Beruflich Dokumente
Kultur Dokumente
Health Information
VISION
Date of most recent screening:
Type of screening:
D Yes D No
es
As a result of the screening, is there any indication of a need for further assessment or
adjustment? If Yes, explain:
HEARING
Date of most recent screening:
Type of screening:
Yes
HEALTH
Yes No Does Student exhibit any signs of health or medical problems? If Yes, cite observations:
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1999-2016 esped.com
Date:
ID#
Grade
MEDICAID#
CA PUS
Health Information
D Yes D No Is there a need for further assessment or referral of a me ical problem? If Yes, explain:
Yes D No Does this student require adaptive quipment or facility adaptation? If Yes, specify:
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1999-2016 esped.conrt
DATE
Date of Initiated:
CAMPUS
Position: _
No
CD Yes
No
Has this student been referred for special education services before?
If YES. dive previous referral date:
ED Yes
No
No
Has this student been suspended for disciplinary reasons during the current school year? If
YES, explain:
CD Yes
Results:
Informant:
For a student identified as limited English proficient, briefly describe the Language Proficiency Assessment Committee's
recommendations: A COPY MUST BE ATTACHED.
ATTENDANCE
This student has been absent, days out of. school days this year to date.
Reasons:
Compared to last year, this year this student has been absent: . [ MORE C LESS E ABOUT THE SAME
List all schools previously attended:
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Date of Initiated:
CAMPUS
E Yes
No
Date:
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Date:
OBSERVATION DATA
The observation should be completed, in an academic area, by someone other than the student's regular teacher.
Observer:
Teacher:
D English / LA
Science
n Reading D Other:
History / Social Studies D Other:
Math
Other:
Classroom Arrangement:
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Yes
No
Not Observed
Date:
OBSERVATION DATA
Attach samples of student's work
What instructional concerns do you have about this student?
n Poor progress acquiring basic reading skills E Difficulty producing written work
Poor progress acquiring basic math skills
D Difficulty in spelling E
Other: _
D None
1 2 3 4 5 N
1 2 3 4 5 N
2.
1 2 3 4 5 N
1 2 3 4 5 N
3.
1 2 3 4 5 N
1 2 3 4 5 N
4.
1 2 3 4 5 N
1 2 3 4 5 N
1 2 3 4 5 N
1 2 3 4 5 N
2.
1 2 3 4 5 N
1 2 3 4 5 N
3.
1 2 3 4 5 N
1 2 3 4 5 N
4.
1 2 3 4 5 N
1 2 3 4 5
5.
1 2 3 4 5 N
1 2 3 4 5 N
C. Emotional/Behavioral/Social
1.
1 2 3 4 5 N
2.
1 2 3 4 5 N
3.
1 2 3 4 5 N
4.
1 2 3 4 5 N
5.
1 2 3 4 5 N
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Date:
Grade MEDICAID#
CAMPUS
OBSERVATION DATA
6.
1 2 3 4 5 N
7.
1 2 3 4 5 N
8.
1 2 3 4 5 N
9.
1 2 3 4 5 N
1 2 3 4 5 N
setbacks
D. Motor Coordination
. 1. Exhibits adequate gross motor coordination (walking,
1 2 3 4 5
running, etc.)
GRADE LEVEL.
1. Reads material aloud (estimated grade level: )
1 2 3 4 5 N
1 2 3 4 5 N
1 2 3 4 5 N
4.
1 2 3 4 5 N
5.
1 2 3 4 5 N
6.
1 2 3 4 5 N
7.
1 2 3 4 5 N
8.
1 2 3 4 5 N
Circle one: 1=POOR 2=BELOW AVERAGE 3=AVERAGE 4=ABOVE AVERAGE 5 SUPERIOR N-MOT OBSERVED
For Sections A, B, C, and D: Rate student's behavior in relation to other student's of the same AGE.
Counseling
Bilingual
program
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Date:
OBSERVATION DATA
Other:
Instructional accommodations attempted in response to student's problem(s) include:
Individual tutoring
Alternate materials
Ability grouping
Changed seat
Changed class
Behavior management
Grading on basis of individual growth
Oral tests
Peer tutoring
Shortened assignments
Extra time for completion of work
Taping written materials
Spell checkers
Calculators
Taped textbooks
Other:
English as a second language strategies
Hands on activities
Yes D No Does this student exhibit any behaviors in the classroom which might indicate vision or hearing
problems? If YES, cite specific observations:
Yes D No Does this student exhibit any signs of a health or medical problem in the classroom? If YES,
cite specific observations:
What type of assistance which cannot be provided in the general classroom do you feel this student needs?
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Date:
EDICAID#
CAMPUS
OBSERVATION DATA
SIGNATURE OF PERSO CO PLETING THIS SECTION DATE
Page 5 of 5
DATE
Date:
by:
Position:
Date:
GENERAL INFORMATION (If additional space is needed, please use the comment page.)
Parent / Guardlant OCCUPATION
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Date:
CAMPUS
your child:
HEALTH HISTORY
Yes n No Were there any problems
before, during, or immediately
after birth? If YES, please
explain:
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Date:
EDICAID#
CA PUS
n Yes
D Yes D No
D Yes
n Yes D No
No
No
D Yes D No
Would you like to talk to the D Yes D No Is your child receiving services
person coordinating your child s from another agency? If YES,
assessment before the please explain:
assessment begins? If YES,
phone number where you can
be reached:
D Yes
No
Comments:
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