Summer Explorers Intermediate Accountibility Form

Name_________________________________ Class ___________________

Date__________________________ Teacher_______________________
Today I chose not to be:
See

Feel/Do
Want

Result

Respectful

Responsible

Safe

Cooperative

Who was involved?___________________________________________________

__________________________________________________________________
What happened?_____________________________________________________
__________________________________________________________________
Where did it happen?__________________________________________________
Why did it happen?_____________________________________________________
How did it happen?_____________________________________________________
I felt_______________,so I___________________________________________
When you did that, what did you want?
__I wanted to be in charge of what was happening
__I wanted to avoid doing my work
__I wanted to be noticed by the other kids
__I wanted to be noticed by the teacher
__I wanted to get out of work I didnt think I could do correctly or understand
__I wanted to challenge the teachers authority
__I wanted to get even with someone
__ Other I wanted________________________________________________
__________________________________________________________________
Did I get what I wanted?
Yes, because_________________________________________________________
___________________________________________________________________
No, because__________________________________________________________
___________________________________________________________________

Choices

List other things you could have done.

1. ___________________________________________________________
2. ___________________________________________________________
3. ___________________________________________________________

Plan

What will you do next time?_____________________________________________

__________________________________________________________________

Student Signature____________________________________
Parent Signature_____________________________________ Date_________________
Please return this form to school