TEACHER INPUT FORM



TEACHER INPUT FORM

STUDENT REEVALUATION – MDS/BEHAVIORAL CURRICULUM

|STUDENT: | |TEACHER: | |

|EXCEPTIONALITY: | |PROGRAM/GRADE: | |

|BIRTHDATE: | |AGE: | |BUILDING: | |

|DATE: | |HOME DISTRICT: | |

PLANNED COURSE AREA

Communication Skills (Make sure to include information from ABLLS Sections C-J)

IEP Goals: (if there are specific goals)

Materials Used

Present Skill Levels – description of skills in classroom/community, grade levels

Recommendations for IEP

Social/Behavior Skills (Make sure to include information from ABLLS Sections L-N)

IEP Goals: (if there are specific goals)

Materials Used

Present Skill Levels – description of skills in classroom/community, grade levels

Recommendations for IEP

Motor Skills (Make sure to include information from ABLLS Sections Y, Z)

IEP Goals: (if there are specific goals)

Materials Used

Present Skill Levels – description of skills in classroom/community, grade levels

Recommendations for IEP

Self Help/Daily Living (Make sure to include information from ABLLS Sections U, V, W, X/LCCE Domains I and II)

IEP Goals: (if there are specific goals)

Materials Used

Present Skill Levels – description of skills in classroom/community, grade levels

Recommendations for IEP

Functional Academics

Reading/Language Arts (Make sure to include information from ABLLS Section Q)

IEP Goals: (if there are specific goals)

Materials Used

Present Skill Levels – description of skills in classroom/community, grade levels

Recommendations for IEP

Math (Make sure to include information from ABLLS Section R)

IEP Goals: (if there are specific goals)

Materials Used

Present Skill Levels – description of skills in classroom/community, grade levels

Recommendations for IEP

Written Language (Make sure to include information from ABLLS Sections S, T)

IEP Goals: (if there are specific goals)

Materials Used

Present Skill Levels – description of skills in classroom/community, grade levels

Recommendations for IEP

Community Skills

IEP Goals: (if there are specific goals)

Materials Used

Present Skill Levels – description of skills in classroom/community, grade levels

Recommendations for IEP

Vocational/Work Skills (Make sure to include information from LCCE Domain III)

IEP Goals: (if there are specific goals)

Materials Used

Present Skill Levels – description of skills in classroom/community, grade levels

Recommendations for IEP

Leisure/Recreation (Make sure to include information from ABLLS Section K)

IEP Goals: (if there are specific goals)

Materials Used

Present Skill Levels – description of skills in classroom/community, grade levels

Recommendations for IEP

PARTICIPATION IN REGULAR EDUCATION

Subject/Activities

Comments

Recommendations for IEP

GENERAL OBSERVATIONS TO INCLUDE STRENGTHS AND NEEDS OF THE STUDENT:

SPECIALLY DESIGNED INSTRUCTION WHICH HAS BEEN SUCCESSFUL:

The following specially designed instruction has been successful:

Behavior Management Program Stimuli Reduction Modeling

Daily Schedule Errorless Learning Techniques Physical Prompts

Small Group Instruction Functional Curriculum Verbal Cues

Strategic Seating Alternative Skills Instruction Manipulatives

Staff Proximity Frequent Home/School Contact Partial Participation

Positive Reinforcement Peer Tutoring Repeated Practice

Adjusted Language Level Community Based Instruction Other _____________

Computer Assisted Instruction Multi-modal Techniques Other _____________

Assistive Technology Task Analysis Other _____________

One to one Instruction Least to Most Prompts

MEDICAL CONCERNS:

OTHER ISSUES:

GENERAL RECOMMENDATIONS:

Teacher Input Form – Student Reevaluation – MDS-Behavioral Curriculum.doc

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