I&RS/504 Teacher Request for Assistance-T.R.S.
Student last name *
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Student first name *
Your answer
Date of birth *
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Grade level of student *
Teacher *
Your answer
Subject area *
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Please indicate all previously attempted interventions:
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.
Your answer
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