SAMPLE Affective Response Form

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SAMPLE Affective Response Form - J.S.

This form will track Jimmy's IPP affective reports in the domain of Key Responsibility Statements (adapted from McNabb, J. Journal of Teacher Education, 1997. V.34, N. 4)

Name

Homeroom Teacher

Drama Teacher

Science Teacher

Jimmy

Date

May 1

May 2

May 3

May 4

May 5

Jimmy turns in assignments on time.

1 - Never; 2 - Rarely/Sometimes; 3 - Usually; 4 - Almost Always

Clear selection

Jimmy brings appropriate materials to class.

1 - Never; 2 - Rarely/Sometimes; 3 - Usually; 4 - Almost Always

Clear selection

Jimmy is in class on time.

1 - Never; 2 - Rarely/Sometimes; 3 - Usually; 4 - Almost Always

Clear selection

Jimmy accepts consequences of his behavior.

1 - Never; 2 - Rarely/Sometimes; 3 - Usually; 4 - Almost Always

Clear selection

In general, Jimmy had a _____ day today in class.

1 - Very Poor; 2 - Fair; 3 - Good; 4 - Excellent

Clear selection

Today's Anectodal Record:

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This form was created inside of Elk Island Public Schools.