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.dot

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