ࡱ> %` \bjbjNN :,,6|||||||(((8($)#;*****+++B:D:D:D:D:D:D:$<he?h:u|,++,,h:||**:...,d|*|*B:.,B:..:3,||3**  (,d3 f4:0#;3.#@T-*#@33#@|4d+"+.+++++h:h:~.^+++#;,,,,$#((||||||  STUDENT INFORMATION FORM (Grades 7 through 12) Your student is being assessed for attention, academic and or behavioral problems. In order to gain an accurate picture of this student it is essential to know how s/he is functioning in school. The information you provide will be used in combination with home and medical information during this students evaluation. If multiple teachers are responsible for the education of this student, please gather information from these other teachers to ensure this form represents all academic content areas. A Consent to Share Information Form is included for your files. Students name: _________________________________________________ Date of Birth: ___________ Person completing this form: _____________________________________ Date: __________________ Telephone: ________________________________________ E-mail address: ______ Your Position: _____________________________________ Students Grade: ______________________ School / Program (include address): _________________________________________________________ Is there a designated contact person for this student, other than you? R' No R' Yes Name of contact: ________________________________________________________________________ How well do you know this student? R' Not Well R' Moderately Well R' Very well Please describe the classroom: _________________________________________________________ __________________________________________________________________________________ Has s/he ever repeated any grades? R' No R' Yes Grade(s) repeated ___________ In the past or present time has s/he received any support services such as: R' I don t know R' Educational support team, R' OT/PT/Speech-language services, R' 504 Plan, R' Special Education services, R' No support services Please specify: ______________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ What does this student enjoy? What are his/her special strengths and skills? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please provide the results of any testing or evaluations done with this student. Please enclose copies of assessments or list the tests and findings as well as the dates administered (attach additional pages, if necessary): DATE TEST/EVALUATION FINDINGS ____________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________ Please list any tests/evaluations planned for the future, if any. ______________________________________________________________________________________________________________________________________________________________________ Please give a general description of this students temperament in the school setting (i.e., hyperactive, placid, withdrawn, temper tantrums, happy, moody, etc.) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you consider this students behavior to be of concern in the classroom? R' No R' Yes If yes, please describe below. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please describe this students interactions with peers in the school setting (e.g. classroom, recess, lunch, specials, bus). _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What is your estimate of this students academic achievement in the following areas? above average average problematic N/A123451. Classroom Assignment Completion2. Homework Completion3. Getting Homework to and from School 4. Organizational Skills5. Reading (Basic)6. Reading Comprehension7. Written Expression8. Spelling9. Handwriting10. Mathematics Calculation11. Mathematics Reasoning 12. Listening Comprehension N/A1234513. Oral Expression14. Social Studies15. Science16. Art17. Foreign language18. Integrated skills (Health, Home Ec., Woodworking, Automotive)19. Other:( list)N/A means this does not apply at this time What are your primary concern(s) about this student, if any? a. ______________________________________________________________________________ b. ______________________________________________________________________________ 2s & ( 8 : < JLNdfhRTbdRTnprv  FHLpvF־֚֩֩֩֩֩֩֩֩֩֩֩֩hJ@CJPJaJhJ@CJaJheuheu@CJPJaJ(heuheu@CJOJPJQJ^JaJh.