Form 1 - Data For Possible Initial Educational Evaluation Page 2
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21. What scientific research based interventions have been utilized to remedy this specific problem? Attach additional information.
a.
Intervention:______________________________________________________________________________________
Date:___________ Results: _____________________________________________________________________________
b.
Intervention:______________________________________________________________________________________
Date:___________ Results: _____________________________________________________________________________
2. Has student ever been retained? ___________________ What grades? _______________________
3. ++ Attach copy of Grades, ISTEP+ Reports, Group Test Results, Notes from Intervention Team Meetings++
COMPLETE SECTION 4 AND SECTION 5:
4. Please write the appropriate number for each skill below. Please attach any additional information:
Never-- 0
Rarely (25%)--1
Sometimes (50%)--2
Usually (75%)--3
Always (100%)--4
Individual Achievement:
_____ a. Reading--achieves on above grade level
_____ c. Complies with school/classroom rules
_____ b. Written Expression--achieves on/above grade level
_____ d. Shows activity level appropriate for age
_____ c. Math--achieves on or above grade level
Daily Classroom Performance:
_____ d. Spelling--achieves on or above grade level
_____ a. Completes assignments during class
Self-Help Skills:
_____ b. Follows directions on assignments
_____ a. Starts work without prompting
_____ c. Participates/asks questions
_____ b. Attends to personal appearance and grooming
_____ d. Completes and turns in homework
_____ c. Organized papers and materials effectively
Speech/Language:
_____ d. Seeks help when uncertain
_____ a. Articulates clearly when speaking
Motor Skills:
_____ b. Uses vocabulary appropriate for age
_____ a. Writes with legible handwriting
_____ c. Understands oral instructions
_____ b. Can cut and color (appropriate for age)
_____ d. Speaks in complete sentences
_____ c. Can copy (appropriate for age)
Socialization:
_____ d. Age appropriate gross-motor skills (running, jumping)
_____ a. Interacts well with peers
Attention / Behavior:
_____ b. Is accepted by peers
_____ a. Attends to instruction
_____ c. Interacts appropriately with adults
_____ b. Thinks carefully before acting
_____ d. Shows positive attitude toward school
5. DEVELOPMENTAL / FUNCTIONAL INFORMATION
Communication
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Self-help
____________________________________________________________________________________________
____________________________________________________________________________________________________
Motor Skills / Sensory
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Socialization
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Behavior/Attention
____________________________________________________________________________________________________
____________________________________________________________________________________________________
This form was completed by:
__________________________________________________
__________________________________
GENERAL EDUCATION TEACHER SIGNATURE
DATE
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