Student Observation Form

Student: Grade: Date:

Teacher: Observer:
Time Observed:
Subject: Student to Staff Ratio:
Area(s) of concern stated in referral:
[ ] Oral Expression [ ] Written Expression [ ] Basic Reading Skills
[ ] Reading Fluency [ ] Math Calculations [ ] Math Problem Solving
[ ] Listening Comprehension [ ] Social Skills [ ] Behavior

Appearance
Describe_______________________________ Relationship with teacher
___Cooperative
___Withdrawn
Student’s Level of Activity ___Seeks attention
___Hyperactive ___Needs individual attention
___Appropriate ___Refuses to follow instructions
___Lethargic/Tired
___ Other __________________
Behavioral concerns
Attention ___Inappropriate vocalizations
___Listens to instructions Describe
___Understands directions
___Able to stay on task ___Repetitive motor movements
___Easily distracted Describe
___Able to work independently
___Understands concept presented ___Aggression
___Staring blankly/daydreaming Describe
___Fiddles with objects
___Doodling ___Self-injurious behaviors
___Distracts other children Describe

Effort/Motivation ___Avoids peer interaction

___Tries hard Describe________________________________
___Gives up easily
___Careless in work Temperament
___Eager to please ___Happy
___Hesitant to begin working ___Depressed/withdrawn
___Apathetic/Indifferent ___Angry/hostile
___Works at reasonable pace ___Anxious
___Works slowly ___Confused
___Easily upset
Relationship with peers
___Works/plays alone Transitions/Movement
___Participates in group activities ___Moves around room appropriately
___Interacts well with others ___Starts new tasks
___Hitting, poking, distracting peers ___Prepares materials for beginning/end of
___Initiates social interaction lesson
___Waits for others to initiate ___Unable to transition appropriately
Describe
Classroom Noise Level: ___much ___some ___little ___none
Movement in Classroom: ___much ___some ___little ___none

Detailed sequence of events that occurred during the observation: