A single-page form for the informal assessment of the affective behavior of bilingual learning impaired students is presented. Space is provided for: (1) description of the behavior in relation to native country standards; (2) description of the behavior in relation to United States standards; (3) remediation strategies (behavioral objectives) from the bilingual staff; (4) strategies (goals and objectives) from the special education staff; and (5) recommendations and test scores obtained from the multi-evaluation team consisting of a psychologist, a bilingual teacher, parents, a teacher consultant, and others. Space is also provided for recording English and native language proficiency test scores and for listing general advantages, disadvantages, and recommendations. (DC)