TEACHERS SHORT CONNERS

Student Name

Student DOB

Gender

Male Female

Grade

TEACHER NAME

CLASS TAUGHT

Time Known Student

MONTHS

INSTRUCTIONS:: Here are some things that teachers might say about their students. Please tell us about THIS student and what he/she has been like in the PAST MONTH. Read each item carefully, then mark how well it describes the student or how frequently it has happened in the PAST MONTH.

0 = In the past month, this was NOT TRUE AT ALL about the student. It never(or seldom) happened.
1 = In the past month, this was JUST ALITTLE TRUE about the student. It happened occasionally.
2 = In the past month, this was PRETTY MUCH TRUE about the student. It happend often. (or quite a bit)
3 = In the past month, this was VERY MUCH TRUE about the student. It happend very often. (very frequently)

Please respond to each item. If you are unsure about an item please give your best guess.

1. Is constantly moving

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

2. Has to struggle to complete hard tasks

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

3. Inattentive, easily distracted

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

4. Makes mistakes

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

5. Bullies, threatens, or scares others.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

6. Cannot do things right

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

7. Is angry and resentful

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

8. Excitable, impulsive

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

9. Is fun to be around

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

10. Has trouble keeping his/her mind on work or play for long

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

11. Has poor social skills

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

12. Actively refuses to do what adults tell him/her to do

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

13. Is happy, cheerful, and has a positive attitude

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

14. Cannot grasp arithmetic

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

15. Tries to get even with people

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

16. Has trouble getting started on tasks or projects

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

17. Acts in sneaky or manipulative ways.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

18. Does not understand what he/she reads

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

19. Tells the truth; does not even tell "little white lies'

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

20. Appears to be unaccepted by group.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

21. Is hard to motivate (Even with highly desireable rewards).

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

22. Restless or overactive.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

23. Is good at planning ahead.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

24. Fidgets or squirms in seat.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

25. Is patient or content, even when waiting in a long line.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

26. Doesn't may attention to details; makes careless mistakes.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

27. Is one of the last to be picked for teams or games.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

28. Spelling is poor.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

29. Has trouble keeping friends.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

30. Leaves seat when he/she shold stay seated.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

31. Behaves like an angel.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

32. Talks out of turn.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

33. Is difficult to please or amuse.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

34. Is perfect in every way.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

35. Forgets things already learned.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

36. Has short attention span

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

37. Does not know how to make friends.

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

38. I cannot figure out what makes him/her happy

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

39. Is sidetracked easily

Not true at all (Never, Seldom) Just a little true (Occasionally)

1

Pretty much true (Often, Quite a bit)

2

Very Much True (Very often, Very Frequently)

3

40. Do you have other concerns about this student?

41. What strengths or skills does this child have?

Todays Date

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