Daily Behavior Checklist

Student Name:____________________________
Date: 8:00 - 9:55 10:05 - 11:30
On task & working on schoolwork Yes No Yes No
Following directions Yes No Yes No
Interacting appropriately with classmates Yes No Yes No
Interacting appropriately with adults Yes No Yes No
Playing with items in / on desk Yes No Yes No
Out of seat Yes No Yes No
Interfereing with others' learning Yes No Yes No
Interfering with teaching Yes No Yes No
What caused these behaviors?

Sent to Resource Room for

Yes No ( ___ times) Yes No ( ___ times)
Yes No ( ___ times) Yes No ( ___ times)
Yes No ( ___ times) Yes No ( ___ times)
Modifications attempted
Different Seating
Yes No Yes No

Successful? Yes No Successful? Yes No

Shortened assignments
Yes No Yes No

Successful? Yes No Successful? Yes No

Resource Room
Yes No Yes No

Successful? Yes No Successful? Yes No

Comments:
Parent Signature __________________________________________________
 12:10 - 1:55
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Yes No ( ___ times)

Yes No ( ___ times)
Yes No ( ___ times)

Yes No

Successful? Yes No

Yes No

Successful? Yes No

Yes No

Successful? Yes No
____________