TEACHER INPUT FORM - BLaST Intermediate Unit 17
TEACHER INPUT FORM
(New Referrals)
Student’s Name: _________________________ Teacher’s Name: _____________________
Instructions: In your own words, please provide information regarding your observations of this student in the various areas specified below. Specific types of information are requested under each of the general headings provided.
Please indicate whether this student displays specific behaviors and whether the student is deficient in specific areas.
Please indicate any additional areas of strength or weakness which you feel are important in assessing this student’s needs.
Please be as comprehensive as possible so that the information can be effectively used in making decisions regarding this student.
1) Academic Behaviors:
(Attention to task; on task; follows directions; complies with teacher instructions;
organized; prepared for class; stays in seat; completes classroom assignments;
completes homework assignments; works independently, etc.)
Indicate your rating of student’s overall difficulties in this area:
Circle One: No problems Minor problems Moderate problems Severe problems
2) Classroom/School Behaviors:
(Participants in class; volunteers in class; initiates discussions; asks questions; seeks
teacher assistance; motivated; positive attitude toward school; polite; courteous;
respectful; complies with authority; aggressive; oppositional; defiant, etc.)
Indicate your rating of student’s overall difficulties in this area:
Circle One: No problems Minor problems Moderate problems Severe problems
3) Peer Interactions:
(Initiates interactions with other students; plays/works well with other students; makes
friends easily; has several/few friends in school; displays appropriate social skills, etc.)
Indicate your rating of student’s overall difficulties in this area:
Circle One: No problems Minor problems Moderate problems Severe problems
4) Situational Behaviors
(General behaviors across settings-structured versus unstructured; on the bus; in the
hallways; at lunch; at recess; in co-curriculuars, etc.)
Indicate your rating of student’s overall difficulties in this area:
Circle One: No problems Minor problems Moderate problems Severe problems
______________________________________________________________________________
5) Specific Academic Abilities
(Sound-symbol associations; letter recognition; sight vocabulary; word attack skills; reading comprehension; oral comprehension; reading fluency; number recognition; basic math’s skills; paper & pencil math skills; applied math skills; word problems; spelling skills; grammar; punctuation; usage; written expression; handwriting; oral expression; specific content are information, etc.)
Indicate your rating of student’s overall difficulties in this area:
Circle One: No problems Minor problems Moderate problems Severe problems
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