Risk Indicator Survey I

District / Parish : ______Compiled by:______

RISK INDICATOR SURVEY I

Note: Please check any appropriate box that applies to the FINS complaint being made.

Defiant  Suspected substance  Argues with authority abuse figures  Risky physical  Uses obscene behavior language or gestures  Stealing  Other:______ Other:______

Aggressive Developmental Issues  Bullies/threatens/inti  Sucks thumb midates others  Enuresis  Hits or bites peers or  Sleeps at teachers inappropriate times  Breaks or throws  Eating problems or object disorder  Other:______ Speech/language/heari ______ng problem(s)  Other:______Parental Attitudes ______ Minimizes child’s problems Comments:  Blames others for child’s behavior Hyperactivity  Unresponsive to  Can’t sit still attempts to contact  Short attention span  Other:______for age/grade ______ Other: ______Emotional Responses ______ Inappropriate response to correction Isolated  Lack of empathy  Ignored by peers  Flat affect—just stares  Rejected by peers  Does not express joy  Withdrawn  Other:______ Other:______

Risk Taking Behavior Attention Seeker  Harms self  Wants teacher’s intentionally undivided attention  Sexual acting out  Causes class disruptions District / Parish : ______Compiled by:______

 Talks at inappropriate times  Other: ______

Unmotivated  No desire to learn  Not prepared daily  Doesn’t do homework —frequently  Exhibits apathy or unconcern  Other:______

Unstable Home Life  Poor hygiene  Complains of hunger regularly  Inappropriate clothing for weather  Inappropriate medical care  Lack of school supplies  Suspected alcohol/substance abuse in home  Other:______