Observation Report Form

Student:______________________ Date:___/___/___ Grade:__________ Time of Day:______________

Teacher:______________________Observer:___________________ Length of Observation:__________

Physical Environment: lighting, sound, number of students, seating, room arrangement, etc.

Number of Students:__________ Seating Arrangement: Tables_____ Desk______

Position in classroom:_________________ Area organized?: Y N

Description of Learning Environment:

Activity/Subject Observed:_______________________ Type of Instruction: _______________________

Stimulus Materials: Teacher/Pupil: Mode of Instruction:

___textbook ___tutor ___directions
___worksheet ___auxiliary personnel ___questions
___pictures ___one to one ___cuing
___chalkboard/Smartboard ___group ___prompting
___graphs ___small group ___modeling
___films ___lecture
___flashcards Mode of Input:
___manipulation ___visual Rate of Instruction:
___games ___auditory ___fast
___tape/headphones ___tactile (touch) ___moderate
___computer ___kinesthetic ___slow

Did the Teacher Provide: Interaction with peers: Fidgetiness:

___verbalization ___much ___extremely
___physical development ___some ___markedly
___token reward ___few ___normal
___activities & privileges ___none ___underactive
___awards
___individual explanation Motivation: Interest:
___answer questions ___high ___high
___other: ___average ___average
___low ___low

Assistance:
___needs continuous prompts
___needs occasional prompts
___needs minimal prompts
Distractibility:
___seeks distraction
___easily distracted
___occasionally distracted
___not distracted
Description of Student Behavior: Check all items that apply or mark frequently observed

___withdrawn ___attentive in class

___inattentive in class
___asks teacher to repeat
___constantly seeking others approval
___displays unusual behaviors
___unable to sit still
___taps fingers, ruler, pencil, etc.
___asks many questions
___short attention span
___irritable temperament
___seemingly unmotivated
___appears to be uncoordinated
___excessive physical contact
___handles a pen or pencil awkwardly
___work area is unusually messy
___does not follow directions adequately
___unkempt appearance
___reversals
___points rather than speaking
___stares off
___sits up on desk or legs
___disrupts classroom procedures
___follows directions
___seems to understand directions
___hyperactive
___looks at others papers
___stumbles on words
___cant stay in line
___distracted by noises
___confusion with directions
___sits and does nothing
___immature speech/language
___completes written assignments
___erases often
___seems to recall facts or simple ideas
___wears glasses
___seems shy
___inappropriate discussion responses
___excessive display of affection
___blurts out answers
___other:_______________________

Additional Information:

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In the judgment of the classroom teacher, was the students behavior during this observation typical
of his/her usual school performance _____yes, _____no