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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