Sutton Elementary



Sutton Elementary

IAT

REFERRAL FORM

|Student: D.O.B. Student I.D.# |

|Referred By/Position: Grade: Date |

|Reason for Referral: (Primary Concern): _______Academic ________Behavioral _______Speech |

Is this student receiving any special programs or services? Check all that apply.

□ Section 504 □ Speech □ Resource □ ESL □ Bilingual □ Other

Has this student been retained? ______Yes _______ No What Grade(s)__________

|Current |Grades | |

|Subject Area |Grade |Failing? Y/N |

| Reading | | |

|Language Arts | | |

|Math | | |

|TAKS Rdg. | | |

|TAKS Math | | |

|Stanford/Aprenda | | |

|TPRI/Tejas Lee | | |

|Conduct | | |

| |Parental Contacts |

|Date |Purpose/Result |

| | |

| | |

| | |

| | |

| | |

1. What is the specific primary concern for IAT referral? Please describe in educational terms. _______________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

2. Academic Strengths: ______________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

3. Academic Weaknesses: ____________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Behavioral Strengths: _____________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

5. Behavioral Weaknesses____________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

6. Problems in ancillary classes (Art/Music/ P.E./Computer/Drama/Other?) _____________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

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To schedule an IAT conference, you may submit the referral folder and the following documents after at least 4 weeks of documented interventions:

1. At least 5 student work samples

2. Last report card and Progress reports

3. Test results: Common Assessments, TPRI/Tejas Lee, Benchmarks, etc

4. Proof of Teacher Interventions

IAT

Referral Information

Tier I Instructional Practices

Targeted Needs: □Phonics/Decoding □Reading Comprehension □ Fluency □Vocabulary

□Written Expression □Expressive Language (Oral Expression) □Receptive Language (Listening)

□ Computation/Calculation □Problem-Solving □Other (Explain) ______________________________

□ Behavior

| I. CLASSROOM STRATEGIES CHECKLIST |

|Adaptation of Materials |In Use |Will Use | Student’s Response |

|Peer to read materials to student | | | |

|Peer to take notes for student | | | |

|Use of highlighter for emphasis | | | |

|Altered format of materials | | | |

|Study aids/manipulatives | | | |

|Outlines/graphic organizers and study guides | | | |

|Assignment sheets/notebook | | | |

|Former Teacher/Grade Level Consultation | | | |

|Other: | | | |

|Instructional Accommodations |In Use |Will Use | Student’s Response |

|Tutorials | | | |

|Reduce task into sub tasks | | | |

|Visual aids | | | |

|Auditory aids | | | |

|Minimize auditory directions | | | |

|Assistance in class discussions | | | |

|Change seating | | | |

|Small group/one on one instruction | | | |

|Former Teacher/Grade Level Consultation | | | |

|Other: | | | |

|Modification of Assignments |In Use |Will Use | Student’s Response |

|Simplified/Reduced length of assignments | | | |

|Extra time for completing assignments | | | |

|Opportunity for oral responses | | | |

|Retest | | | |

|Assess/Test in different ways | | | |

|Former Teacher/Grade Level Consultation | | | |

|Other | | | |

|Motivational Strategies |In Use |Will Use | Student’s Response |

|Opportunity to help teachers | | | |

|Reward system/Positive reinforcement | | | |

|Co-operative Learning | | | |

|Emphasis on student’s strength | | | |

|Goal sheet | | | |

|Secret signal between teacher and student | | | |

|Former Teacher/Grade Level Consultation | | | |

|Other: | | | |

| OTHER ACTION TAKEN | RESULTS |

|Student Conference | |

|AP Intervention | |

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