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East Hollywood High School's General Education Teacher Academic -Behavior Survey
Please fill out this form on any student who you have concerns about needing additional supports either through a 504 plan or an IEP. Please include a copy of their grade-book in your class, and a sample of their work. Put all of this in the box of an IEP teacher.
Student:
Class Subject:
Teacher:
Date:
Describe the concerns you have about the student
Behaviors that interfere with this student's learning:
Behaviors that support this student's learning:
Classroom Habits and Behavior
Poor
Okay
Good
Excellent
Comments
Task Completion
Turning in Assignments
Participating in class discussions
Participating in group work
Seeking help from peers
Seeking help from adults
Attendance
Effort
Organization
Classroom rule compliance
Attention/Focus/Engagement
Time on task
Relationship with peers
Relationships with adults in general
Clear selection
Academic Skills
Poor
Okay
Good
Excellent
Not Sure
Grade Level if applicable
Reading Fluency
Reading Comprehension
Writing Structure and organization
Use of Vocabulary
Penmanship
Math Calculation
Math Concepts
Math Problem solving
Understanding oral language
articulation through speaking
Is this student getting pulled for additional supports in reading, from the reading interventionist?
Clear selection
Tracking interventions that you have tried (only mark if applicable)
Did work
Did not work
extended time
Peer tudor
One - on-one conferences to check in on progress
Guided notes
Re-Direct to stay on Task
Differentiated instruction: i.e. products, process, pace, time, content, environment
One- on - One guided practice
Class discipline modifications
Breaks for anxiety
Breaks after completing tasks
Modified Assignments
Alternate location for testing
May Use Computer to Take Notes
Turn in phone/electronic devices
Text - To - Speech
Human Reader When Needed
Small Group Setting
Chunk big assignments down into smaller ones
Positive Reinforcement
Paraphrase Instruction
Ask detailed questions to get a read on the progress
When Assigning Group Work, Give Advance Warning
Alternate mediums to prove comprehension
Modeled desired behavior
Utilized supplemental materials
Extended/structured responses
Another intervention not listed:____________________________________________________________________________
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