@CJaJheuheu>*@CJaJheuheu@CJaJh6"5@CJ\aJheuheu5@CJ\aJ423, - m n - . 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" " " " $*$Ifgdeul\ " "%kd $$Ifl֞)C] w"$.M t0644 la """""""" $*$Ifgdeul" "%kd` $$Ifl֞)C] w"$.M t0644 la "(")"*"+","-"." $*$Ifgdeul."/"%kd $$Ifl֞)C] w"$.M t0644 la/"D"E"F"G"H"I"J" $*$IfgdeulJ"K"%kd $$Ifl֞)C] w"$.M t0644 laK"""""""" $*$Ifgdeul\""%kd $$Ifl֞)C] w"$.M t0644 la"""""""" $*$Ifgdeul""%kd8$$Ifl֞)C] w"$.M t0644 la"""""""" $*$Ifgdeul""%kd$$Ifl֞)C] w"$.M t0644 la"""""""" $*$IfgdeulT""%kd$$Ifl֞)C] w"$.M t0644 la""""'#z##S1$gdeu & F1$gdeu h1$^hgdeu & F*$1$gdeu*$1$gdeu 0*$1$gdeu & F 0*$1$gdeu 00*$1$^`0gdeu   4<*$1$gdeu c. ______________________________________________________________________________ d. ______________________________________________________________________________ f. ______________________________________________________________________________ Please summarize what has been done, informally or formally about your concern(s) (e.g., teaching strategies, other referrals, accommodations, etc.): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please use this space to provide any additional comments you think will be helpful in assessment of this student. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ THANK YOU VERY MUCH FOR YOUR ASSISTANCE     PAGE 3 Physician Name and Address #$%'(*+-.01<=>YZ[\$a$gdeuh]hgdeu&` $1$a$gdeu1$gdeu<=>GPXYZ[\h.1hhkhN5\mH sH hN5\mH sH hNhN5\hN hrCrhN 8 00P:p!/ =!"8#$8% $$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a$$If!vh5(5S55555#v(#vS#v#v:Vl t65.5M55/ a@@@ NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No List**&oStyle1 FrC@r euBody Text Indent  00*$1$^`0@CJOJQJ^JaJF @F euFooter !1$@OJQJ^J.)@!. eu Page NumberF@2F euHeader !1$@OJQJ^Jv@Cv eu Table Grid<:V0a1$_HG 23,-mn-.FGW]:;F9 : ; =   D I J K 4 5 *CDJKOQSUWYZ~    +,-./012IJKLMNOP]^_`abcdtuvwxyz{    $%&'()*+789:;<=>FGHIJKLMbcdefghiE>|vw'()DEH000000000000000000000000 0 00 0 00000000 0000 0000000 000 00 000 0 00 0 000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000 0 0000000 0 00 0 00000ي00@0X00@0X00@0X00@0X00@0@0@0@0@0X00  558F!<\/LdJ- ; < f g !!1!2!E!F!\!]!!!!!!!!!!! " "" "."/"J"K"""""""""\ !"#$%&'()*+,-.0123456789:;<=>?@ABCDEFGK[ 8!8@0(  B S  ?=T#=a"HH8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsplace $&EH&EHW;8  K 5 *ID iF|w)2;CEHEHSc/Zx hhh^h`.h88^8`.hL^`L.h  ^ `.h  ^ `.hxLx^x`L.hHH^H`.h^`.hL^`L. hh^h`hH) ^`hH) 88^8`hH) ^`hH() ^`hH() pp^p`hH()   ^ `hH. @ @ ^@ `hH.   ^ `hH.ZxSc/         je.1&o)6"G{:XGjwSrQ]gm2n.!Nk7euJJKOQSUWYZ~    +,-./012IJKLMNOP]^_`abcdtuvwxyz{    $%&'()*+789:;<=>FGHIJKLMbcdefghiH@T pG@ (@<@ @UnknownGz Times New Roman5Symbol3& z Arial]  MS MinchoArial Unicode MSI& ??Arial Unicode MS71 CourierCFComic Sans MS"1hXFXFR- /- /!x4d2Q HX ?G{:2.STUDENT INFORMATION FORM (Grades 7 through 12)drjodybrakeleyJennifer James Oh+'0( @L l x  0STUDENT INFORMATION FORM (Grades 7 through 12)drjodybrakeley Normal.dotJennifer James2Microsoft Office Word@G@0w@8@8-՜.+,0 hp|  / ' /STUDENT INFORMATION FORM (Grades 7 through 12) Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMOPQRSTUVXYZ[\]^_`abcdefghijklmnopqrstuvwyz{|}~Root Entry F Data NZ1TableW7@WordDocument:SummaryInformation(xDocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q