
Provides clear and accurate modeling for students, relevant to content
of lesson.
Selects developmentally appropriate instructional goals
Prioritizes student needs and plans instruction accordingly to meet
curriculum guidelines.
Plans for coherent instruction (flow, structure, sequence, assessment)
Ensures students’ understanding of how elements of the lesson relate
to one another and how new concepts relate to prior schema.
Utilizes assessment for learning
Uses evidence of attainment of objectives to inform future instruction.
Modifies appropriately for special needs students
Utilizes flexible grouping, modified assignments and techniques for
varied learning styles, when necessary.
(Satisfactory, Needs Improvement, Unsatisfactory, Not Applicable) S N U N/A
Checks in the N or U columns will be accompanied by a comment in the
recommendation section.
Instruction
Lesson reflects a balanced variety of strategies to motivate and
engage students (scaffolding, modeling, summary/closure,
assessment/evaluation, flexible/cooperative grouping)
Achieves balance through comfortable pacing and smooth transition
from one activity to another. Varies strategies throughout the lesson
and unit.
Communicates clearly and accurately
Uses explicit modeling to clarify concepts and chooses student-friendly
language for directions/examples.
Uses questioning and discussion techniques appropriately
Facilitates interactions that lead to deeper understanding of concepts.
Engages learners in meaningful tasks
Connects lesson tasks to students’ prior experience and assigns tasks
that assist students in applying concepts to real-life situations.
Provides frequent feedback
Utilizes individual/group feedback strategies such as discussion,
polling, exit slips, gallery charts, etc.
Demonstrates flexibility and responsiveness
Monitors and adjusts teaching to accommodate student confusions,
questions, responses, etc.
Differentiates/modifies instruction, as appropriate
Demonstrates ability to differentiate through student choice,
varied/tiered assessments, multi-sensory approaches, ability grouping,
centers, etc.
Equitably shares responsibilities for instructional tasks with
coteacher(s)
Works collaboratively to plan lessons, instruct, assess and evaluate
students, communicate with parents and team members, and attempts
to share involvement equitably.
(Satisfactory, Needs Improvement, Unsatisfactory, Not Applicable) S N U N/A
Checks in the N or U columns will be accompanied by a comment in the
recommendation section.
Professional Responsibilities
Maintains accurate records relative to the lesson
Maintains grade book, lesson plans, student work portfolios, etc. in
organized, up to date, and easy to access fashion. (Observer: Use
N/A when records were not evident or requested during observation.)
Reflects on classroom practices
Self-examines success of each instructional choice made and
communicates willingness to discuss rationale for classroom practices.
Demonstrates professionalism
Strives to be a role-model. Communicates with students, colleagues,
and administrators in a positive/productive manner. Exhibits ability to
accept criticism, when appropriate. Is prompt and prepared for lesson.
Utilizes paraprofessionals to enhance instruction
Manages classroom in ways that fully utilize classroom aides’ abilities
to maximize students’ safety, comfort and learning potential.
COMMENDATIONS:
RECOMMENDATIONS:
TEACHER COMMENTS:
________________________________________ ______________________________________
STAFF MEMBERS SIGNATURE* SUPERVISOR’S SIGNATURE
*NOTE: Staff member’s signature does not indicate agreement, but awareness of the report.
POST-CONFERENCE HELD ON: ______________________________________________________________
(Date and Time)
Post-Observation Conference
Date/Time
POST OBSERVATION SELF REFLECTION NOTES
Teacher: __________________________________ Date of Observation: _______________
In order to contribute to the post-observation conference discussion, take a few moments today to reflect
on your lesson. Keep in mind that your observer will evaluate your lesson based on the competencies
listed on the back of this form. (This form is for your use only. It will not be collected or attached to your
observation report.)
To organize your thoughts for the post-observation conference, briefly write your reflections on the
following questions:
1. Do you feel the lesson objectives were achieved? Explain.
2. What instructional strategies, activities, or materials were you particularly satisfied with in the
lesson?
3. If you were planning this lesson again, what might you change or add to it? (Instructional
strategies, materials, activities, evaluation method)
4. Additional Comments:
ANNUAL PERFORMANCE APPRAISAL REPORT
TEACHER
TEACHING STAFF MEMBER: ________________________ EVALUATOR: ________________________
DATE: _________________ GRADE/SUBJECT: _______________ SCHOOL: _______________________
This report will be completed once annually during the spring semester.
