(Based on Heacox, 1991)
1. What is one area of your class performance that you really want to improve? (This is your long term goal. It may take you several weeks, months, or even a whole school year to improve this goal.)
This goal is important to me because
2. What is one thing that you can do NOW to help you reach your long-term goal? (This is your short-term goal. You should be able to accomplish this goal in 2-4 weeks.)
3. What steps do you need to reach your short-term goal?
4. What things or people might keep you from reaching your goal? These are your obstacles.
5. What can you do to get around your obstacles? These are your solutions.
6. What special materials or help do you need to reach your goal? These are your resources.
7. How will you reward yourself when you achieve your goal? These are your incentives.
8. How and when will you check on your progress toward your goal? Who will help you to check on your progress?
Checkpoint 1 Date: ______________________________________
Checkpoint 2 Date: ______________________________________
I am committed to working toward achieving my short term goal and my long-term goal.
Student’s signature: _____________________________________________
Today’s date: ___________________________________________________
Witness (Teacher’s) signature: ____________________________________