NOTRE DAME OF TALISAY CIT
Carmela Valley Homes, Talisay City, Negros Occidental
BEHAVIORAL REFERRAL FORM
Name: _____________________________ Date: _______
Quarter: ___________________ Gr./Yr. & Section: ______
Number of referrals made of students: [ 1 , 2 , 3 , 4 , 5 , 6 ]
A. Tends to lack value for time
_____ 1. Frequently comes to class late
_____ 2. Comes in late during exchange of periods
B. Appears to lack interest in school
_____ 1. Reads comics, magazines or paly cards during class hours.
_____ 2. Always absent from class
_____ 3. Engage in idle talk.
C. Tends to lack preparation for school
_____ 1. Always asks for pieces of papers.
_____ 2. Always borrows things from classmates.
D. Easily gets emotional
_____ 1. Seems to show rebellious attitude.
_____ 2. Tends to engage in quarrels with others.
_____ 3. Speaks indecent or vulgar words.
E. Tends to lack respect for property of other
_____ 1. Forgery
_____ 2. Vandalism
_____ 3. Theft
_____ 4. Keeps / hides classmates’ things.
F. Appears to display unacceptable behavior
_____ 1. Flies paper airplanes.
_____ 2. Folds paper always.
_____ 3. Always eats inside the classroom
_____ 4. Continuous to talk in spite of warning
G. Others _____________________________________________________________
Name of Teacher: _______________________________________
Subject : _______________________________________
Date : _______________________________________
NOTRE DAME OF TALISAY CITY
Carmela Valley Homes, Talisay City, Negros Occidental
BEHAVIORAL REFERRAL FORM
Name: _____________________________ Date: _______
Quarter: ___________________ Gr./Yr. & Section: ______
Number of referrals made of students: [ 1 , 2 , 3 , 4 , 5 , 6 ]
A. Tends to lack value for time
_____ 1. Frequently comes to class late
_____ 2. Comes in late during exchange of periods
B. Appears to lack interest in school
_____ 1. Reads comics, magazines or paly cards during class hours.
_____ 2. Always absent from class
_____ 3. Engage in idle talk.
C. Tends to lack preparation for school
_____ 1. Always asks for pieces of papers.
_____ 2. Always borrows things from classmates.
D. Easily gets emotional
_____ 1. Seems to show rebellious attitude.
_____ 2. Tends to engage in quarrels with others.
_____ 3. Speaks indecent or vulgar words.
E. Tends to lack respect for property of other
_____ 1. Forgery
_____ 2. Vandalism
_____ 3. Theft
_____ 4. Keeps / hides classmates’ things.
F. Appears to display unacceptable behavior
_____ 1. Flies paper airplanes.
_____ 2. Folds paper always.
_____ 3. Always eats inside the classroom
_____ 4. Continuous to talk in spite of warning
G. Others _____________________________________________________________
Name of Teacher: _______________________________________
Subject : _______________________________________
Date : _______________________________________