National Survey of Child and Adolescent Well-Being: Infant Follow-Up -- Teacher Survey

National Teacher Survey on Children

Sponsored by the Administration for Children and Families

U.S. Department of Health and Human Services

This questionnaire asks about the school performance of the student named in the letter that was included with this questionnaire. Your responses are extremely important. You may consult other teachers, administrators, and school records, as necessary, to complete this survey. Please return the survey even if you are unable to complete all of the questions. Note that you may complete the questionnaire on the Internet if you prefer (see enclosed instruction sheet)

Case ID #:

Teacher Name:

Web Questionnaire website: [WEBSITE]

USERNAME:

PASSWORD:

Thank you for answering these questions!

RTI International

P.O. Box 12194

Research Triangle Park

North Carolina 27709-2194 USA

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0202. The time required to complete this collection is estimated to be 30 minutes.

A. Your Relationship With the Student

You were selected to participate in this study because you teach the student named on the cover of this questionnaire. Your responses to these questions will help us obtain a complete picture of the student=s academic performance, social skills, and relationships with peers.

Please note that some questions ask about your knowledge of the student in Athis class@, specifically. However, most of the questions ask you to report based on your full knowledge of the student.

1. Which subject areas do you teach the student currently? Mark an X in each box that applies.

Self-contained classroom G1

Language arts G2

Reading G3

Social studies G4

Science G5

Mathematics G6

Arts (e.g., art, music) G7

Enrichment or gifted G8

Health G9

Electives or exploratories G10

Physical education G11

Vocational or technical G12

Resource G13

Other G14

2. What is the average size of the classes you teach that include this student?

Less than 10 students G1

10 - 15 students G2

16 - 20 students G3

21 - 25 students G4

More than 25 students G5

3. How long have you known the student?

Months

4. How well do you know this student?

Not well G1

Moderately well G2

Very well G3

B. Peer Relationships

The next questions ask about how this student relates to other peers in his/her class.

1. How often are each of the following statements true about the student?

	Never	Seldom	Some-times	Often	Very Often
					
When this child has been teased or threatened, he/she gets angry easily and strikes back	G	G	G	G	G
The child claims that other children are to blame in a fight and feels that they started the trouble.	G	G	G	G	G
When a peer accidentally hurts this child, such as by bumping into him/her, this child assumes that the peer meant to do it, and then overreacts with anger and fighting	G	G	G	G	G
The child gets other kids to gang up on a peer that he/she does not like.	G	G	G	G	G
The child uses physical force (or threatens to use force) in order to dominate other kids.	G	G	G	G	G
The child threatens or bullies others in order to get his/her own way	G	G	G	G	G

C. Social Skills: Grades K-6

(Complete Section C only if the student is in grades K-6. If the student is in grades 7-12, turn to Section D.)

Please read each of the following items and think about this student=s behavior during the past month or two. Decide how often the student does the behavior described.

If the student never does this behavior, mark an X in the box for ANever@ (0).

If the student sometimes does this behavior, mark an X in the box for ASometimes@ (1).

If the student very often does this behavior, mark an X in the box for AVery often@ (2).

	Never	Sometimes	Very Often
			
Controls temper in conflict situations with peers	G0	G1	G2
Introduces herself or himself to new people without being told	G0	G1	G2
Appropriately questions rules that may be unfair	G0	G1	G2
Compromises in conflict situations by changing own ideas to reach agreement	G0	G1	G2
Responds appropriately to peer pressure	G0	G1	G2
Says nice things about himself or herself when appropriate	G0	G1	G2
Invites others to join in activities	G0	G1	G2
Uses free time in an acceptable way	G0	G1	G2
Finishes class assignments within time limits	G0	G1	G2
Makes friends easily	G0	G1	G2
Responds appropriately to teasing by peers	G0	G1	G2
Controls temper in conflict situations with adults	G0	G1	G2
Receives criticism well	G0	G1	G2
Initiates conversations with peers	G0	G1	G2
Uses time appropriately while waiting for help	G0	G1	G2
Produces correct schoolwork	G0	G1	G2
Appropriately tells you when he or she thinks you have treated him or her unfairly
Accepts peers= ideas for group activities	G0	G1	G2
Gives compliments to peers	G0	G1	G2
Follows your directions	G0	G1	G2
Puts work materials or school property away	G0	G1	G2
Cooperates with peers without prompting	G0	G1	G2
Volunteers to help peers with classroom tasks	G0	G1	G2
Joins ongoing activity or group without being told to do so	G0	G1	G2
Responds appropriately when pushed or hit by other children	G0	G1	G2
Ignores peer distractions when doing class work	G0	G1	G2
Keeps desk clean and neat without being reminded	G0	G1	G2
Attends to your instructions	G0	G1	G2
Easily makes transition from one classroom activity to another	G0	G1	G2
Gets along with people who are different	G0	G1	G2

