I&RS/504 Teacher Request for Assistance-D.W.S.
Student last name
Student first name
Date of birth
Grade level of student
Current DRA level
Provide the number of absences thus far.
Was this student retained
Please indicate all previously attempted interventions. Parent and principal must be aware of the problems. A majority of these MUST be checked off:
spoke to student privately to explain rules and/or concerns
spoke to parent via phone
portfolio/cumulative folder/samples of work- Bring to the Update meeting**
in person parent conference- MUST be done***
emailed parent about concerns
established contingency plan with student
informed administration about student-***Must be done!
special help offered by teacher-at least once a week- *Must be done
reviewed the permanent record folder and spoke to the previous teacher- *Must be done.
What language is spoken at home?
List names of academic support teachers/ESL teachers and subjects covered if services are provided.
By checking the box, you have verified that all appropriate interventions have been completed and that you are prepared to submit documentation.
Describe the concern, academic and/or behavioral, that student displays in class. If it is an academic concern, list 2 specific skills that are of immediate need.
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