Jefferson County School District 509-J



Jefferson County School District 509J

Student Intervention Team

Student Referral Form

Referral Date: ___________________________

Student: ________________________________ DOB: ____________________ School: ______________________________

Teacher: _____________________ Grade: ______ Date teacher notified the parent/s of concern: _________________

Parent/s: _________________________________ Phone: ________________________ (h) _______________________ (wk)

Address: __________________________________________________________________________________________________

1. List the schools this student has attended: _____________________________________________________________

______________________________________________________________________________________________________

2. Attendance (absences/yr.) K ____ 1 ____ 2 ____ 3 ____ 4 ____ 5 ____ 6 ____ 7____ 8 ____ 9 ____ 10 ____ 11 ____ 12____

3. Has the student ever been retained? If yes, at what grade? ______________________________________________

4. Health (Please check with School Secretary to complete this section).

If this student’s vision or hearing has not been screened in the past year, please arrange to have this done before SIT referral.

Vision Screening Hearing Screening

Date: ______________ Pass / Fail Date: ____________ Pass / Fail

Date: ______________ Pass / Fail Date: ____________ Pass / Fail

Has prescription Glasses? ________ Has a Hearing Aid? _______________

Wears Glasses Regularly? _______ Uses Hearing Aid Regularly? ________

Other Medical Concerns/Medications: ______________________________________________________________________

__________________________________________________________________________________________________________

5. Circle all other services this student has currently or had previously received:

Title 1A Title 1C ESL 504 Plan Special Education

* If the student has received any of the above services, please consult with the program specialist

and attach program documentation.

6. Primary Language: _____ English _____ Spanish _____ Other

Please list any available ESL data information below:

|Data Source (ELPA, IPT, |Date |Results |

|Woodcock-Munoz, other) | | |

| | | |

| | | |

| | | |

SIT Referral Form (Page 2)

Student Strengths: ____________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The primary concern and reason for SIT (Student Intervention Team) referral: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Strategies attempted: ____________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

|READING |DATE/S |SCORE/S |

|DIBELS/ORF | | |

|OAKS | | |

|Other ______________________ | | |

|Other ______________________ | | |

|Other ______________________ | | |

|MATHEMATHICS |DATE/S |SCORES/S |

|OAKS | | |

|GRADES (Report Card) | | |

|Curriculum Based Assessment | | |

|Describe: ___________________ | | |

|Other ______________________ | | |

|Other ______________________ | | |

|WRITING |DATE/S |SCORE/S |

|State Writing Score | | |

|Writing Samples (attach) | | |

|CWS | | |

|Other ______________________ | | |

|Other ______________________ | | |

|BEHAVIOR (Check areas of concern) |

|_____ Assignments/Homework |_____ Attention/Focus |_____ Emotions |

|_____ Relationships with adults |_____ Relationships with peers |_____ Safety |

|_____ Participation |_____ Other: |_____ Other: |

|COMMUNICATION/ARTICULATION (Check areas of concern) |

|_____ Follows Multiple Directions | Speech/Articulation |_____ Social Language |

| |_____ (Clarity of Speech) | |

| Receptive Language |_____ Expressive Language |_____ Other: |

|_____ (Vocabulary/Word Meaning) | | |

|MOTOR SKILLS (Check areas of concern) |

|_____ Fine Motor |_____ Gross Motor |_____ Handwriting |

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