ࡱ> }|%` bjbjNN :,,6\&\&\&8&$&D6((((((((6666666$8h$;96u(((((96((6m+m+m+(d((6m+(6m+m+:0,0(' P \&])dG0 0<606Q0.;)B;0;0X((m+(((((9696+j(((6((((D!\&\&  STUDENT INFORMATION FORM (Grades Kindergarten through 6) 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 student s 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? far below below at above a. Reading N/A grade grade grade grade Remembering sound-symbol associationsDecoding unfamiliar words orallyIdentifying main ideasUnderstanding what he/she readsVocabularyOral/Silent readingN/A means not applicable at this grade level far below below at above b. Spelling/written word N/A grade grade grade grade Letter formation- accurate/legibleCopying from board accuratelySpelling accurately in isolationCapitalization/punctuationN/A means not applicable at this grade level far below below at above c. Mathematics N/A grade grade grade grade Identifying numbersFactsComputationAcquiring basic conceptsProblem solvingN/A means not applicable at this grade level far below below at above d. Language skills N/A grade grade grade grade Understanding verbal directionsArticulation Relating personal experiencesElaborating on thoughts verballyN/A means not applicable at this grade level far below below at above e. Executive Functions N/A grade grade grade grade Planning Organizational skillsReasoningProblem solvingN/A means not applicable at this grade level What is/are your primary concern(s) about this student, if any? a. ______________________________________________________________________________ b. ______________________________________________________________________________ c. ______________________________________________________________________________ <8 Y | P ` (*,XZ\"*,f ָָָ֮֘֘p֘p֘p֘p֘papָphuhu@CJPJaJ(huhu@CJOJPJQJ^JaJ$huhu@CJOJQJ^JaJ+huhu@CJOJPJQJ^JaJo(hui@CJaJhuhu>*C0u6@CauuCuu5@Ca0ܳ5@Ca&<=5 6 v w 6 7 N P  1$gdu*$1$gdur(>BDZ & F 0*$1$gdu 0h*$1$^hgdu & F 0*$1$gd0 0*$1$gdu h*$1$^hgdu & F*$1$gdu "<>@vxz>D   "{|ϹϹϹϹϹϨϊϹϹϊρuhuhu5@\huhu@huhu>*@CJaJhuhu5@CJ\aJ!huhu5>*@CJ\aJ+huhu@CJOJPJQJ^JaJo(huhu@CJaJhuhu@CJPJaJ(huhu@CJOJPJQJ^JaJ+rt"$%z{t  B*$1$gdu   4<*$1$gdu *$1$gdu & F *$1$gdu 00*$1$^`0gdu 0h*$1$^hgdu & F 0*$1$gdu 0*$1$gdu !"#$%& 0$*$1$Ifgdu&'HIJ8((( 0$*$1$Ifgdukd$$IflֈP!%88888 t0$644 lazJKLMN(kd$$IflֈP!%88888 t0$644 laz 0$*$1$IfgduNefghij 0$*$1$Ifgdujk8((( 0$*$1$Ifgdukd$$IflֈP!%88888 t0$644 laz(kdO$$IflֈP!%88888 t0$644 laz 0$*$1$Ifgdu 0$*$1$Ifgdu8((( 0$*$1$Ifgdukd$$IflֈP!%88888 t0$644 laz(kd$$IflֈP!%88888 t0$644 laz 0$*$1$Ifgduu !!6!8!!%"("R"T""""W#Z##### $]$`$$$$%|=}7~зеЧ~jhu0JUhN`jhN`Uh.1huhu@OJQJ^Jhuhu>*@CJaJUhuhu@huhu5@CJ\aJhuhu@CJaJhuhu6@CJ]aJ$huhu56@CJ\]aJ/ u  0$*$1$Ifgdu  B*$1$gdu   4<*$1$gdu 0*$1$gdu 8((( 0$*$1$Ifgdukd$$IflֈP!%88888 t0$644 laz (kdc$$IflֈP!%88888 t0$644 laz 0$*$1$Ifgdu  0$*$1$Ifgdu !!!8((( 0$*$1$Ifgdukd($$IflֈP!%88888 t0$644 laz!!! ! !(kd$$IflֈP!%88888 t0$644 laz 0$*$1$Ifgdu !7!>!k!!!!!!!! 0$*$1$Ifgdu  B*$1$gdu   4<*$1$gdu 0*$1$gdu !!!!!8((( 0$*$1$Ifgdukd$$IflֈP!%88888 t0$644 laz!!!!!(kdw$$IflֈP!%88888 t0$644 laz 0$*$1$Ifgdu!!!!!!! 0$*$1$Ifgdu!! " " "8((( 0$*$1$Ifgdukd< $$IflֈP!%88888 t0$644 laz " " """(kd $$IflֈP!%88888 t0$644 laz 0$*$1$Ifgdu"" "!"""#"$" 0$*$1$Ifgdu$"%"R"S""8,,, 0*$1$gdukd $$IflֈP!