Teacher Questionaire

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)

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.

This page is intentionally blank.

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 1

Language arts 2

Reading 3

Social studies 4

Science 5

Mathematics 6

Arts (e.g., art, music) 7

Enrichment or gifted 8

Health 9

Electives or exploratories 10

Physical education 11

Vocational or technical 12

Resource 13

Other 14

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

Less than 10 students 1

10 - 15 students 2

16 - 20 students 3

21 - 25 students 4

More than 25 students 5

3. How long have you known the student?

Months

4. How well do you know this student?

Not well 1

Moderately well 2

Very well 3

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
					
1. When this child has been teased or threatened, he/she gets angry easily and strikes back	1	2	3	4	5
2. The child claims that other children are to blame in a fight and feels that they started the trouble.	1	2	3	4	5
3. 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	1	2	3	4	5
4. The child gets other kids to gang up on a peer that he/she does not like.	1	2	3	4	5
5. The child uses physical force (or threatens to use force) in order to dominate other kids.	1	2	3	4	5
6. The child threatens or bullies others in order to get his/her own way	1	2	3	4	5

2. What grade do you (or did you) teach the student?

K to 6………………………………. CONTINUE TO SECTION C ON PAGE 5

7 to 12……………………………..  SKIP TO SECTION D ON PAGE 6

C. Social Skills: Grades K-6

(Complete Section C only if you instructed the student in grades K-6. If you instructed the student in grades 7-12, go 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	0	1	2
Introduces herself or himself to new people without being told	0	1	2
Appropriately questions rules that may be unfair	0	1	2
Compromises in conflict situations by changing own ideas to reach agreement	0	1	2
Responds appropriately to peer pressure	0	1	2
Says nice things about himself or herself when appropriate	0	1	2
Invites others to join in activities	0	1	2
Uses free time in an acceptable way	0	1	2
Finishes class assignments within time limits	0	1	2
Makes friends easily	0	1	2
Responds appropriately to teasing by peers	0	1	2
Controls temper in conflict situations with adults	0	1	2
Receives criticism well	0	1	2
Initiates conversations with peers	0	1	2
Uses time appropriately while waiting for help	0	1	2
Produces correct schoolwork	0	1	2
Appropriately tells you when he or she thinks you have treated him or her unfairly	0	1	2
Accepts peers= ideas for group activities	0	1	2
Gives compliments to peers	0	1	2
Follows your directions	0	1	2
Puts work materials or school property away	0	1	2
Cooperates with peers without prompting	0	1	2
Volunteers to help peers with classroom tasks	0	1	2
Joins ongoing activity or group without being told to do so	0	1	2
Responds appropriately when pushed or hit by other children	0	1	2
Ignores peer distractions when doing class work	0	1	2
Keeps desk clean and neat without being reminded	0	1	2
Attends to your instructions	0	1	2
Easily makes transition from one classroom activity to another	0	1	2
Gets along with people who are different	0	1	2

SKIP TO SECTION E ON PAGE 7

81990, American Guidance Service, Inc.

Reproduced by permission.

4. Social Skills: Grades 7-12

(Complete Section D only if you instructed the student in grades 7-12. Otherwise, go to Section E on page 7.)

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	0	1	2
Keeps his or her work area clean without being reminded	0	1	2
Responds appropriately to physical aggression from peers	0	1	2
Initiates conversations with peers	0	1	2
Volunteers to help peers on classroom tasks	0	1	2
Politely refuses unreasonable requests from others	0	1	2
Appropriately questions rules that may be unfair	0	1	2
Responds appropriately to teasing by peers	0	1	2
Accepts peers= ideas for group activities	0	1	2
Appropriately expresses feelings when wronged	0	1	2
Receives criticism well	0	1	2
Attends to your instructions	0	1	2
Uses time appropriately while waiting for your help	0	1	2
Introduces himself or herself to new people without being told	0	1	2
Compromises in conflict situations by changing own ideas to reach agreement	0	1	2
Acknowledges compliments or praise from peers	0	1	2
Easily makes transition from one classroom activity to another	0	1	2
Controls temper in conflict situations with peers	0	1	2
Finishes class assignments within time limits	0	1	2
Listens to classmates when they present their work or ideas	0	1	2
Appears confident in social interactions with opposite-sex peers	0	1	2
Invites others to join in activities	0	1	2
Controls temper in conflict situations with adults	0	1	2
Ignores peer distractions when doing class work	0	1	2
Stands up for peers when they have been unfairly criticized	0	1	2
Puts work materials or school property away	0	1	2
Appropriately tells you when he or she thinks you have treated him or her unfairly	0	1	2
Gives compliments to members of the opposite sex	0	1	2
Complies with your directions	0	1	2
Responds appropriately to peer pressure	0	1	2

