Name: ______________________________________ Date: _________________

How are you feeling?

Scared Angry Sad Worried

Parent Signature Parent Signature

What Happened?
Not on task Not following directions
Pushing
Not or hitting
following directions
Not using kind words Being disrespectful
Not using kind words
Not on task
Pushing or hitting Not on_____________
Other: task

Not using kind words Not following directions

What will
Not on taskyou do differently next
Pushing or hittingtime?
Not using kind words
_________________________________________________
Not on task
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
______________________ _____________________ ______________________
Teacher Signature Student Signature Parent Signature
_________________________________________________
Parent Signature
_________________________________________________
 Name: ______________________________________ Date: _________________

How are you feeling?

Scared Angry Sad Worried

Parent Signature Parent Signature

What Happened?
Not on task Not following directions
Pushing
Not or hitting
following directions
Not using kind words Being disrespectful
Not using kind words
Not on task
Pushing or hitting Not on_____________
Other: task

Not using kind words Not following directions

What will
Not on taskyou do differently next
Pushing or hittingtime?
Not using kind words
_________________________________________________
Next time I feel mad, I will go to the quiet corner and sit until I am feeling better or
Not on task
_________________________________________________
talk to my teacher instead of hitting my friends.

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
______________________ _____________________ ______________________
Teacher Signature Student Signature Parent/Guardian Signature
_________________________________________________
Parent Signature
_________________________________________________
 The student will color in the face at the top as to how they are feeling. They will then put an X on the box that

indicates what their behavior was. The teacher will sit down with the student and make sure they marked the correct box

and help the student to form a plan of action to improve the behavior. The teacher will write the plan of action in the space

provided for the student. The document will then be signed by the teacher, the student, and their parent/legal guardian.