%88888 t0$644 laz"""""""" 0$*$1$Ifgdu  Bl*$1$gdu""###8((( 0$*$1$Ifgdukd $$IflֈP!%88888 t0$644 laz# # # # #(kdP $$IflֈP!%88888 t0$644 laz 0$*$1$Ifgdu #*#+#,#-#.#/# 0$*$1$Ifgdu/#0#Q#R#S#8((( 0$*$1$Ifgdukd $$IflֈP!%88888 t0$644 lazS#T#U#V#W#(kd $$IflֈP!%88888 t0$644 laz 0$*$1$IfgduW#### $$$$$$$ 0$*$1$Ifgdu  Bl*$1$gdu  <*$1$gdu 0*$1$gdu $$1$2$3$8((( 0$*$1$Ifgdukd$$IflֈP!%88888 t0$644 laz3$4$5$6$7$(kdd$$IflֈP!%88888 t0$644 laz 0$*$1$Ifgdu7$A$B$C$D$E$F$ 0$*$1$IfgduF$G$W$X$Y$8((( 0$*$1$Ifgdukd)$$IflֈP!%88888 t0$644 lazY$Z$[$\$]$(kd$$IflֈP!%88888 t0$644 laz 0$*$1$Ifgdu]$$$$%q%%S|||=}7~8~ $1$a$gdu & F1$gdu1$gdu h1$^hgdu & F*$1$gdu*$1$gdu & F 0*$1$gdu 00*$1$^`0gdu 0*$1$gdu d. ______________________________________________________________________________ f. ______________________________________________________________________________ Please summarize what has been done, informally or formally about your concern(s) (e.g., teaching strategies, other referrals, accommodations, etc.): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please use this space to provide any additional comments you think will be helpful in assessment of this student. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ THANK YOU VERY MUCH FOR YOUR ASSISTANCE     PAGE 3 Physician Name and Address $a$gd0Zuh]h&`h.1hN`h0humH sH h0ZumH sH huh30JmHnHujhu0JU hu0J 8 00P:pu/ =!"8#$% $$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az$$Ifz!vh55858585858#v#v8:V l t0$6558/ az@@@ NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No List**&oStyle1 FrC@r uBody Text Indent  00*$1$^`0@CJOJQJ^JaJF @F uFooter !1$@OJQJ^J.)@!. u Page NumberF@2F uHeader !1$@OJQJ^J<=56vw67OP`abiZ  9:$%z{!"#$%&'HIJKLMNefghijku  7>k      !"#$%RS    *+,-./0QRSTUVW 1234567ABCDEFGWXYZ[\]qjkhij00000000000000000000000000 0 00 0 0000000 00 00000 000 00 000 0 0 0 0000 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 00000 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 00000 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 00000 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 00000 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 000000 0 00 0 000ي0@0X0@0X0@0X0@0X0@0@0@0@0@0X0  558 "B&JNj ! !!!!! ""$"""# #/#S#W#$3$7$F$Y$]$ !#$%&'()*+,-./0123456789:;<=A 8!8@0(  B S  ?i ? :*%ku %W ]knjSc/Zx hhh^h`.h88^8`.hL^`L.h  ^ `.h  ^ `.hxLx^x`L.hHH^H`.h^`.hL^`L. hh^h`hH) ^`hH) 88^8`hH) ^`hH() ^`hH() pp^p`hH()   ^ `hH. @ @ ^@ `hH.   ^ `hH.ZxSc/         3.1&oui0G{:M Xvhgm0Zu2nN`u'7p!"#$%&'HIJKLMNefghijku        !"#$%    *+,-./0QRSTUVW 1234567ABCDEFGWXYZ[\]@XW pp@p pppp(@pp8@p@UnknownGz Times New Roman5Symbol3& z ArialI& ??Arial Unicode MSK,Bookman Old Style71 CourierCFComic Sans MS"1hZFZFRCP3CP3!x4d2 HX ?G{:28STUDENT INFORMATION FORM (Grades Kindergarten through 6)drjodybrakeleyJennifer James Oh+'0 4 LX x   <STUDENT INFORMATION FORM (Grades Kindergarten through 6)drjodybrakeley Normal.dotJennifer James2Microsoft Office Word@@*w@Ĉ@ĈCP՜.+,0  hp|  3' 9STUDENT INFORMATION FORM (Grades Kindergarten through 6) Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCEFGHIJKLNOPQRSTUVWXYZ[\]^_`abcdefghijkmnopqrsuvwxyz{~Root Entry F@ Data D1TableM <WordDocument:SummaryInformation(lDocumentSummaryInformation8tCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q