Curtis Classroom Self Check Behavior Form

Fill out the form below. Students in our class should remember to always Be Safe, Be Respectful, and Be Responsible!

Name: *

Your answer

Select the appropriate sentence(s) below. *

I am filling out this form because I was not BEING SAFE.

I am filling out this form because I was not BEING RESPECTFUL.

I am filling out this form because I was not BEING RESPONSIBLE.

Other:

Required

Using complete sentences please describe the problem that caused you to be sent to fill out the Self Check Behavior Form. *

Your answer

Using complete sentences describe what was the setting that caused the behavior problem. *

Your answer

Why were your actions a problem? Include reasons why your behavior may have hurt yourself or others. Use full sentences to answer the question. Include the question as part of your answer. *

Your answer

How you can prevent or change this problem from being a problem in the future? Use full sentences to answer the question. Include the question as part of your answer. *

Your answer

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