81990, American Guidance Service, Inc.

SKIP TO SECTION E. Reproduced by permission

4. Social Skills: Grades 7-12

(Complete Section D only if the student is in grades 7-12.)

Please read each of the following items and think about this student=s behavior during the past month or two. Decide how often the student does the behavior described.

If the student never does this behavior, mark an X in the box for ANever@ (0).

If the student sometimes does this behavior, mark an X in the box for ASometimes@ (1).

If the student very often does this behavior, mark an X in the box for AVery often@ (2).

	Never	Sometimes	Very Often
			
Produces correct schoolwork	G0	G1	G2
Keeps his or her work area clean without being reminded	G0	G1	G2
Responds appropriately to physical aggression from peers	G0	G1	G2
Initiates conversations with peers	G0	G1	G2
Volunteers to help peers on classroom tasks	G0	G1	G2
Politely refuses unreasonable requests from others	G0	G1	G2
Appropriately questions rules that may be unfair	G0	G1	G2
Responds appropriately to teasing by peers	G0	G1	G2
Accepts peers= ideas for group activities	G0	G1	G2
Appropriately expresses feelings when wronged	G0	G1	G2
Receives criticism well	G0	G1	G2
Attends to your instructions	G0	G1	G2
Uses time appropriately while waiting for your help	G0	G1	G2
Introduces himself or herself to new people without being told	G0	G1	G2
Compromises in conflict situations by changing own ideas to reach agreement	G0	G1	G2
Acknowledges compliments or praise from peers	G0	G1	G2
Easily makes transition from one classroom activity to another	G0	G1	G2
Controls temper in conflict situations with peers	G0	G1	G2
Finishes class assignments within time limits	G0	G1	G2
Listens to classmates when they present their work or ideas	G0	G1	G2
Appears confident in social interactions with opposite-sex peers	G0	G1	G2
Invites others to join in activities	G0	G1	G2
Controls temper in conflict situations with adults	G0	G1	G2
Ignores peer distractions when doing class work	G0	G1	G2
Stands up for peers when they have been unfairly criticized	G0	G1	G2
Puts work materials or school property away	G0	G1	G2
Appropriately tells you when he or she thinks you have treated him or her unfairly	G0	G1	G2
Gives compliments to members of the opposite sex	G0	G1	G2
Complies with your directions	G0	G1	G2
Responds appropriately to peer pressure	G0	G1	G2

81990, American Guidance Service, Inc.

Reproduced by permission.

4. Student Behavior

Below is a list of items that describe students. For each item that describes the student now or within the past 2 months, please code A2" if the item is very true or often true. Code A1" if the item is somewhat or sometimes true of the student. If the item is not true of the student, code A0". Please answer all items as well as you can, even if some do not seem to apply to this student.

