Pre-Assessment

Please respond to the following statements as honestly as possible by circling the

number with which you most closely agree, with 1 = Strongly Disagree, 2 =
Disagree, 3 = Agree, 4 = Strongly Agree.
I have realistic academic goals I want to achieve.
1
2
3
4
I know when and how to achieve my academic goals.
1
2
3
4
My academic goals are beneficial and important to me.
1
2
3
4
I am aware of potential obstacles and solutions to help me
overcome these obstacles in reaching my academic goals.
1
2
3
4
I have someone I trust to hold me accountable for achieving my
academic goals.
1
2
3
4

Week 1 Check-In
Please respond to the following statements as honestly as possible by circling the
number with which you most closely agree, with 1 = Strongly Disagree, 2 =
Disagree, 3 = Agree, 4 = Strongly Agree.

Over the last week, I have been:

Paying attention to the speaker and not classmates side
conversations during Science class.
1
2
3
4
Reviewing my notes on Blue days for one hour on the evening
before each Science class.
1
2
3
4
Raising my hand to participate when I know the answer to the
Science teachers question.
1
2
3
4
Finding time before, during, or after class to ask my Science
teacher questions when I do not understand something.
1
2
3
4
Meeting with my counselor once/week to check-in with my
progress toward reaching my academics goals.
1
2
3
4

Week 2 Check-In
Please respond to the following statements as honestly as possible by circling the
number with which you most closely agree, with 1 = Strongly Disagree, 2 =
Disagree, 3 = Agree, 4 = Strongly Agree.
Over the last week, I have been:
Paying attention to the speaker and not classmates side
conversations during Science class.
1
2
3
4
Reviewing my notes on Blue days for one hour on the evening
before each Science class.
1
2
3
4
Raising my hand to participate when I know the answer to the
Science teachers question.
1
2
3
4
Finding time before, during, or after class to ask my Science
teacher questions when I do not understand something.
1
2
3
4
Meeting with my counselor once/week to check-in with my
progress toward reaching my academics goals.
1
2
3
4

Week 3 Check-In
Please respond to the following statements as honestly as possible by circling the
number with which you most closely agree, with 1 = Strongly Disagree, 2 =
Disagree, 3 = Agree, 4 = Strongly Agree.
Over the last week, I have been:

Paying attention to the speaker and not classmates side

conversations during Science class.
1
2
3
4
Reviewing my notes on Blue days for one hour on the evening
before each Science class.
1
2
3
4
Raising my hand to participate when I know the answer to the
Science teachers question.
1
2
3
4
Finding time before, during, or after class to ask my Science
teacher questions when I do not understand something.
1
2
3
4
Meeting with my counselor once/week to check-in with my
progress toward reaching my academics goals.
1
2
3
4

Week 4 Check-In
Please respond to the following statements as honestly as possible by circling the
number with which you most closely agree, with 1 = Strongly Disagree, 2 =
Disagree, 3 = Agree, 4 = Strongly Agree.
Over the last week, I have been:
Paying attention to the speaker and not classmates side
conversations during Science class.
1
2
3
4
Reviewing my notes on Blue days for one hour on the evening
before each Science class.
1
2
3
4
Raising my hand to participate when I know the answer to the
Science teachers question.
1
2
3
4
Finding time before, during, or after class to ask my Science
teacher questions when I do not understand something.
1
2
3
4
Meeting with my counselor once/week to check-in with my
progress toward reaching my academics goals.
1
2
3
4

Overall Rating of Effort and Commitment Toward Reaching

Academic Goals
Please respond to the following statements as honestly as possible by circling the
number with which you most closely agree, with 1 = Strongly Disagree, 2 =
Disagree, 3 = Agree, 4 = Strongly Agree.
Over the last four weeks, I have been:
Paying attention to the speaker and not classmates side
conversations during Science class.
1
2
3
4x
Reviewing my notes on Blue days for one hour on the evening
before each Science class.
1
2
3x
4
Raising my hand to participate when I know the answer to the
Science teachers question.
1
2
3x
4
Finding time before, during, or after class to ask my Science
teacher questions when I do not understand something.
1
2
3x
4
Meeting with my counselor once/week to check-in with my
progress toward reaching my academics goals.
1
2
3
4x

Post-Assessment
Please respond to the following statements as honestly as possible by circling the
number with which you most closely agree, with 1 = Strongly Disagree, 2 =
Disagree, 3 = Agree, 4 = Strongly Agree.
I have realistic academic goals I want to achieve.
1
2
3
4x
I know when and how to achieve my academic goals.

1
2
3x
4
My academic goals are beneficial and important to me.
1
2
3
4x
I am aware of potential obstacles and potential solutions to help
me overcome these obstacles in reaching my academic goals.
1
2
3x
4
I have someone I trust to hold me accountable for achieving my
academic goals.
1
2
3
4x
One academic goal I have for the semester is:
_____________________________________________________________________________________

Also checked in with Science teacher each week regarding how

often AR asked the teacher questions, participated in class,
and demonstrated that AR was paying attention.