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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* 2. Subject Taught

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

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* 4. First Student's Grade Band

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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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* 7. Second Student's Grade Band

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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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* 10. Third Student's Grade Band

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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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* 13. Fourth Student's Grade Band

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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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* 16. Fifth Student's Grade Band

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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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* 19. Sixth Student's Grade Band

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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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* 22. Seventh Student's Grade Band

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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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* 25. Eighth Student's Grade Band

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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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* 28. Ninth Student's Grade Band

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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.

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* 30. Tenth Student's Name (Last, First)

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* 31. Tenth Student's Grade Band

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* 32. To what extent has this Tenth 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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* 33. Eleventh Student's Name (Last, First)

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* 34. Eleventh Student's Grade Band

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* 35. To what extent has this Eleventh 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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* 36. Twelfth Student's Name (Last, First)

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* 37. Twelfth Student's Grade Band

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* 38. To what extent has this Twelfth 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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* 39. Thirteenth Student's Name (Last, First)

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* 40. Thirteenth Student's Grade Band

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* 41. To what extent has this Thirteenth 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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* 42. Fourteenth Student's Name (Last, First)

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* 43. Fourteenth Student's Grade Band

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* 44. To what extent has this Fourteenth 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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* 45. Fifteenth Student's Name (Last, First)

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* 46. Fifteenth Student's Grade Band

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* 47. To what extent has this Fifteenth 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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* 48. Sixteenth Student's Name (Last, First)

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* 49. Sixteenth Student's Grade Band

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* 50. To what extent has this Sixteenth 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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* 51. Seventeenth Student's Name (Last, First)

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* 52. Seventeenth Student's Grade Band

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* 53. To what extent has this Seventeenth 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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* 54. Eighteenth Student's Name (Last, First)

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* 55. Eighteenth Student's Grade Band

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* 56. To what extent has this Eighteenth 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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* 57. Nineteenth Student's Name (Last, First)

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* 58. Nineteenth Student's Grade Band

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* 59. To what extent has this Nineteenth 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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* 60. Twentieth Student's Name (Last, First)

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* 61. Twentieth Student's Grade Band

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* 62. To what extent has this Twentieth 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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* 63. Twenty-first Student's Name (Last, First)

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* 64. Twenty-first Student's Grade Band

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* 65. To what extent has this Twenty-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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* 66. Twenty-second Student's Name (Last, First)

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* 67. Twenty-second Student's Grade Band

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* 68. To what extent has this Twenty-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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* 69. Twenty-third Student's Name (Last, First)

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* 70. Twenty-third Student's Grade Band

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* 71. To what extent has this Twenty-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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* 72. Twenty-fourth Student's Name (Last, First)

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* 73. Twenty-fourth Student's Grade Band

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* 74. To what extent has this Twenty-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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* 75. Twenty-fifth Student's Name (Last, First)

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* 76. Twenty-fifth Student's Grade Band

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* 77. To what extent has this Twenty-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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* 78. Twenty-sixth Student's Name (Last, First)

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* 79. Twenty-sixth Student's Grade Band

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* 80. To what extent has this Twenty-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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* 81. Twenty-seventh Student's Name (Last, First)

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* 82. Twenty-seventh Student's Grade Band

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* 83. To what extent has this Twenty-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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* 84. Twenty-eighth Student's Name (Last, First)

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* 85. Twenty-eighth Student's Grade Band

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* 86. To what extent has this Twenty-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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* 87. Twenty-ninth Student's Name (Last, First)

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* 88. Twenty-ninth Student's Grade Band

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* 89. To what extent has this Twenty-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.

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* 90. Thirtieth Student's Name (Last, First)

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* 91. Thirtieth Student's Grade Band

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* 92. To what extent has this Thirtieth 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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