	Not True	Somewhat or Sometimes True	Very True or Often True
			
Acts too young for his/her age	G0	G1	G2
Hums or makes other odd noises in class	G0	G1	G2
Argues a lot	G0	G1	G2
Fails to finish things he/she starts	G0	G1	G2
Behaves like opposite sex	G0	G1	G2
Defiant, talks back to staff	G0	G1	G2
Bragging, boasting	G0	G1	G2
Can=t concentrate, can=t pay attention for long	G0	G1	G2
Can=t get his/her mind off certain thoughts; obsessions	G0	G1	G2
Can=t sit still, restless, or hyperactive	G0	G1	G2
Clings to adults or too dependent	G0	G1	G2
Complains of loneliness	G0	G1	G2
Confused or seems to be in a fog	G0	G1	G2
Cries a lot	G0	G1	G2
Fidgets	G0	G1	G2
Cruelty, bullying, or meanness to others	G0	G1	G2
Daydreams or gets lost in his/her thoughts	G0	G1	G2
Deliberately harms self or attempts suicide	G0	G1	G2
Demands a lot of attention	G0	G1	G2
Destroys his/her own things	G0	G1	G2
Easily jealous	G0	G1	G2
Destroys property belonging to others	G0	G1	G2
Difficulty following directions	G0	G1	G2
Disobedient at school	G0	G1	G2
Disturbs other pupils	G0	G1	G2
Doesn’t get along with other pupils	G0	G1	G2
Doesn’t seem to feel guilty after misbehaving	G0	G1	G2
Eats or drinks things that are not food - don=t include sweets	G0	G1	G2
Fears certain animals, situations, or places other than school	G0	G1	G2
Fears going to school	G0	G1	G2
Fears he/she might think or do something bad	G0	G1	G2
Feels he/she has to be perfect	G0	G1	G2
Feels or complains that no one loves him/her	G0	G1	G2
Feels worthless or inferior	G0	G1	G2
Feels others are out to get him/her	G0	G1	G2
Gets hurt a lot, accident-prone	G0	G1	G2
Gets in many fights	G0	G1	G2
Gets teased a lot	G0	G1	G2
Impulsive or acts without thinking	G0	G1	G2
Hangs around with others who get in trouble	G0	G1	G2
Hears sounds or voices that aren’t there	G0	G1	G2
Would rather be alone than with others	G0	G1	G2
Lying or cheating	G0	G1	G2
Bites fingernails	G0	G1	G2
Nervous, high-strung, or tense	G0	G1	G2
Nervous movements or twitching	G0	G1	G2
Overconforms to rules	G0	G1	G2
Not liked by other pupils	G0	G1	G2
Has difficulty learning	G0	G1	G2
Too fearful or anxious	G0	G1	G2
Feels dizzy	G0	G1	G2
Feels too guilty	G0	G1	G2
Talks out of turn	G0	G1	G2
Overtired	G0	G1	G2
Overweight	G0	G1	G2
Physical problems without known medical cause:	G0	G1	G2
Aches or pains (not stomach or headaches)	G0	G1	G2
Headaches	G0	G1	G2
Nausea, feel sick	G0	G1	G2
Problems with eyes (not if corrected by glasses)	G0	G1	G2
Rashes or other skin problems	G0	G1	G2
Stomachaches or cramps	G0	G1	G2
Vomiting, throwing up	G0	G1	G2
Physically attacks people	G0	G1	G2
Picks nose, skin, or other parts of body	G0	G1	G2
Sleeps in class	G0	G1	G2
Apathetic or unmotivated	G0	G1	G2
Poor school work	G0	G1	G2
Poorly coordinated or clumsy	G0	G1	G2
Prefers being with older children or youths	G0	G1	G2
Prefers being with younger children	G0	G1	G2
Refuses to talk	G0	G1	G2
Repeats certain acts over and over; compulsions	G0	G1	G2
Disrupts class discipline	G0	G1	G2
Screams a lot	G0	G1	G2
Secretive, keeps things to self	G0	G1	G2
Sees things that aren’t there	G0	G1	G2
Self-conscious or easily embarrassed	G0	G1	G2
Messy work	G0	G1	G2
Behaves irresponsibly	G0	G1	G2
Showing off or clowning	G0	G1	G2
Shy or timid	G0	G1	G2
Explosive and unpredictable behavior	G0	G1	G2
Demands must be met immediately, easily frustrated	G0	G1	G2
Inattentive, easily distracted	G0	G1	G2
Speech problem	G0	G1	G2
Stares blankly	G0	G1	G2
Feels hurt when criticized	G0	G1	G2
Steals	G0	G1	G2
Stores up things he/she doesn’tt need	G0	G1	G2
Strange behavior	G0	G1	G2
Strange ideas	G0	G1	G2
Stubborn, sullen, or irritable	G0	G1	G2
Sudden changes in mood or feelings	G0	G1	G2
Sulks a lot	G0	G1	G2
Suspicious	G0	G1	G2
Swearing or obscene language	G0	G1	G2
Talks about killing self	G0	G1	G2
Underachieving, not working up to potential	G0	G1	G2
Talks too much	G0	G1	G2
Teases a lot	G0	G1	G2
Temper tantrums or hot temper	G0	G1	G2
-Seems preoccupied with sex	G0	G1	G2
Threatens people	G0	G1	G2
Tardy to school or class	G0	G1	G2
Too concerned with neatness or cleanliness	G0	G1	G2
Fails to carry out assigned tasks	G0	G1	G2
Truancy or unexplained absence	G0	G1	G2
Underactive, slow moving, or lacks energy	G0	G1	G2
Unhappy, sad, or depressed	G0	G1	G2
Unusually loud	G0	G1	G2
Uses alcohol or drugs for nonmedical purposes	G0	G1	G2
Overly anxious to please	G0	G1	G2
Dislikes school	G0	G1	G2
Is afraid of making mistakes	G0	G1	G2
Whining	G0	G1	G2
Unclean personal appearance	G0	G1	G2
Withdrawn, doesn’t get involved with others	G0	G1	G2
Worries	G0	G1	G2

