Form Sts0129 Pset 1: Private/home School Initiation printable pdf download

St. Lucie Public Schools

PSET 1: Private/Home School Initiation

Student Name

Other ID

DOB

Grade

Ethnicity

Gender

School

Homeroom Teacher

Parent/Guardian Name:

Parent Phone:

Address (Street, City, Zip)

Please refer to the student’s cumulative record to obtain the following information.

Attendance Concerns

Total Days Absent this year: ______

Health concerns

 Check if student wears glasses

 Check if student wears hearing aids

 Check if student is on medications. List here _______________________________________________

Discipline History

Prior School Year

__________ Number of referrals ____

Current School Year __________ Number of referrals ____

Retention History

K 1 2 3 3 4 5 6 7 8 9 10 11 12

If yes, indicate grade level(s) retained

Language History

Is the student’s 1

language English?  Yes  No If no, please identify language _________________________

Language spoken at Home: _______________________________

Parent/Guardian Consultation:

Date of Parent Conference

Reason for Referral

Student’s Strengths: Check all that apply.

 Flexible ; Adapts easily to new situations

 Artistic / Musical

 Confident; Sets high standards for self

 Imaginative; Verbally expressive

 Athletic

 Creative in thoughts, new ideas, seeing associations, etc.

 Inquisitive; exhibits intellectual curiosity

 Independent; takes initiative

 Empathetic; Sensitive to the feelings of others

 Leader; Well-liked by classmates

 Positive Attitude

 Humorous; Highly developed sense of humor

 Motivated; Requires little direction

 Positive Role Model

 Persistent; Stays with a project until completed

 Responsible; Follows through with tasks

 Respectful

 Resourceful; Reasons things out in ingenious ways

 Venturesome; Willing to take risks

 Self-Starter; Engages in self-directed activities

Teacher Observations: Check all that apply.

 Appears inattentive, easily distracted

 Constantly seeks attention-especially from adults

 Withdrawn

 Misinterprets verbal questions & directions

 Reverses or confuses letters-numbers- words

 Low frustration tolerance

 Difficulty following direction in sequence

 Leads or joins others in inappropriate behavior

 Poor fine motor control

 Difficulty staying on the line when writing

 Use of poor judgment in social and interpersonal relationships

 Poor gross motor control

 Impulsive-talks out-difficulty waiting turn

 Makes inappropriate responses to conversation

 Difficulty expressing ideas

 Performs inconsistently from day to day

 Engages in destructive and/or aggressive behavior

 Difficulty completing assignments

 Frequently loses place when reading

 Slow to react to and follow directions

 Poor understanding of vocabulary

CURRENT LEVELS

Reading Curriculum used: ______________________________________ Student’s level ____________ Current grade A B C

D F

Math Curriculum used:_________________________________________ Student’s level ___________ Current grade A B C

D F

Writing Curriculum used: _______________________________________ Student’s level ____________ Current grade A B C

D F

Interventions Tried:

 Small group instruction focusing on _______________________________________________ Beginning on ___/___/___ to ___/___/___

Delivered by _______________________________________________

 In classroom

 Pull out

 Individual instruction focusing on _________________________________________________ Beginning on ___/___/___ to ___/___/___

Delivered by _______________________________________________

 In classroom

 Pull out

arrative Observation:

______________________________________________________________________________________________________________________

Completed by: ______________________________________________________________ Date: __________________

Revised: 7/17/13

STS0129

Form Sts0129 Pset 1: Private/home School Initiation

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