Student’s name: ____________________________ Age: ________
Grade: ________ School:__________________________
Form Completed by: ______________________________________
Position: ________________________ Date: _________________
Information gathered by (circle all that apply):
in person by telephone by email
Information gathered from (circle all that apply):
classroom teacher special education teacher paraprofessional learning specialist/gifted/talented teacher speech pathologist…..occupational therapist physical therapist allied health assistant school psychologist/social worker/counselor nurse/medical professional special Education coordinator principal parent/family member student
I. CONCERNS
Who raised the concerns? (please describe their role with student)
What are the concerns?
How long have people had these concerns?
Does the family share these concerns?
II. POTENTIAL IMPACT
How much are these issues currently getting in the way of a student’s educational performance on a day-to-day basis?
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Not at all |
Somewhat interfering |
Very interfering |
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Student’s learning |
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Learning of other students |
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Student’s ability to independently function within school setting |
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Student’s ability to handle frustration |
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Student’s ability to adapt to changing circumstances, make transitions |
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Student’s safety* |
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Safety of other students* |
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Student’s ability to work cooperatively with peers |
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Student’s ability to participate in different learning situations (e.g., small/large group, etc.) |
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Other: |
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*Please describe concerns about safety in more detail. If this is an urgent situation or concerns suggest the student or others may not be safe, then enact an emergency plan as appropriate.
SAFETY CONCERNS:
III. BACKGROUND
Does the student currently have a 504? _______ an IEP? _______
If so, what is his/her current eligibility determination?
Please describe the student’s current and past educational settings & experiences:
Does the student have a history of any significant medical conditions?
To your knowledge, have there been any significant changes in the student’s life – any major transitions, or traumatic events in the past few years?
Who are the family members that the school communicates with?
Is home-school collaboration fairly positive or are there issues to be aware of as we try to learn more about this student?
IV. FOLLOW-UP/COMMUNICATION
What’s been discussed about the educational identification process so far (with the family, within the school team)?
Has a parent/legal guardian given written permission to evaluate? (circle one)
YES NO DON’T KNOW
Is it okay if a member of the Educational Identification Team contacts parents to discuss initiating an evaluation? (circle one)
YES NO DON’T KNOW
CONTACT INFORMATION
What is the contact information for the family?
Who is an appropriate contact person at the school and what’s the best way to reach them?
Who is the Special Education Coordinator overseeing this student’s program?
Who else at the school is involved and should be included in correspondence on follow-up of this student?