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	0	1	2
Hums or makes other odd noises in class	0	1	2
Argues a lot	0	1	2
Fails to finish things he/she starts	0	1	2
Behaves like opposite sex	0	1	2
Defiant, talks back to staff	0	1	2
Bragging, boasting	0	1	2
Can=t concentrate, can=t pay attention for long	0	1	2
Can=t get his/her mind off certain thoughts; obsessions	0	1	2
Can=t sit still, restless, or hyperactive	0	1	2
Clings to adults or too dependent	0	1	2
Complains of loneliness	0	1	2
Confused or seems to be in a fog	0	1	2
Cries a lot	0	1	2
Fidgets	0	1	2
Cruelty, bullying, or meanness to others	0	1	2
Daydreams or gets lost in his/her thoughts	0	1	2
Deliberately harms self or attempts suicide	0	1	2
Demands a lot of attention	0	1	2
Destroys his/her own things	0	1	2
Easily jealous	0	1	2
Destroys property belonging to others	0	1	2
Difficulty following directions	0	1	2
Disobedient at school	0	1	2
Disturbs other pupils	0	1	2
Doesn’t get along with other pupils	0	1	2
Doesn’t seem to feel guilty after misbehaving	0	1	2
Eats or drinks things that are not food - don=t include sweets	0	1	2
Fears certain animals, situations, or places other than school	0	1	2
Fears going to school	0	1	2
Fears he/she might think or do something bad	0	1	2
Feels he/she has to be perfect	0	1	2
Feels or complains that no one loves him/her	0	1	2
Feels worthless or inferior	0	1	2
Feels others are out to get him/her	0	1	2
Gets hurt a lot, accident-prone	0	1	2
Gets in many fights	0	1	2
Gets teased a lot	0	1	2
Impulsive or acts without thinking	0	1	2
Hangs around with others who get in trouble	0	1	2
Hears sounds or voices that aren’t there	0	1	2
Would rather be alone than with others	0	1	2
Lying or cheating	0	1	2
Bites fingernails	0	1	2
Nervous, high-strung, or tense	0	1	2
Nervous movements or twitching	0	1	2
Overconforms to rules	0	1	2
Not liked by other pupils	0	1	2
Has difficulty learning	0	1	2
Too fearful or anxious	0	1	2
Feels dizzy	0	1	2
Feels too guilty	0	1	2
Talks out of turn	0	1	2
Overtired	0	1	2
Overweight	0	1	2
Physical problems without known medical cause:	0	1	2
Aches or pains (not stomach or headaches)	0	1	2
Headaches	0	1	2
Nausea, feel sick	0	1	2
Problems with eyes (not if corrected by glasses)	0	1	2
Rashes or other skin problems	0	1	2
Stomachaches or cramps	0	1	2
Vomiting, throwing up	0	1	2
Physically attacks people	0	1	2
Picks nose, skin, or other parts of body	0	1	2
Sleeps in class	0	1	2
Apathetic or unmotivated	0	1	2
Poor school work	0	1	2
Poorly coordinated or clumsy	0	1	2
Prefers being with older children or youths	0	1	2
Prefers being with younger children	0	1	2
Refuses to talk	0	1	2
Repeats certain acts over and over; compulsions	0	1	2
Disrupts class discipline	0	1	2
Screams a lot	0	1	2
Secretive, keeps things to self	0	1	2
Sees things that aren’t there	0	1	2
Self-conscious or easily embarrassed	0	1	2
Messy work	0	1	2
Behaves irresponsibly	0	1	2
Showing off or clowning	0	1	2
Shy or timid	0	1	2
Explosive and unpredictable behavior	0	1	2
Demands must be met immediately, easily frustrated	0	1	2
Inattentive, easily distracted	0	1	2
Speech problem	0	1	2
Stares blankly	0	1	2
Feels hurt when criticized	0	1	2
Steals	0	1	2
Stores up things he/she doesn’t need	0	1	2
Strange behavior	0	1	2
Strange ideas	0	1	2
Stubborn, sullen, or irritable	0	1	2
Sudden changes in mood or feelings	0	1	2
Sulks a lot	0	1	2
Suspicious	0	1	2
Swearing or obscene language	0	1	2
Talks about killing self	0	1	2
Underachieving, not working up to potential	0	1	2
Talks too much	0	1	2
Teases a lot	0	1	2
Temper tantrums or hot temper	0	1	2
Seems preoccupied with sex	0	1	2
Threatens people	0	1	2
Tardy to school or class	0	1	2
Too concerned with neatness or cleanliness	0	1	2
Fails to carry out assigned tasks	0	1	2
Truancy or unexplained absence	0	1	2
Underactive, slow moving, or lacks energy	0	1	2
Unhappy, sad, or depressed	0	1	2
Unusually loud	0	1	2
Uses alcohol or drugs for nonmedical purposes	0	1	2
Overly anxious to please	0	1	2
Dislikes school	0	1	2
Is afraid of making mistakes	0	1	2
Whining	0	1	2
Unclean personal appearance	0	1	2
Withdrawn, doesn’t get involved with others	0	1	2
Worries	0	1	2

