A: Baseline Questionnaire

Name:__________________________________________________________________

1. Do you like coming to school? YES NO

2. What kinds of things do you like to do in classroom?

_____________________________________________________________________

_____________________________________________________________________

3. Do you like writing? (If it is writing lesson) YES NO

4. What do you like to write about?

_____________________________________________________________________

_____________________________________________________________________

5. What are your favorite things to do in school?

_____________________________________________________________________

_____________________________________________________________________

6. What are your favorite things to do at home?

_____________________________________________________________________

_____________________________________________________________________

B: Initial Observation

Rating Scale for Disruptive Behavior

Student Name:

Rating Scale Point Values:

1. Zero or one occurrence of disruptive behavior that period.2. Two to four occurrences of disruptive behavior at that time.3. More than four occurrences of disruptive behavior at that time4. More than eight of occurrences disruptive behavior at that time.

Class Period Rating Obtained 5 minutes at the beginning -When they’re doing their assignments -5 minutes before the class end -

C: Daily Questionnaire

Name:__________________________________________________________________

1. How are you feeling today?

(TN): teacher may ask questions about why he (the student) have this feeling

2. What did you eat today

_____________________________________________________________________

_____________________________________________________________________

(TN): teacher may ask about student’s home condition

3. What have happened today that help you in the lesson, why is it helpful? Why/ why

not

_____________________________________________________________________

_____________________________________________________________________

(TN): teacher may ask about today’s problem.

4. What do you wish you could do today? Why/why not

_____________________________________________________________________

_____________________________________________________________________

(TN): teacher may ask what are you going today at the school, after school end, and at

home

D: Work Sample Interview

1. Did you try your best?

2. Why did you try your best (or not try your best, depending on the student’s answer)?

3. Do you show your family your schoolwork? If so, what do they say?

4. Do you practice/get help at home?

5. Did you like doing this assignment? Why or why not?