Henry Timrod Elementary School
Student Self-Assessment Form 2-3
Name ____________________________________
Date_______________________
1. Which school rule did you break? (circle the rule or rules)
Responsible
Obedient
Achieve
Respect
2. Why did you break the rule? (Circle one reason)
I didn’t want
to do my work.
Other Reason
________________
I wanted someone’s
attention.
3. How were you feeling? (circle one picture)
Angry
Happy
Sad
4. Tell what happened and what you did.
__________________________________________________________________________
__________________________________________________________________________
5. To make a better choice, I could _______________________________________
___________________________________________________________________________
Parent Signature_______________________________________
Date_____________________________________________________
Additional Information on the back of this form.
Revised 2/9/12
Confused
Time___________________
Completed by Teacher
Teacher Signature____________________________
Description of
Behavior_________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________________
Completed By PBIS Team Member
Date____________________________
PBIS Team Member Signature_____________________________________________
Parent Contact__________________________________________
Teacher Preventive Actions:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________
Revised 2/9/12
Revised 2/9/12