TEACHER’S REFERRAL QUESTIONNAIRE

NAME OF THE CHILD
CLASS
TEACHER’S NAME

DATE

Please answer all questions. Mark beside each question indicating the degree of the problem.
Behavior observed
Not
Just
Pretty Very
At All A
Much Much
True
Little
1. Incomplete work/fails to finish work on time
2. Frequent absences
3. Noninvolvement in activities
4. Poor Hygiene/unclean/shabbily dressed
5. Problems with peers
6. Withdrawn
7. Attention span problem
8. Sudden outbursts
9. Acting smart (disrespectful, rude, ill- mannered,
denying, arguing)
10. Verbal abuse/obscene gestures
11. Follows instructions
12. Fidgets/squirms/ restless/unstill
13. Disturbs other children /quarrelsome/ uncooperative
with classmates /bullies other children
14. Sulks (feels sorry for oneself)/sad
15. Difficulty in learning
16. Impulsive
Teacher’s comments :
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