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Student Name: Date:
TEACHER COMMENTS:
PARENT SIGNATURE/ COMMENT:
0=did not meet goal 1=attempted to meet goal 2=achieved goal
1 2 3 4 Lunch
6 Art, Music,
Gym, Library
8
I will raise my hand and
wait to be called on to
speak.
I will use a calm voice
when interacting with my
peers
I will sit properly in my
chair & stay in my assigned
seat/area.
When I am upset, I will
use a break card or other
appropriate coping skill.
I will follow directions the
first time they are given.
Teacher Initials
Totals
*Needs 64/80 (80%) for a reward TOTAL POINTS
/80
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