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
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