Area of
Satisfactory Concern Comments PIP
1. Makes every effort within the area of their professional
expertise, the scope of their certification, the financial
limitations of the school district and the supervisory
assistance provided to them, to instruct children in their
charge in accordance with the curriculum adopted by
the Board of Education.
2. Meets and/or instructs assigned children in the locations
and at the time designated in the affective and cognitive
areas.
3. Develops and maintains a positive classroom
environment conducive to learning.
4. Prepares for classes assigned, and shows written
evidence of preparation upon request of immediate
superior.
5. Employs instructional techniques and instructional
media appropriate to the needs and capabilities of the
individuals or student groups involved.
6. Modifies instruction to meet the diverse needs of
individual students in their charge.
7. Evaluates and reports student progress in the area of
instruction.
8. Encourages students to set and maintain standards of
school behavior, and take appropriate disciplinary
measures.
9. Takes all necessary and reasonable precautions to
protect students, equipment, materials and facilities.
10. Maintains accurate and complete records.
11. Implements and/or follows administrative regulations
and directives, Board Policy and State Law.
12. Strives to establish cooperative relations with parents
and students which include such things as: being
available to students and parents for education-related
purposes outside the instructional day.
13. Cooperates with other staff members in educational
matters.
14. Continues his/her own professional growth.
15. Shows concern for all students and staff regardless of
race, creed, sex, ancestry, national origin or social
economic status.
16. Maintains appropriate performance standards relative to
specific assignments, i.e. Reading Recovery certification
for Reading Recovery teachers and CPR
training/recertification for Physical Education teachers.
Comments and PIP address themselves to areas of strength and/or areas of concern. There must be a
comment and/or PIP objective for each area of concern checked.
ANNUAL PERFORMANCE APPRAISAL REPORT (PAIR Form)
NAME__________________________________ BUILDING ________________________________
Accomplishments in Instructional Areas:
Related Educational Activities:
Professional Development Hours:
PIP-Current Year Progress:
PIP-For Upcoming School Year:
Indicators of Pupil Progress:
_____ Teacher Observation _____ Parental Conferences _____ Progress Reports
_____ Cumulative Records _____ State Assessments _____ Teacher Made
Assessments
_____ Projects/Reports _____ Student Demonstrations, Performances, etc.
_____ Others (Please List Below)
____________________________________________________________________________________
____________________________________________________________________________________
Attendance as of ______________________________: Illness: __________ Personal: __________
Observer Comments:
Teacher Comments:
___________________________ ___________________________ ___________________
________
Teacher’s Signature Evaluator’s Signature Title
Date
*This signature indicates that the staff member and the evaluator together discussed this report. It does
not necessarily denote agreement with all factors of the evaluation.
EVESHAM TOWNSHIP SCHOOLS
FIELD TRIP/SOCIAL EVENT REQUEST
REQUEST FORM MUST BE RECEIVED AT LEAST SIX WEEKS IN ADVANCE
**This form will be returned if all information is not filled in.**
School ____________________________________ Grade _______________________
Destination _________________________________ Date of Trip __________________
No. of People: Children ___________________ Adults _______________________
Total Fee ________ (check will be issued in this amount) Cost Per Person _______
Transportation Time: From __________ to ________ Directions Known / Unknown
BUSES ARE AVAILABLE FROM 8:30 A.M. TO 1:30 P.M. ONLY
Contact Person / Registrar at Site of Field Trip:
Name ______________________________________ Title ________________________
Address ____________________________________ Phone ______________________
____________________________________ (must have phone number at the site)
Reservation/Confirmation # (# needed in order to process payment)
How does the proposed trip relate to or supplement classroom instruction?
___________________________________________________________________________________
___________________________________________________________________________________
_______________________________________________________________________
List below all adults accompanying the students on the trip.
Teacher(s) ____________________________ Aides _______________________
____________________________ _______________________
____________________________ _______________________
Chaperone(s)____________________________ Date Submitted ________________
____________________________
____________________________
Principal’s Approval: _____________________________________________________
Date
Assistant Superintendent’s Approval: _________________________________________
Superintendent’s Approval: ________________________________________________
Transportation Department Approval: _________________________________________
(# of buses issued _____________)
Business Administrator Approval:_____________________ Check issued:__________
(field trip account #11-190-100-890-00-013 social event account # _________________________)
date
ALL CHANGES MUST BE SUBMITTED IN WRITING. forms:fieldtriprequest
Recorded: REVISED 7/20/05
REVISED 9-20-07 EVESHAM TOWNSHIP SCHOOLS
Request for Professional Day
Requests must be submitted a minimum of eight weeks prior to date of request
NAME: BUILDING:
GRADE/SUBJECT AREA/POSITION: Professional Staff Other Staff
Teacher Assistant
NAME OF WORKSHOP/MEETING/VISITATION:
SPONSOR OF WORKSHOP: LOCATION:
DATE(S) OF VISITATION: TIME: -
(end)(start)
PURPOSE OF PROFESSIONAL DAY: (If this visitation directly relates to your professional improvement plan, please indicate.
