Sexual Harassment Complaint Form (Page 5 of 10) in pdf

File: IGB-E

STUDENT BEHAVIORAL INVENTORY

TO __________________________________

STUDENT ____________________________

DATE ____________________________

Please return this CONFIDENTIAL information to _________________ by _______________

Please check those behaviors you have observed. Please write additional information and comments at

the end or on the back of this inventory. Your assistance in this matter is vital in our effort to help this

student and is greatly appreciated.

ATTENDANCE

__1. Excessive absenteeism # ____

__26. Change of friends

__56. Denies behavior

__2. Excessive tardiness #____

__27. Older social group

__57. Cries frequently

__3. Cutting class

__28. Argumentative

__58. Irritable

__4. Frequent use of restroom #___

__29. Aggressive behavior

__59. Impulsive

__30. Fighting

__60. Mood swing

__31. Dramatic attention getting

__61. Appears delusional

HEALTH AND APPEARANCE

__5. Neglect of personal appearance

__32. Sudden popularity

__62. Appears to hallucinate

__6. Excessive weight loss or gain

__33. Sexual intimacy in public

__63. Acts disoriented

__7. Frequent health complaints

__64. Frequent use of restroom

__8. Frequent health room visits

__65. Wandering in halls

ADULT RELATIONS

__9. Nausea or vomiting

__34. Overly sensitive to criticism

__66. Secretive

__10. Glassy or bloodshot eyes

__35. Recent family loss

__67. Smells of alcohol

__11. Slurred speech

__36. Recent family turmoil

__68. Talks about alcohol use

__12. Coordination problems

__37. Defiance of rules

__69. Smells of marijuana

__13. Hyperactive

__38. Seeks advice without

__70. Talks about drug use

specific problem

__14. Lethargic

__39, Disrespectful

__71. Suspicious locker behavior

__40. Verbally abusive

__41. Argumentative

__72. Suspicious exchange of $$

ACADEMICS

__15. Noticeable drop in grades

__42. Passive-aggressive

__73. Carries a lot of money

__16. Decrease in class participation

__43. Withdrawn

__74. Talks about suicide/death

__17. Failure to complete assignments

__75. Talks about recent changes,

i.e., moving

__18. Short attention span

GENERAL BEHAVIORS

__19. Poor memory and recall

__44. Disruptive

COMMENTS AND

ADDITIONAL INFORMATION

__20. Lack of effort/motivation

__45. Excessive talking

____________________________

__21. Dissatisfaction with school

__46. Sudden outbursts

____________________________

__22. Handwriting problems

__47. Erratic behavior

____________________________

__23. Reading problems/reversals

__48. Irresponsible

____________________________

__49. Low self-esteem

____________________________

__50. Seems depressed

____________________________

PEER RELATIONS

__24. Loner

__51. Daydreams

____________________________

__25. Exclusion by peers

__52. Sleeps in class

____________________________

__53. Destroys properly

____________________________

__54. Uses obscene language

____________________________

__55. Overly defensive

McDonald Local School District, McDonald, Ohio

Sexual Harassment Complaint Form Page 5

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