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


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?



How much are these issues currently getting in the way of a student’s educational performance on a day-to-day basis?


Not at all

Somewhat interfering

Very interfering

Student’s learning




Learning of other students




Student’s ability to independently function within school setting




Student’s ability to handle frustration




Student’s ability to adapt to changing circumstances, make transitions




Student’s safety*




Safety of other students*




Student’s ability to work cooperatively with peers




Student’s ability to participate in different learning situations (e.g., small/large group, etc.)








*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. 




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?



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



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?







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