Department of Education

CARAG Region

Name: _________________________ Grade & Section:

ANECDOTAL RECORD

Please check all that you have observed about the learner.
STRENGTHS AND RESILIENCY FACTORS ACADEMIC PERFORMANCE INFORMATION
⁄ able to work independently cheating
can accept re-direction/criticism daydreams
⁄ considerate of others decrease in participation
cooperative difficulty retaining new or recent information
demonstrates constructive use of time does not take advantage of extra assistance offered/available
demonstrates desire/commitment to learn easily frustrated
displays good logic/reasoning & decision making failure to complete homework (repeatedly)
⁄ displays positive values (responsibility, honesty, equality, failure to complete in class assignments
caring)
exhibits leadership skills performing at or above ability
⁄ good communication skills performing significantly below ability
helps others poor test scores
is connected to and likes school and staff reading below grade level
⁄ participates in extra-curricular activities short attention span (explain specific behavior)
possesses good interpersonal skills sleeping in class
recognizes and respects appropriate boundaries & unprepared for class discussion/recitation
expectations
⁄ strives to achieve his/her best verbalized disinterest in academic performance
⁄ works well in a group Others (Please specify)
PHYSICAL ATTRIBUTES ATYPICAL BEHAVIOR/ILLICIT ACTIVITIES
complaining of nausea /stomach ache carrying large amounts of money
disoriented criticize others/self
fatigue denying responsibility, blaming others
food issues (example: refusal to eat lunch, etc.) disturbing other students
frequent cold-like symptoms easily distracted
frequently expressing concern with personal health expresses anger toward parent or other authority figure
glassy/bloodshot eyes expresses hopelessness, worthlessness, helplessness
noticeable change in weight (please explain) fighting/ hitting, pushing others
poor hygiene inappropriate dress (specify)
poor motor skills involvement in theft (student reported)
self-injury/self-harm lies
skin problems obscene language and/or gestures
slurred speech threatens or harasses others
unexplained physical injuries withdrawn/loner
unsteady on feet vandalism (student reported)
Others (Please specify) Others (Please specify)

________________________________ _______________________________
Signature of Learner Signature of Parent
Adviser School Head