8T.M. Achenbach

Reproduced by permission.

4. Grade Progression/Academic Performance

1. Has this student skipped any grades?

Yes 1  Which grades?_____________________________

No 2

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

Yes 1

No 2

Don=t know 99

3. Has this student repeated any grades?

Yes 1  Which grades? _____________________________

No 2  Skip to Question 5

Don=t know (not available) 99  Skip to Question 5

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

Yes 1

No 2

Don=t know 99

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)	1	2	3	4	5
Science (Biology, Chemistry, Physics, Environmental or Earth Science)	1	2	3	4	5
Social Studies (Civics, Economics, Geography, Government, History, Humanities, Sociology)	1	2	3	4	5
Mathematical skills (Counting, Basic Math, Pre‑Algebra, Algebra, Geometry, Trigonometry, Calculus)	1	2	3	4	5

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 1

No 2  Skip to Question 10

Don=t know 99  Skip to Question 10

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

Once 1

More than once 2

Don=t know 99

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

Yes 1  What was the reason for this
contact?

No 2

Don=t know 99

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

On grade 1

Below grade 2

Above grade 3

Don=t know 99

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 1

No 2

Don=t Know 99

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 1

No 2

Don=t Know 99

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 1

No 2  Go to THANK YOU on Page 18

Don=t Know 99

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 1

No 2

Don=t Know 99

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. 1

2. Deafness. 2

3. Emotional disturbance. 3

4. Hearing impaired. 4

5. Mental retardation. 5

6. `Multiply disabled. 6

7. Orthopedic impairment. 7

8. Specific learning disability. 8

9. Speech or language impairment 9

10. Traumatic brain injury 10

11. Visual impairment including blindness 11

12. ADHD (Attention deficient hyperactive disorder). 12

13. Developmental disability 13

14. Other health impairment. 14

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

1. Autism. 1

2. Deafness. 2

3. Emotional disturbance. 3

4. Hearing impaired. 4

5. Mental retardation. 5

6. Multiply disabled. 6

7. Orthopedic impairment. 7

8. Specific learning disability. 8

9. Speech or language impairment 9

10. Traumatic brain injury 10

11. Visual impairment including blindness 11

12. ADHD (Attention deficient hyperactive disorder). 12

13. Developmental disability 13

14. Other health impairment. 14

7. Is this child being educated in a:

	Yes	No
		
a) Regular class (i.e., general education)?	1	2
b) Special school?	1	2
c) Special class in a regular school (i.e., self-contained)?	1	2
d) Resource room (i.e., special education/services are provided outside the regular classroom for 21-60% of the day)?	1	2

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

0% 1

25% 2

50% 3

75% 4

100% 5

Don=t know 99

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

1 year or less 1

2 - 4 years 2

5 years or more 3

Don=t know 99

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

Public school 1

Private school or program 2

Social Service (child or family welfare) agency 3

Mental health agency 4

Public health (including substance abuse) agency 5

Private community-based agency 6

Other agency 7

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? 1

2. Psychological services? 2

3. Physical and/or occupational therapy? 3

4. Recreation/therapeutic recreation services? 4

5. Social work services? 5

6. Counseling services, including rehabilitation services? 6

7. Orientation and mobility services 7

8. Medical services for diagnostic and evaluation purposes? 8

9. Special transportation services 9

10. Parenting classes? 10

11. Assistive technology services? 11

12. Assistive technology devices 12

13. Transition from preschool to elementary school services? 13

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

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

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) 1

Is actively and regularly involved with the school 2

Is actively and regularly involved with other agencies providing services to the child 3

Receives assistance or services from a training center for parents of children with disabilities 4

Not involved at all 5

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

Yes, definitely 1

This child is receiving some education and services, but they could be improved 2

No, this child is not receiving the education and services he/she needs 3

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

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

4