Teacher Feedback Form

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Student:________________________
Teacher: __________________ Class:____________________________
From:_____________________________ Date:
Please Return by: _____________________________
TUHSD TEACHER FEEDBACK
This student is being reviewed for possible intervention. Please respond to each item, indicating your observations of
this student and his/her school functioning. The information will be utilized in support planning for this student.
Your feedback may be shared directly with students and parents.
Classroom Behavior
Low
Avg
High
Academic Skills
Low
Avg
High
Follows directions
1
2
3
4
5
Reading: decoding & oral
1
2
3
4
5
Brings materials to class
1
2
3
4
5
Reading: comprehension
1
2
3
4
5
Behavior and comments
1
2
3
4
5
Reading: fluency & speed
1
2
3
4
5
Participates in class discussions
1
2
3
4
5
Writing: grammar & mechanics
1
2
3
4
5
Stays on task during class
1
2
3
4
5
Writing: content & quality
1
2
3
4
5
Peer/adult relationships
1
2
3
4
5
Math: operations & calculation
1
2
3
4
5
Overall effort and attitude
1
2
3
4
5
Math: reasoning & word problems
1
2
3
4
5
Cognitive/Processing/Memory Skills
Low
Avg
High
Classroom Performance/Student Skills
Low
Avg
High
Auditory processing/listening
1
2
3
4
5
Note-taking skills
1
2
3
4
5
Visual processing abilities
1
2
3
4
5
Completes tests in allotted time
1
2
3
4
5
Abstract thinking & reasoning
Test and Quiz grades
1
2
3
4
5
1
2
3
4
5
Memory
1
2
3
4
5
Long-term assignment completion
1
2
3
4
5
Attention & concentration
1
2
3
4
5
Overall quality of work
1
2
3
4
5
Speaking/expression of ideas
1
2
3
4
5
Homework completion
1
2
3
4
5
Have you observed this student to …?
(Please check those which seem significant)
have difficulty with relationships
be under the influence of drugs or alcohol
present as exhausted, fatigued, low energy
be sad, tearful, or have crying spells
seem easily angered or aggressive
have flat affect or fluctuating mood
be overly negative, pessimistic, or irritable
seem overly anxious, worried, or confused
engage in self-injurious behavior or scars
have many health or somatic complaints
make self-deprecating comments; self-esteem
make suicidal comments or writings
seem disheveled, unkempt, or poor hygiene
to have suffered weight loss or weight gain
Current Grade:
What do you think are his/her strengths?
What do you think are his/her challenges?
What interventions or strategies have you tried, for how long, and with what success?
Ideas/Suggestions as to what might help this student succeed:

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