SST Teacher Input Request

Sacramento City Unified School District

School Name

SST Teacher Input Request

Dear Teacher,

We will be holding a Student Study Team (SST) meeting for

Student:

Date: / / Time: Room:

In the meantime, your input on this student is critical to his/her success and we would like you to complete and return this form by / / .

Name: Title:

Thank you!

Teacher Name: Subject Taught:

Date Completed: / / Student’s Current Grade:

Student’s Attendance: Tardies:_____ Excused Absences:_____ Truancies:____

I. Student Strengths (Please X all)

Always / Usually / Sometimes / Rarely / Unsure
1.  Makes an effort
2.  Works well with others
3.  Shows academic improvement
4.  Works independently
5.  Timely to class
6.  Turns in assignments
7.  Involved in class discussions
8.  Respects class rules
9.  Displays respect toward teacher
10.  Needs teacher interventions
11.  Willing to help others
12.  Avoids talking excessively or out of turn
13.  Positive Peer Relationships
14.  Other______

II. Academic Data

List most recent scores (where applicable):

BMK / Classroom Assessments
SBAC: ELA / SBAC: Math / CELDT / Other / Math / Reading / Writing

III. Behavior Regularly displayed

o Aggression / o Crying / o Fearfulness / o Indifference / o Showing Off
o Anxiety / o Defiance / o Foul Language / o Insecurity / o Stealing
o Apathy / o Dependability / o Frustration / o Lying / o Tries Hard
o Cheerfulness / o Explosiveness / o Grandiosity / o Moodiness / o Withdrawal
o Cooperation / o Facial Tics / o Hyperactivity / o Nail Biting / o Other:

IV. Current/Past Interventions

Please check all current and/or past interventions attempted with student, and list result:

Environment / Teaching Techniques
Intervention / Outcome / Intervention / Outcome
o Clarify rules
o Change seating
o Reduce distractions
o Change class activities
o Change groups
o Increased physical space
o Special quiet/time-out area
o Modify schedule
o Add structure / o Vary voice volume
o Use hand on shoulder contact
o Reduce stimulation
o Teacher circulates around room
o Repeat instruction same way
o Designate activities
o Use behavior modification
o Use visual aids
Activities / Miscellaneous
Intervention / Outcome / Intervention / Outcome
o Simplify
o Shorten
o Individual contracts
o Buddy system
o Notebooks for assignments
o Alt assignment structure
o Use of tape recorder
o Review cum folder / o Keep work samples
o Assessment results
o Parent contact
o Refer to school social worker/
counselor
o Referral to Student Support Ctr
o Referral to office
o Referral to (specify):
Instruction Program / Materials
Intervention / Outcome / Intervention / Outcome
o Cooperative learning
o Individualized instruction
o Health awareness
o Guidance lesson
o Small group
o Other (specify): / o Use varied materials
o Tapes
o Soft music
o Play activities
o Computer
o Books/stories

Additional comments to help create a success plan (suggested accommodation, interventions, connections with home, etc):

SCUSD SST Form 3: Teacher Input Request Page 2 of 2