8T.M. Achenbach

Reproduced by permission.

4. Grade Progression/Academic Performance

1. Has this student skipped any grades?

Yes G1 Which grades?_____________________________

No G2

2. Is this student a member of your school=s gifted/talented program?

Yes G1

No G2

Don=t know G99

3. Has this student repeated any grades?

Yes G1 Which grades? _____________________________

No G2 Skip to Question 5

Don=t know (not available) G99 Skip to Question 5

4. Will retention be recommended for this student this year?

Yes G1

No G2

Don=t know G99

5. Please rate this child’s overall academic skills in each of the following areas, compared to other children at the same grade level. Mark an X in the box that indicates the student’s performance in each subject area. Consult student records and the child’s other teachers if you do not have direct knowledge. Do not include performance in areas outside those listed, such as physical education and sports, performing arts, practical arts (e.g. business), computers, and vocational education.

	Far below average	Below average	Average	Above Average	Far above average
					
Language and literacy skills (Reading, Writing, Spelling, Phonics, Grammar, English, Foreign Languages)	G	G	G	G	G
Science (Biology, Chemistry, Physics, Environmental or Earth Science)	G	G	G	G	G
Social Studies (Civics, Economics, Geography, Government, History, Humanities, Sociology)	G	G	G	G	G
Mathematical skills (Counting, Basic Math, Pre-Algebra, Algebra, Geometry, Trigonometry, Calculus)	G	G	G	G	G

6. Since the beginning of the school year, how many days in total has this student been absent?

Days

7. In this school year, has the student had any behavior or discipline problems at this school which resulted in suspension or expulsion?

Yes G1

No G2  Skip to Question 11

Don=t know G99  Skip to Question 11

8. Has this happened just once or more than once?

Once G1

More than once G2

Don=t know G99

9. Have you had any other contact (in person, on the phone, or by a note sent home) with this student=s parents?

Yes G1  What was the reason for this contact?

No G2

Don=t know G99

10. Is this student=s reading level...

On grade G1

Below grade G2

Above grade G3

Don=t know G99

4. Special Educational Needs of the Child

Please consult the student’s folder, as necessary, in order to answer the special education items below.

1. Does this student have any physical, emotional or mental condition which interferes with or limits his/her ability to do regular school work at grade level?

Yes G1

No G2

Don=t Know G99

2. Does this student have any physical, emotional or mental condition which interferes with or limits his/her ability to take part in sports, games, or other activities with students his/her age?

Yes G1

No G2

Don=t Know G99

3. Has this student EVER been classified as needing special education? That is, has he/she ever been given an Individual Education Plan (I.E.P.) or an Individualized Family Services Plan (I.F.S.P.)?

