WESTMORELAND INTERMEDIATE UNIT

102 Equity Drive  Greensburg, PA 15601

NON-PUBLIC SCHOOL SERVICES – TEACHER INPUT FORM

Teacher Input Form 1

Student’s Name:______Teacher: ______

Grade: ______Subjects taught:______Date Completed:______

1)What is the specific reason(s) for this referral? Please give examples of student’s behavior or academic issues. How do you feel this affects the child’s performance in other areas?

______

2)Student Strengths and Weaknesses

Please indicate weaknesses with W, strengths with an S, and NA if not applicable.

___independent reading assignments___oral reading assignments

___following oral instructions___following written instructions

___grasping new skills___mastery of prerequisite skills

___completing homework assignments___test taking skills

___note taking skills___attendance

___behavior___organizational skills

___perception skills___transfer skills (copying from board, etc…)

___Other______Other______

Comments: ______

______

______

3)Student Performance (Please check appropriate level for each)

  • Student is performing______at his/her potential

______above

______below

  • Student is working______consistently in academic efforts

______inconsistently

  • Student’s motivation is______average

______high

______low

  • Student’s overall grade is______

4)What content area(s) are a particular problem for this student?

5)Homework by the student is completed:

_____almost always_____Sporadically_____Almost Never

6)What is the student’s learning style?

_____auditory_____visual_____Multisensory

7)Adaptations/Modifications that have been tried in the classroom(academic and/or behavioral):

Please add additional adaptations/modifications if necessary.

  • Adaptation/modification used:______

Frequency: ____daily____weekly____monthly____other

Effectiveness:____high____medium____low

  • Adaptation/modification used:______

Frequency: ____daily____weekly____monthly____other

Effectiveness:____high____medium____low

  • Adaptation/modification used:______

Frequency: ____daily____weekly____monthly____other

Effectiveness:____high____medium____low

Please list all current modifications/adaptations that are in use:______

______

______

8)Please list any strengths or weaknesses you have observed with the student in an academic setting.

Strengths (including academic, social, emotional, behavioral, etc…):

Weaknesses (including academic, social, emotional, behavioral, etc…):

9)Are there any special skills or interests that the child possesses? (Art, Music, Hobbies, Sports, etc…) Please list.

10)How is the child socially – does he/she interact appropriately with others? Does he/she have friends? How does he/she work within a group? How do they work independently? Does the child respect other people’s property? Do they respect their own property/belongings? (Please give examples)

______

______

11)Does the student voluntarily engage in classroom activities? If not, what do you perceive to be the problem? (Is he/she preoccupied? Daydreaming? Shy? Is the material too difficult?, etc…)

______

12) Behavioral Characteristics Noted:

The Student…. YES NO

Is overly active______

Displays general awkwardness______

Exhibits frequent reversals (reading or writing)______

Is underachieving in reading______

Is underachieving in mathematics______

Is underachieving in spelling______

Displays poor printing, writing, or drawing______

Shows confusion about instruction______

Demonstrates aggressive/explosive behavior______

Has difficulty initiating/sustaining relationships______

Displays short attention span______

Accepts adult authority______

Has poor school/parent relationship______

Exhibits withdrawn behavior______

Exhibits low self-esteem______

13)Is there any other information you would like to provide for this evaluation? Additional concerns?

______

Teacher Input Form 1