Specify relationship to your PIP, if applicable.)
Attach a copy of any workshop brochures, registration forms or conference itinerary.
Professional Day/Curriculum Related Project (check one)
Workshop/Conference/Grade Level/Dept. Meeting Curriculum Project Exposition (e.g. Cognetics)
Field Trip/Assembly/Concert Other
IEP Meetings and Related Tasks (check one – if applicable)
IEP Writing Transition Meeting Parent Meeting
CHECK ALL THAT APPLY
Release Time In District Full Day Multiple Days
After School/Saturday Out of District Half Day
Registration Fee __________________________________ Account # _______________________________________
Substitute Needed YES NO Account # _______________________________________
Estimated Reimbursement @ 50.5¢ per mile Account # _______________________________________
for Mileage, Parking and Tolls _______________________
Approval Granted
Building Principal ___________________________ Approval Denied Date: _______________
Approval Granted
Supervisor ________________________________ Approval Denied Date: _______________
Approval Granted
Asst. Supt. ________________________________ Approval Denied Date: _______________
Approval Granted
Superintendent _____________________________ Approval Denied Date: _______________
FOR CONFERENCES/VISITATIONS OUTSIDE THE SCHOOL DISTRICT:
Within two weeks after your professional day, submit to Mary Anne Domico a brief account of your visit/conference/inservice using the
conference report form on the other side of this form.
It is understood that you will present what you have learned to other staff at an appropriate faculty, department or grade level
meeting, as requested.
FOR OFFICE USE ONLY
BOARD OF EDUCATION APPROVAL DATE
Year One Evaluation
Year Five Evaluation
CURRICULUM NEEDS ASSESSMENT
Name Date
School Grade
Please use your curriculum guide and units along with the attached newly revised Core Curriculum Content Standards to reflect on our current
curriculum. Then identify areas of strength and/or need as indicated on this form. In order to prepare for our conversation, please bring this completed
form with you to our next scheduled grade level/department meeting.
- 1 2 3 4 5 + STRENGTHS NEEDS
Alignment to Core Curriculum
Content Standards (see attached)
1 2 3 4 5
Curriculum Organization
1 2 3 4 5
Instructional Materials/Resources
1 2 3 4 5
Pacing
1 2 3 4 5
Professional Development
1 2 3 4 5
Appropriate to Needs of All Students
1 2 3 4 5
Use other side for additional comments
EVESHAM TOWNSHIP SCHOOL DISTRICT
SUBSTANCE ABUSE POLICY VIOLATION CHECKLIST
STUDENT:
PARENT/GUARDIAN:
ADMINISTRATOR:
SCHOOL:
DATE:
DATE / TIME
Report the Incident to Principal/Designee and School Nurse
Remove the Student to a Protective Environment
Summon Substance Awareness Coordinator
Assess the Physical State of the Student
School Nurse Assesses that the Student is or is not in Need of Emergency Medical Treatment
Notify Parent/Guardian and Superintendent
Carry out Due-Process Procedure (Refer to R5530)
Inform Parent/Guardian of Options for Immediate Medical Examination (distribute/sign letter)
Arrange for Emergency Medical Examination
Arrange for Appropriate Care of Student While Awaiting the Results of Medical Examination
Transport to Medical Exam
NEGATIVE DIAGNOSIS:
Substance Awareness Coordinator and Principal/designee to Meet with Student and
Parent/Guardian
POSITIVE DIAGNOSIS:
Meet with Parent/Guardian
Inform Parent/Guardian of Disciplinary Action
Inform Parent/Guardian of Mandatory Drug/Alcohol Evaluation/Counseling Component
(Substance Awareness Coordinator)
Parent Signs Consent Form for Random Drug Testing
Substance Awareness Coordinator to Provide List of Contracted Service Providers for Evaluation
and Treatment
POSSESSION:
Report the Incident to Principal/Designee
Secure Evidence, Seal and Label as per R5530
Principal/Designee Notifies Police
Notify Superintendent and Parent/Guardian
Inform Parent/Guardian of Options for Immediate Medical Examination (distribute/sign letter)
Arrange for Emergency Medical Examination
Arrange for Appropriate Care of Student While Awaiting the Results of Medical Examination
Transport to Medical Exam
EVESHAM TOWNSHIP SCHOOL DISTRICT
REFERRAL CHECKLIST OF AT-RISK BEHAVIORS
Student’s Name: School:
Date and Time of Observation:
School or Activity Location:
Referred by:
REFERRAL TO PRINCIPAL
Warrants reporting to building administrator and/or nurse.