Yes G1

No G2  Go to THANK YOU on Page 16

Don=t Know G99

4. Is this student currently receiving special education? That is, does he/she currently have an Individual Education Plan (I.E.P.) or an Individualized Family Services Plan (I.F.S.P)?

Yes G1

No G2

Don=t Know G99

Questions 5 through 13 should only be answered if you responded Ayes@ to Question 3 above (that is, the student has special educational needs).

5. How is the student classified? What is the PRIMARY special education handicapping code? Mark an X in one box.

1. Autism. G

2. Deafness. G

3. Emotional disturbance. G

4. Hearing impaired. G

5. Mental retardation. G

6. Multiply disabled. G

7. Orthopedic impairment. G

8. Specific learning disability. G

9. Speech or language impairment G

10. Traumatic brain injury G

11. Visual impairment including blindness G

12. ADHD (Attention deficient hyperactive disorder). G

13. Developmental disability G

14. Other health impairment. G

6. As part of the Individual Education Plan (I.E.P), does this student have any SECONDARY handicapping codes or problems? Mark and X in each box that applies.

1. Autism. G

2. Deafness. G

3. Emotional disturbance. G

4. Hearing impaired. G

5. Mental retardation. G

6. Multiply disabled. G

7. Orthopedic impairment. G

8. Specific learning disability. G

9. Speech or language impairment G

10. Traumatic brain injury G

11. Visual impairment including blindness G

12. ADHD (Attention deficient hyperactive disorder). G

13. Developmental disability G

14. Other health impairment. G

7. Is this child being educated in a:

	Yes	No
		
Regular class (i.e., general education)?	G1	G2
Regular class (i.e., general education)?	G1	G2
Special school?	G1	G2
Special class in a regular school (i.e., self-contained)?	G1	G2
Resource room (i.e., special education/services are provided outside the regular classroom for 21-60% of the day)?	G1	G2

8. About what portion of the school day is this student served by special education?

0% G1

25% G2

50% G3

75% G4

100% G5

Don=t know G99

9. Approximately how many years of special education instruction have been provided for this student, including kindergarten?

1 year or less G1

2 - 4 years G2

5 years or more G3

Don=t know G99

10. What agency provides (delivers) the special education instruction to the student? Select as many agencies as apply.

Public school G1

Private school or program G2

Social Service (child or family welfare) agency G3

Mental health agency G4

Public health (including substance abuse) agency G5

Private community-based agency G6

Other agency G7

The next questions are about other services the student or his/her family may be receiving to support his/her disability or special educational needs.

11. Which of the following services is the student or his/her family receiving? Mark an X in each box that applies

1. Speech-language pathology and/or audiology services? G1

2. Psychological services? G2

3. Physical and/or occupational therapy? G3

4. Recreation/therapeutic recreation services? G4

5. Social work services? G5

6. Counseling services, including rehabilitation services? G6

7. Orientation and mobility services G7

8. Medical services for diagnostic and evaluation purposes? G8

9. Special transportation services G9

10. Parenting classes? G10

11. Assistive technology services? G11

12. Assistive technology devices G12

13. Transition from preschool to elementary school services? G13

14. Transition from secondary school to post-secondary school services? G14

15. Any other services to address the student’s disability or special educational needs? G15

12. What is the involvement of the child=s parent or caregiver in the decision-making regarding the child=s special education and related services? Mark an X for all that apply.

Participates in meetings regarding the child=s Individualized Education Program (IEP) G1

Is actively and regularly involved with the school G2

Is actively and regularly involved with other agencies providing services to the child G3

Receives assistance or services from a training center for parents of children with disabilities G4

Not involved at all G5

13. Overall, do you believe the student is receiving the appropriate special education and related services needed to address his/her disability?

Yes, definitely G1

This child is receiving some education and services, but they could be improved G2

No, this child is not receiving the education and services he/she needs G3

THANK YOU -- FOR YOUR PARTICIPATION IN THIS VERY IMPORTANT SURVEY!

PLEASE RETURN YOUR COMPLETED QUESTIONNAIRE IN THE POSTAGE-PAID ENVELOPE PROVIDED.

3