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Student Support Problem Identification Checklist
Student Name: _______________________________ Completed By:______________________________ Date: ___________
The student The student The student The student
always frequently occasionally never
demonstrates demonstrates demonstrates demonstrates
this behavior this behavior this behavior this behavior
Disruptive (e.g., calls out; makes noises; talks with
peers; gets out of seat)
Disrespectful to adults (e.g., talks back; argues with
teacher; uses rude language; walks away when teacher
is talking)
Disrespectful to peers (e.g., teases, bullies, calls
names, argues, puts peers in awkward position)
Despondent (e.g., puts head down, withdraws from
conversation; does not participate)
Insubordinate (e.g., does not follow directions; repeats
behaviors previously told not to do; proceeds doing
something despite being told to stop)
Aggressive (e.g., pushes, shoves, hits, wrestles,
physically intimidates; threatens)
Other:
Sponsored by New Jersey Department of Education, Office of Special Education Programs (NJOSEP) in collaboration with the Elizabeth M. Boggs Center on Developmental Disabilities, UMDNJ-Robert
Wood Johnson Medical School. Funded by IDEA, Part B. www.njpbs.org
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The student The student The student The student I’m Not
School Success Indicators always frequently occasionally never Sure
demonstrates demonstrates demonstrates demonstrates
this indicator this indicator this indicator this indicator
Classroom Functioning Indicators
Arrives for class on time
Follows directions
Transitions between activities smoothly
Follows typical class routines
Comes to class prepared with materials
Keeps belongings organized
Academic Performance Indicators
Completes in class assignments
Completes homework and other projects
Pays attention in class
Can work on assignments independently
Participates in class discussions
Stays with a challenging assignment or problem
Social-Emotional Functioning Indicators
Tends to be quiet or stay to self
Makes friends easily
Observant of and responsive to social cues
Comfortable interacting socially with other students
Cooperative and respectful with adults
Responds well to constructive criticism
Appears confident in social situations
Has an identifiable group of friends
Is able to work through social problems
Holds conversation on a variety of topics
Expresses concern for others
Mood / disposition is consistent day to day
Manages stressful situations well
Tolerates mild friendly teasing
Sponsored by New Jersey Department of Education, Office of Special Education Programs (NJOSEP) in collaboration with the Elizabeth M. Boggs Center on Developmental Disabilities, UMDNJ-Robert
Wood Johnson Medical School. Funded by IDEA, Part B. www.njpbs.org
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Thinking about the problem behaviors you identified that occurred in your classroom, please review the following list and check off any
conditions that serve as triggers for the student’s problem behavior (i.e. set the student off):
When asked to do a chore, or helping task, or academic work, Transition at the beginning of a class/routine/activity
or something non preferred (e.g., reading out loud) Unstructured situations or settings
When held to a time limit (e.g., finish a preferred activity) When he/she can not have something they want
Tasks that are difficult or confuse the student Preferred peer group present
When working/playing/entertaining independently When given an ultimatum or a direction to follow
When working in group activities When corrected, or told “no” or stop
Not prepared with materials When there is a change in routine (e.g., visitors in the class)
Multi-step work or projects When adult attention is on others
Lecture: with note taking OR without note taking Other:
Being teased or being joked around with
When problem behavior occurs, how do you (or students in the class) typically respond?
Give a non verbal cue (e.g., look at student) Send the student to an administrator
Verbally correct the student or provide a reminder Have the student take a break (e.g., go to guidance or
Speak to the student after class or in a conference bathroom)
Call the student’s parents Teacher assigned detention
Help the student to get on task Moved seat
Other students laugh or “egg” the student on Take a privilege away (e.g., loss of recess)
Other:
What is your best guess as to why the problem behavior is occurring?
To Get Out of / Escape Situations: To Get / Gain Access to:
That are too difficult/challenging The validation of peers (reputation/ perceived popularity)
That are perceived as boring / irrelevant Time alone
Where the student is embarrassed or need to save face Control over the situation and / or predictability
Where the student is not sure what to do Adult attention (even if it is negative)
That are too stimulating Peer attention (even if it is negative)
Other: To get something he/she wants
Other:
Sponsored by New Jersey Department of Education, Office of Special Education Programs (NJOSEP) in collaboration with the Elizabeth M. Boggs Center on Developmental Disabilities, UMDNJ-Robert
Wood Johnson Medical School. Funded by IDEA, Part B. www.njpbs.org
4
Sponsored by New Jersey Department of Education, Office of Special Education Programs (NJOSEP) in collaboration with the Elizabeth M. Boggs Center on Developmental Disabilities, UMDNJ-Robert
Wood Johnson Medical School. Funded by IDEA, Part B. www.njpbs.org
5
Sponsored by New Jersey Department of Education, Office of Special Education Programs (NJOSEP) in collaboration with the Elizabeth M. Boggs Center on Developmental Disabilities, UMDNJ-Robert
Wood Johnson Medical School. Funded by IDEA, Part B. www.njpbs.org