A. Behaviors indicating a reasonable suspicion of student being under the influence.
OBSERVATIONS:
1. ____ POSSESSION ____ SALE ____ DISTRIBUTION
2. ODOR OF ALCOHOL ON BREATH ____ Yes ____ No
3. ODOR OF MARIJUANA ____ Yes ____ No
4. ____ Student admits to being under the influence.
5. ____ Evidence of illegal substance use, possession, sale or delivery while at school or school activities.
REFERRAL TO NURSE
B. Other at-risk behaviors that warrant a screening by school nurse:
1. SPEECH: ____ Normal ____ Incoherent ____ Confused ____Slurred ____ Silent when spoken to
____Shouting ____ Rambling ____Slobbering ____ Boisterous ____ Hoarse ____ Whining
____ Crying ____ Slow ____ Whispering when spoken to ____ Abnormal stutter
2. BALANCE / ABILITY TO WALK: ____ Normal ____Swaying ____ Staggering ____ Falling
____ On hands/knees ____ Moved in circles ____ Grasping for support ____Arms raised for balance
3. AWARENESS: ____ Normal ____ Confused ____ Sleepy or stupor ____ Sleeping in class
____ Lack of coordination
4. EYES: ____ Normal ____ Bloodshot ____ Glassy eyed ____ Watery ____ Droopy lids ____ Clear
____ Wearing glasses or contacts ____ Not wearing glasses or contacts
5. MOVEMENT OF HANDS: ____ Normal ____ Fumbling ____ Slow
6. FACE: ____ Normal ____ Flushed ____ Pale
7. Other abnormal observed actions or behaviors:
8. ____ Significant change in individual personality (e.g. repeated abusive behavior, insubordination, etc.)
9. ____ Weight loss
10. ____ Student admission regarding substance use, while not at school (weekend user, recreational, evenings,
etc.)
11. CLOTHING: ____ Normal ____ Mussed ____ Dirty ____ Partly dressed ____ Vomited on
____ Urinated in clothes
12. ____ Reports by other students that an individual or group has been involved in possible at-risk behaviors:
____ substance use ____ talking about substance use ____ self-mutilation
Additional observations by nurse:
REFERRAL TO GUIDANCE COUNSELOR
C. Other at-risk behaviors that warrant further investigation by guidance counselor and/or administration:
1. DEMEANOR: ____ Normal ____ Fighting ____ Excited ____ Inappropriate Laughter ____ Sleepy
____ Cooperative ____Polite ____ Indifferent ____Crying ____ Antagonistic ____ Calm
2. ACTIONS: ____ Normal ____ Punching ____ Kicking ____ Resisting ____ Profanity
____ Threatening ____ Disrespectful ____ Difficult to awaken
3. CLOTHING: ____ Normal ____ Mussed ____ Dirty ____ Partly dressed ____ Vomited on
____ Urinated in clothes
4. Other abnormal observed actions or behaviors:
5. ____ Adequately documented pattern of unsatisfactory school performance, or a change in a student’s prior
patterns of school performance.
6. ____ Error in judgment that results in occurrence of an accident or flagrant violations of established safety,
security, or other operating procedures.
7. ____ Fighting (to mean physical contact) and assaults, or erratic, aggressive or violent behavior.
8. ____ Significant change in individual personality (e.g. repeated abusive behavior, insubordination, etc.)
9. ____ Change in school attendance.
10. ____ Change in grades.
11. ____ Change in friends.
12. ____ Change of clothing style.
13. ____ Reports by other students that an individual or group has been involved in possible at-risk behaviors:
____ substance use ____ talking about substance use ____ self-mutilation
14. ____ Student admission regarding substance use, while not at school (weekend user, recreational, evenings,
etc.).
Additional observations by guidance counselor: