Focus Forward Reflection Worksheet
Self-Advocacy & Behavior Reflection
HALLWAY SAFETY REFLECTION
2-Week Period
Week: [ 1 ] [ 2 ]
Name:
Date:
1
Hallway Check-In: What was my speed & movement?
Check all statements that describe what happened today:
I used a steady walking pace
I ran / jogged / speed walked in the hallway
I bumped into someone or an object
I felt rushed to beat the bell
Crowded hall was hard to see through
I used the wall or landmark to guide me
2
Cause & Effect: How did running impact self and others?
Impact on ME
When I run instead of walk:
I can trip, fall, or get hurt
My eyes have less time to spot obstacles
I get stressed or get redirected by staff
Impact on OTHERS
When I run through the crowd:
I can startle or knock down another student
Staff have to stop to keep halls safe
Other students feel unsafe around me
3
My Safe Hallway Action Plan
Choose 1 or 2 strategies you will use during the next passing period:
Walk behind a peer to check my speed
Walk on the right side near the wall
Take 3 deep breaths before exiting class
Walk with a designated peer or staff
My written goal for my next walk:
Student Signature:
Provider / Staff Initials:
Self-Advocacy & Behavior Reflection
CLASSROOM & LEARNING HABITS
2-Week Period
Week: [ 1 ] [ 2 ]
Subject/Class:
Period / Time:
1
How Did I React When Work Got Hard / Frustrating / boring?
Check the behaviors that happened during class:
I put my head down and stopped working
I called out or shouted to get help
I avoided asking because I didn't want attention
I raised my hand
2
Vision Tools & Devices Check
Devices I had access to today:
Monocular / Distance tool
Speech to text
Screen Zoom / Digital CCTV
Large Print Paper / Enlarged Tech Materials
Did I actually use my tool?
YES
NO
If NO: Did I feel embarrassed, annoyed, or forget to take it out?
3
The Real Impact: Self vs. Others
Impact on ME:
- Eyes get strained and hurt
- I fall behind and get zero credit
- Frustration builds up inside me
Impact on OTHERS:
- Shouting interrupts peer focus
- Teacher cannot give proper support
- Classroom flow gets paused
4
My Self-Advocacy Power Move For Tomorrow
When I feel stuck, need help, or don't want to use my device, I will:
OPTION A Raise my hand to ask for help.
OPTION B Use my technology / tools I have available
OPTION C Ask a parapro for help / accept help when it is offered
One sentence commitment to myself:
Student Signature:
Goal 4/4 Check: [ ] Complete