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NEDA TOOLKIT for Educators Sample Student Assistance Program information form Please check the appropriate responses in each section and add comments when needed to clarify on the reverse side of this form. The more specific (including dates) the information, the more useful it is to the study. School Staff Note:  Only observable behaviors should be discussed. Please be aware that under the Federal Educational Rights and Privacy Act, parents have the right to review the SAP file as part of their child’s school record. List the types of interventions you have previously tried with this student on the reverse side of this form. Also please provide any other appropriate information concerning this student. Would you like to speak directly to a member of the SAP team?  Yes  No Date: Course: Student: Period/Time of Day: Teacher: A. Class Attendance # Days absent # Days tardy # Classes cut Repeated requests to visit restrooms; health office; and/or counselor B. Academic Performance Present grade Decrease in participation Failure to complete homework Cheating Drop in grades Failure to complete in-class assignments Difficulty retaining new or recent information Verbalized disinterest in academic performance Easily frustrated Verbalized anxiety/fears regarding academic achievement Perfectionism in completing assignments C. Disruptive Behavior Verbally abusive Fighting Sudden outburst of anger Obscene language, gestures Hits, pushes others Disturbs other students Does not take advantage of extra assistance offered/available Denies responsibility, blames others Unprepared for class Distractible Short attention span, explain specific behaviors Repeated violation of rules Constantly threatens or harasses Page  | 19