DATE DISTRIBUTED: DATE COMPLETED: DATE RETURNED: CLASS: How are you feeling about (eudents name) Please Rate . Goals Not Clear-—- Participation in class Behavior Unmanageable- 1 2 . Progress Unnoticeable-—— . Impact on classroom atmosphere Peer connections . Request for my time/ | Too Demanding-Reasonable Amount attention 1 2 3 4 Please list three positive comments and three concems that you may have Se ae iass) POSITIVES CONCERNS Please list any initial thoughts you may have i 5 that address your concerns Source: From “Measuring Perceptions About Inclusion," by M. Prom, 1999, Teaching Exceptional Children, 31, Pp. 38-42. Copyright 1999 by The Council for Exceptional Children. Reprinted with permission.