Form H.5.3 - Behavioral Checklist For Suspected Chemical Abuse

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BEHAVIORAL CHECKLIST FOR SUSPECTED CHEMICAL ABUSE
AUGUST 2001
H.5.3
"Insert name of school"
Office of the School Nurse
STUDENT:
DATE:
Teacher/Staff Member:
Check behaviors that you have witnessed and please document whenever possible. Use the back of this
form if you prefer a narrative style of reporting what you know, or if you have other information which you
feel may be important in our efforts to help this individual.
____ Tardy
#______excused
#______unexcused
____ Absent
#______excused
#______unexcused
Smells of:
_____Ether/acetone, other “chemical” odor
_____Cigarettes
_____Alcohol
_____Mouthwash
Frequent requests to leave classroom:
_____Lavatory _____Phone
_____Nurse
_____Counselor
_____Locker
_____Office
Behaviors displayed in the school setting:
_____Falling asleep
_____Frequent request for schedule change
_____Slurred speech
_____Dramatic attention-getting behaviors
_____Incoherent
_____Change of friends-Negative
_____Stumbles
_____Talks frequently of drub/alcohol use
_____Unsteady gait
_____”Reacts” when drugs are mentioned
_____Sunglasses
_____Name is often heard in connection with
drugs/alcohol use
_____Bad hygiene
_____Concern expressed by other students
_____Eyes red/glassy
_____Homework not completed/sporadic
_____Sweaty
_____Declining grades
_____Non-responsiveness
From:_____________
_____Lack of motivation
To: ______________
_____Negative change of dress
_____Carelessness about appearance
_____Defensiveness
_____Cheating
_____Withdrawn; Loner
_____Fighting
_____Erratic behavior from day to day
_____Sudden outbursts; verbal abuse
_____Students “recognize” this student
_____Poor work performances
when drugs are mentioned
_____Non-productive
or discussed
_____Obscene language or gestures
_____Unusual bruises, sores or indications
self-inflicted injury
_____Class interruptions for this student
OTHER BEHAVIORS OF CONCERN: ____________________________________________________
Teacher/Staff Member Signature

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