Form Sts0130 - Pset 2: Private/home School Educational Information printable pdf download

School Board of St. Lucie County

PSET 2: Private/Home School Educational Information

Student Name

Grade/School

DOB ____/____/____

SECTION ONE: OBSERVATIONS

Student’s Strengths: Check all that apply.

Artistic

 Positive Role Model

Motivated

Inner Direction

Perseverance

Friendly

Athletic

Positive Attitude

Confident

Independent

Trustworthy

Respectful

Flexible

Sense of Humor

Perceptive

Imaginative

Responsible

Dependable

Other:

Teacher Observations: Check all that apply.

Appears inattentive, easily distracted

 Poor fine motor control

 Poor understanding of vocabulary



 Use of poor judgment in social and interpersonal

 Poor gross motor control

 Difficulty following direction in sequence

relationships

 Withdrawn

 Slow to react to and follow directions

 Constantly seeks attention-especially from adults

 Low frustration tolerance

 Performs inconsistently from day to day

 Reverses or confuses letters-numbers-words

 Difficulty completing assignments  Leads or joins others in inappropriate

 Makes inappropriate responses to conversation

Difficulty expressing ideas

behavior



Frequently loses place when reading

Difficulty staying on the line

 Impulsive-talks out-difficulty waiting turn



 Engages in destructive and/or aggressive behavior

when writing

 Misinterprets verbal questions & directions

SECTION TWO: 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

SECTION THREE: REASON FOR REFERRAL

Date of Parent Conference ____/____/____

Reason for Referral:

Team Members Present:

Teacher ________ __________________________________________ Parent ____________________________________________________

Administrator ______ ________________________________________ Parent ____________________________________________________

Other _____________________________________________________ Other _____________________________________________________

SECTION FOUR: PERMISSION TO SCREEN

In order to obtain further information about your child’s abilities, we need your permission to conduct sensory, cognitive, and academic

screenings with your child.

By signing below, I give permission for the educational screening of my child.

Parent and/or Guardian Signature ______________________________________________________________________ Date ____/____/____

School Official’s Signature __________________________________________________________________ Date ____/____/____

Created 9/2009 PSET2

STS0130

Form Sts0130 - Pset 2: Private/home School Educational Information

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