ECIA Gifted and Talented Education Program Referral Questionnaire
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Email *
Name of student being referred for GT testing followed by their first name (Last, First) *
Please enter the student's name *"LAST, FIRST"*. This will be the main way we sort the kids and their names need to be consistent.
Name of person filling out form (last, first) *
Relationship to student (ie. 3rd grade teacher, parent, piano teacher, etc.) *
Campus *
School Year of Referral *
Grade level *
Instructions for Questions
Rate each statement using the following scale:
1-strongly disagree 2-somewhat disagree 3-neutral/don't know 4-somewhat agree 5-strongly agree
The student is easily distracted by noises or movement. *
strongly disagree
strongly agree
The student has an unusually high energy drive. *
strongly disagree
strongly agree
The student is especially fidgety during quiet times or is incapable of sitting still, even for short periods. *
strongly disagree
strongly agree
The student is more competitive than his/her peers. *
strongly disagree
strongly agree
The student feels the need to touch everything they pass. *
strongly disagree
strongly agree
The student is overly sensitive to clothing (tags, seams, general comfort). *
strongly disagree
strongly agree
The student shows an intense appreciation for what they deem beautiful (arts, nature, etc.) *
strongly disagree
strongly agree
The student can be overwhelmed by smells that most people can dismiss. *
strongly disagree
strongly agree
The student has strong opinions on foods, smells, textures. *
strongly disagree
strongly agree
The student often zones out/daydreams. *
strongly disagree
strongly agree
The student sometimes retreats into a fantasy world. *
strongly disagree
strongly agree
The student has difficulty distinguishing their fantasy world from the real world. *
strongly disagree
strongly agree
The student has a quick and mature sense of humor. *
strongly disagree
strongly agree
The student is very detailed when telling or writing a story. *
strongly disagree
strongly agree
The student has a vocabulary that is larger than other children their age. *
strongly disagree
strongly agree
The student can do math quickly in their head &/or reads well above grade level. *
strongly disagree
strongly agree
The student asks many questions and gets upset when someone won't/can't answer them. *
strongly disagree
strongly agree
The student is capable of maintaining intense concentration on a topic they enjoy &/or will do just enough to get by on a topic they do not enjoy. *
strongly disagree
strongly agree
The student's feelings are easily hurt. *
strongly disagree
strongly agree
The student is overly concerned with what is fair or just. *
strongly disagree
strongly agree
The student is extremely empathetic/capable of relating to others experiences. *
strongly disagree
strongly agree
The student has physical reactions to intense emotions (stomach ache when anxious, headache when sad, increased urination when excited, etc.) *
strongly disagree
strongly agree
The student shows extremes of all emotions. *
strongly disagree
strongly agree
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