**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 onl y 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 i s 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 - 8 638) . 1. Yes - I consent to particip ate in the survey GO TO NAME 2. No - I choose not to participate in the survey GO TO END INTERVIEW New ScreenDROP

–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, rarel y, 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 Some times 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 New Screen

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New Screenc. 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, rarel y, 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 Some times 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, rarel y, 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 New Screen

New Screenchild.. 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? New Screen New ScreenPlease select only one response)

1. Excellent 2. Good 3. Fair 4. Poor 5. Very poor 9 . Not sure

A7 . During this school - year, h ave 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) New ScreenA8 . 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 [I

NSERT CHILD’s NAME] received targeted supports for behavior during this school - ye ar? 1. Yes (GO TO A9) 2. No (GO TO A10) 9 . Not Sure (GO TO A10) New Screen New ScreenA10 . What is the nature of this support?

( Please select all that apply) 1. Social skills club 2. Part of group of students that regularl y checks in with an adult to review behavior goals 3. Individualized behavior plan 4. Other: Please specify

in the box below

5. Not sure

A 11 . Has (INSERT CHILD’S NAME) received special educations services this school year? ( Please select only one response) 1. Yes 2. No 9 . Not Sure A 12 . Have you or anyone else referred (INSERT CHILD’S NAME) for testing for special education services this school ye ar? ( Please select only one response) 3. Yes 4. No 9 . Not Sure New Screen

New ScreenEND 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) New Screen