Teacher Ratings of Student Behavior 

Web-Based Survey

Thank you for your participation in the MTSS-B research study. We would like you to answer 

some questions about students in your classroom. This information is crucial in helping us 

understand the impacts of MTSS-B on students. As a token of our appreciation you will receive 

$5 for each student report that you complete.

When answering the questions, please keep in mind the following: 

o Participation is voluntary – You can choose not to answer any question. If you skip a 

question on the web-based survey a screen will appear asking if you intended to skip the 

question and giving you the option to select “Not Sure” or “Decline to Answer.”

o Participation is private - All your responses will be kept private and will be used only 

for this study and related research. Your name and the names of your students will never 

appear in any public document or revealed to people outside of the research team.

MDRC, a non-profit, non-partisan social policy research agency based in New York, is 

conducting this research. (Please see www.mdrc.org for more information.) The U.S. 

Department of Education is providing the funding for this study. 

o Participation is very easy – This survey should take approximately 10 minutes per 

student to complete. You can answer the questions all at once, or over several sittings. 

(Please select “Next” to continue.)

o If you have any questions or concerns about the MTSS-B research study, please contact 

MDRC (fred.doolittle@mdrc.org or 212-340-8638). 

1. Yes - I consent to participate in the survey GO TO NAME

2. No - I choose not to participate in the survey GO TO END INTERVIEW

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DROP –DOWN BOX CONTAINING TEACHER’S LIST OF STUDENT NAMES [in districts 

that require active parental consent for the students a teacher is rating, the list will only be 

populated with the names of consented students]

NAME 1

NAME 2

NAME 3

Please select the name of the student being evaluated.

_________________________

A1. Has this child been present in your classroom for a majority of the time (i.e. at least 8 days) 

during the last three weeks?

(Please select only one response)

1. Yes

2. No

9. Not Sure

A2. In the last three weeks, would you say the following statements were never, rarely, 

sometimes, often, very often, or almost always true of this child?

Please select only one response for each question.

In the last three weeks, the 

child.. Never Rarely Sometimes Often Very 

often

Almost 

always 

true

Not 

Sure

a. Concentrates 1 2 3 4 5 6 9

b. Is friendly 1 2 3 4 5 6 9

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c. Pays attention 1 2 3 4 5 6 9

d. Breaks rules 1 2 3 4 5 6 9

e. Is liked by classmates 1 2 3 4 5 6 9

f. Doesn’t get along well 

with others 1 2 3 4 5 6 9

g. Works hard 1 2 3 4 5 6 9

A3. In the last three weeks, would you say the following statements were never, rarely, 

sometimes, often, very often, or almost always true of this child?

Please select only one response for each question.

In the last three weeks, the 

child.. Never Rarely Sometimes Often Very 

often

Almost 

always 

true

Not 

Sure

a. Harms others 1 2 3 4 5 6 9

b. Shows empathy and 

compassion for others’ 

feelings

1 2 3 4 5 6 9

c. Gets angry when 

provoked by other 

children

1 2 3 4 5 6 9

d. Stays on task 1 2 3 4 5 6 9

e. Yells at others 1 2 3 4 5 6 9

f. Is easily distracted 1 2 3 4 5 6 9

g. Is rejected by 

classmates 1 2 3 4 5 6 9

h. Fights 1 2 3 4 5 6 9

i. Lies 1 2 3 4 5 6 9

A4. In the last three weeks, would you say the following statements were never, rarely, 

sometimes, often, very often, or almost always true of this child?

Please select only one response for each question.

In the last three weeks, the Never Rarely Some- Often Very Almost Not 

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child.. times often always 

true

Sure

a. Has many friends 1 2 3 4 5 6 9

b. Harms property 1 2 3 4 5 6 9

c. Completes assignments 1 2 3 4 5 6 9

d. Teases classmates 1 2 3 4 5 6 9

e. Learns up to ability 1 2 3 4 5 6 9

A5. Please assess this student’s academic or learning behaviors in your classroom. 

Never Seldom Often Very 

Often 

No 

opportunity 

to observer

a. Keeps belongings organized 1 2 3 4 5

b. Shows eagerness to learn 

new things. 1 2 3 4 5

c. Works independently. 1 2 3 4 5

d. Easily adapts to changes in 

routine. 1 2 3 4 5

e. Persists in completing tasks 1 2 3 4 5

f. Pays attention well 1 2 3 4 5

A6. What is your overall rating of (INSERT CHILD’S NAME) behavior in your classroom 

during the last three weeks?

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Please select only one response)

1. Excellent

2. Good

3. Fair

4. Poor

5. Very poor

9. Not sure

A7. During this school-year, have you consulted with anyone about (INSERT CHILD’S 

NAME)‘s behavior?

1. Yes (GO TO A7)

2. No (GO TO A8)

 9. Not Sure (GO TO A8)

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A8. Please indicate below with whom you have consulted?

Please select only one response for each question.

Yes No Not Sure

a. Academic coach 1 2 9

b. Consulting/Master Teachers 1 2 9

c. Principal 1 2 9

d. School social worker 1 2 9

e. School psychologist 1 2 9

f. School nurse 1 2 9

g. Assistant principal 1 2 9

h. Someone else (If yes: Specify) 1 2 9

A9. Has this [INSERT CHILD’s NAME] received targeted supports for behavior during this 

school-year?

1. Yes (GO TO A9)

2. No (GO TO A10)

 9. Not Sure (GO TO A10)

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A10. What is the nature of this support?

(Please select all that apply)

1. Social skills club

2. Part of group of students that regularly checks in with an adult to review behavior goals

3. Individualized behavior plan

4. Other: Please specify in the box below

5. Not sure

A11. Has (INSERT CHILD’S NAME) received special educations services this school year?

(Please select only one response)

1. Yes

2. No

 9. Not Sure

A12. Have you or anyone else referred (INSERT CHILD’S NAME) for testing for special 

education services this school year?

(Please select only one response)

3. Yes

4. No

 9. Not Sure

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END INTERVIEW 

Thank you for your participation in the MTSS-B research study. You should receive your incentive for 

participating approximately two weeks after completing all of the student reports. 

If you have any questions or concerns about the MTSS-B research study, please contact Fred 

Doolittle at MDRC (fred.doolittle @mdrc.org or 212-340-8638). 

(Please select “Next” to exit survey)

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