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* 1. Student's Name:

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* 2. Staff Member Name and Class Taught in program:

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* 3. Please answer in relation to student's LEARNING SKILLS:

Persists on task even when experiencing difficulty.

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* 4. Please answer the in relation to student's LEARNING SKILLS:

Seeks appropriate help from staff in order to understand task.

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* 5. Please answer in relation to student's LEARNING SKILLS:

Appears to work on tasks until they are completed

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* 6. Please answer in relation to the student's LEARNING SKILLS:

Is able to identify his/her own academic strengths and challenges.

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* 7. Please answer in relation to the student's LEARNING SKILLS:

Is able to understand academic concepts being covered.

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* 8. Please answer based on the student's INITIATIVE:

Sets goals for self

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* 9. Please answer based on student's INITIATIVE:

Takes initiative to get information and resources needed to accomplish tasks.

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* 10. Please answer based on student's INITIATIVE:

When encounters a problem, makes own effort to devise and try out possible solutions.

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* 11. Please answer based on student's INITIATIVE:

Demonstrates(verbally) or by actions) motivation to succeed.

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* 12. Please answer based on student's INITIATIVE:

Selects activities that will build his/her skills

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* 13. Please answer based on student's INITIATIVE:

Is able to get started on tasks or projects on his/her own (i.e, without needing prompting or encouragement from adults or peers)

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* 14. Please answer based on student's INITIATIVE:

Volunteers to take on tasks (e.g., to help staff, peers, or contribute to the program).

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* 15. Please answer based on student's ENGAGEMENT IN LEARNING:

Stays focused on task at hand.

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* 16. Please answer based on student's ENGAGEMENT IN LEARNING:

Is alert and focused during group discussions or activities.

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* 17. Please answer based on student's ENGAGEMENT IN LEARNING:

Is interested in participating in new experiences.

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* 18. Please answer based on student's ENGAGEMENT IN LEARNING:

Contributes constructively to group discussions.

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* 19. Please answer based on student's ENGAGEMENT IN LEARNING:

Actively participates in program offerings (i.e. without needing prompting from adults or peers).

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* 20. Please answer based on student's ENGAGEMENT IN LEARNING:

Appears cognitively engaged during activities (e.g. asks questions, shares opinions, offers ideas).

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* 21. Please answer based on student's PROBLEM SOLVING SKILLS:

When encounters difficulty, is able to identify and describe the problem.

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* 22. Please answer based on student's PROBLEM SOLVING SKILLS:

Is able to think up several possible solutions to a problem.

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* 23. Please answer based on student's PROBLEM SOLVING SKILLS:

Persists on task even when experiencing difficulty.

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* 24. Please answer based on student's PROBLEM SOLVING SKILLS:

Is able to stop and think through a potential solution to a problem--before taking action.

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* 25. Please answer based on student's RELATIONS WITH ADULTS:

Seeks recognition and/or approval from adults( Youth may be indirect, e.g., May ask adult his.her opinion on something the youth made or did)

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* 26. Please answer based on student's RELATIONS WITH ADULTS:

Discusses special interests or ideas with staff member.

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* 27. Please answer based on student's RELATIONS WITH ADULTS:

Initiates interactions with adults.

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* 28. Please answer based on student's RELATIONS WITH ADULTS:

Seeks appropriate assistance and support from staff in resolving problems (e.g., may ask an adult to help them think through a problem rather than expecting adults to provide solutions).

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* 29. Please answer based on student's RELATIONS WITH ADULTS:

Appears comfortable spending relaxed time 1:1 with an adult.

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* 30. Please answer based on student's RELATIONS WITH ADULTS:

Is able to disagree with or question adults in a respectful and friendly manner.

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