Teacher 21st Century Survey 2016-17

Please complete the information for each student assigned to you for review. All of the students have participated extensively in the school's 21st Century CLC program this year. This survey is designed to collect information about changes in behaviors during the school year. Select only one response for each of the questions asked in the table below for each student. Survey response options are divided into two groups: (1) Did Not Need to Improve, which suggests that the student had already obtained an acceptable level of functioning and no improvement was needed during the school year; and (2) Acceptable Level of Functioning Not Demonstrated Early in School Year–Improvement Warranted, which suggests the student was not functioning at a desirable level on the behavior described. If the student needed to improve on a given behavior, please indicate the extent to which the student did or did not improve during the course of the school year by indicating: Significant Improvement, Moderate Improvement, or one of the other levels listed. If the behavior described in a given question is not applicable for the student (e.g., homework is not given in your classroom), please do not provide a response for that question.

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* 1. Name of Teacher (Last, First)

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* 3. First Student's Name (Last, First)

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* 5. To what extent has this First student changed their behavior in terms of:

  Did not Need to Improve Significant Improvement Moderate Improvement Slight Improvement No Change Slight Decline Moderate Decline Significant Decline
Turning in his/her homework on time.
Completing homework to your satisfaction.
Participating in class.
Volunteering (e.g., for extra credit or more responsibilities).
Attending class regularly.
Being attentive in class.
Behaving well in class.
Academic performance.
Coming to school motivated to learn.
Getting along well with other students.

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* 6. Second Student's Name (Last, First)

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* 8. To what extent has this Second student changed their behavior in terms of:

  Did not Need to Improve Significant Improvement Moderate Improvement Slight Improvement No Change Slight Decline Moderate Decline Significant Decline
Turning in his/her homework on time.
Completing homework to your satisfaction.
Participating in class.
Volunteering (e.g., for extra credit or more responsibilities).
Attending class regularly.
Being attentive in class.
Behaving well in class.
Academic performance.
Coming to school motivated to learn.
Getting along well with other students.

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* 9. Third Student's Name (Last, First)

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* 11. To what extent has this Third student changed their behavior in terms of:

  Did not Need to Improve Significant Improvement Moderate Improvement Slight Improvement No Change Slight Decline Moderate Decline Significant Decline
Turning in his/her homework on time.
Completing homework to your satisfaction.
Participating in class.
Volunteering (e.g., for extra credit or more responsibilities).
Attending class regularly.
Being attentive in class.
Behaving well in class.
Academic performance.
Coming to school motivated to learn.
Getting along well with other students.

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* 12. Fourth Student's Name (Last, First)

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* 14. To what extent has this Fourth student changed their behavior in terms of:

  Did not Need to Improve Significant Improvement Moderate Improvement Slight Improvement No Change Slight Decline Moderate Decline Significant Decline
Turning in his/her homework on time.
Completing homework to your satisfaction.
Participating in class.
Volunteering (e.g., for extra credit or more responsibilities).
Attending class regularly.
Being attentive in class.
Behaving well in class.
Academic performance.
Coming to school motivated to learn.
Getting along well with other students.

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* 15. Fifth Student's Name (Last, First)

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* 17. To what extent has this Fifth student changed their behavior in terms of:

  Did not Need to Improve Significant Improvement Moderate Improvement Slight Improvement No Change Slight Decline Moderate Decline Significant Decline
Turning in his/her homework on time.
Completing homework to your satisfaction.
Participating in class.
Volunteering (e.g., for extra credit or more responsibilities).
Attending class regularly.
Being attentive in class.
Behaving well in class.
Academic performance.
Coming to school motivated to learn.
Getting along well with other students.

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* 18. Sixth Student's Name (Last, First)

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* 20. To what extent has this Sixth student changed their behavior in terms of:

  Did not Need to Improve Significant Improvement Moderate Improvement Slight Improvement No Change Slight Decline Moderate Decline Significant Decline
Turning in his/her homework on time.
Completing homework to your satisfaction.
Participating in class.
Volunteering (e.g., for extra credit or more responsibilities).
Attending class regularly.
Being attentive in class.
Behaving well in class.
Academic performance.
Coming to school motivated to learn.
Getting along well with other students.

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* 21. Seventh Student's Name (Last, First)

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* 23. To what extent has this Seventh student changed their behavior in terms of:

  Did not Need to Improve Significant Improvement Moderate Improvement Slight Improvement No Change Slight Decline Moderate Decline Significant Decline
Turning in his/her homework on time.
Completing homework to your satisfaction.
Participating in class.
Volunteering (e.g., for extra credit or more responsibilities).
Attending class regularly.
Being attentive in class.
Behaving well in class.
Academic performance.
Coming to school motivated to learn.
Getting along well with other students.

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* 24. Eighth Student's Name (Last, First)

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* 26. To what extent has this Eighth student changed their behavior in terms of:

  Did not Need to Improve Significant Improvement Moderate Improvement Slight Improvement No Change Slight Decline Moderate Decline Significant Decline
Turning in his/her homework on time.
Completing homework to your satisfaction.
Participating in class.
Volunteering (e.g., for extra credit or more responsibilities).
Attending class regularly.
Being attentive in class.
Behaving well in class.
Academic performance.
Coming to school motivated to learn.
Getting along well with other students.

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* 27. Ninth Student's Name (Last, First)

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* 29. To what extent has this Ninth student changed their behavior in terms of:

  Did not Need to Improve Significant Improvement Moderate Improvement Slight Improvement No Change Slight Decline Moderate Decline Significant Decline
Turning in his/her homework on time.
Completing homework to your satisfaction.
Participating in class.
Volunteering (e.g., for extra credit or more responsibilities).
Attending class regularly.
Being attentive in class.
Behaving well in class.
Academic performance.
Coming to school motivated to learn.
Getting along well with other students.