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Pupil: ……………………………….. Form: ……….

The above pupil’s behaviour has been identified as a cause for concern in

…………………………….. taught by …………………………….. on the …………………….

Behaviour that Behaviour that

supports disrupts
learning and teaching learning and teaching

Non Verbal Behaviour Non Verbal Behaviour


Attends all lessons 1 Traunts from lessons
Arrives ontime to lessons 2 Arrives late to lessons
Stays in the classroom 3 Leaves the classroom
Sits on a chair in classroom 4 Wanders about classroom
Remains in the same seat 5 Changes seat in the classroom
Focuses on lesson activity 6 Fidgets in seat
Empties mouth on entry to classroom 7 Chews in class
8 Engages in classroom horseplay
Waits quietly 9 Makes inappropriate noises
Completes all work set 10 Packs away early
Have your books/equipment ready 11 Fails to bring books/equipment
12 Inattentive to instructions
Wear school uniform 13 Leaves coat on
Acknowlegdes and follows instructions 14 Fails to obey school uniform rules
15 Refuses to follow instructions
Recognize your error 16 Fails to do punishment
Accept consequences 17 Fails to do detention
Respect teachers’ belongings 18 Damages/takes teachers’ property
Respect peers’ belongings 19 Damages/takes pupils’ property
Respect school resources 20 Damages/takes school property
Supports school anti-bullying policy 21 Physically threatens pupils
Supports school anti-bullying policy 22 Physically threatens teacher

Verbal Behaviour Verbal Behaviour


Cooperate with staff 1 Refuses to follow instructions
Listen quietly 2 Talks when teacher is talking
All pupils have the right to learn 3 Interferes with other pupils’ work
4 Comments inappropriately to teacher
Raise your hand for help 5 Requests help inappropriately
Wait to be asked 6 Shouts out
7 Mimics others
Speak to pupils respectfully 8 Verbally threatens others pupils
Speak to teachers respectfully 9 Verbally threatens teacher
Wait quietly 10 Makes inappropriate noises
Be respectful 11 Answers back cheekily
Be courteous 12 Uses rude/offensive language

FAO: Form Tutor Head of Year Parent/Guardian Senior Management

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