TEACHER INPUT FORM - Carbon Lehigh Intermediate Unit
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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