Observation Report Form Template

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Observation Report Form
Student:______________________ Date:___/___/___ Grade:__________ Time of Day:______________
Teacher:______________________Observer:___________________ Length of Observation:__________
Physical Environment: lighting, sound, number of students, seating, room arrangement, etc.
Number of Students:__________ Seating Arrangement: Tables_____ Desk______
Position in classroom:_________________ Area organized?:
Y
N
Description of Learning Environment:
Activity/Subject Observed:_______________________ Type of Instruction: _______________________
Stimulus Materials:
Teacher/Pupil:
Mode of Instruction:
___textbook
___tutor
___directions
___worksheet
___auxiliary personnel
___questions
___pictures
___one to one
___cuing
___chalkboard/Smartboard
___group
___prompting
___graphs
___small group
___modeling
___films
___lecture
___flashcards
Mode of Input:
___manipulation
___visual
Rate of Instruction:
___games
___auditory
___fast
___tape/headphones
___tactile (touch)
___moderate
___computer
___kinesthetic
___slow
Did the Teacher Provide:
Interaction with peers:
Fidgetiness:
___verbalization
___much
___extremely
___physical development
___some
___markedly
___token reward
___few
___normal
___activities & privileges
___none
___underactive
___awards
___individual explanation
Motivation:
Interest:
___answer questions
___high
___high
___other:
___average
___average
___low
___low
Assistance:
Distractibility:
___needs continuous prompts
___seeks distraction
___needs occasional prompts
___easily distracted
___needs minimal prompts
___occasionally distracted
___not distracted

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