I&RS Teacher Information Form
Class Name with Level
Current Grade in Class
Place a check next to all behaviors or actions your have observed.
Drop in grades, lower achievement
Does not ask for help when needed
Gives up easily
Begins work in class but does not finish it
Begins HW but is unable to complete on own
Cheating on assignments
Does not use time wisely in class
Poor short term memory
Has demonstrated ability, but does not apply self
Lacks desire to do well in school
Poor note taking skills
Partcipates in class discussions
Lethargic/tired during class
Work and Assessments:
Place a check next to all types of work student struggles with. In comments section below please denote what the struggle is with that type of assessment.
Small group work
Teacher generated assessments
Assessments with short answer questions
Assessments with essay questions
Assessments with multiple choice questions
Assessments with true/false questions
Check any behaviors you have observed in the student.
Tends to stay to self
Ridiculed by classmates
Distrubs other students
Adrgues with teacher
Hits/pushes other students
Does not accept constructive criticism
Regularly seeks to be center of attention
Lacks control in unstructured situations
Change in friends
Difficulty in relating to others
Threatens other students
Demostrates lack of self-confidence
Defiance, violation of rules
Obscene language, gestures
Blaming, denying, not accpeting responsibility
Lack of impulse
Please provide information on any prior interventions you have tried with the student and the outcome of those interventions.
Explained class rules and expectations
Spoke to the student privately and explained concerns with work/behaviors
Provided student help after class/school
Regularly check student agenda
Provided study guides
Changed students seat
Adapted homework assignments
Assigned student detention
Student removed from class
Contacted parent(s) about concerns
No interventions tried
Outcome of Interventions
If you have tried prior interventions with the student please detail about the successes or failures of the interventions. Were there any factors that did not permit the intervention to be successful? Please provide as much detail as possible. We will use this information in the coming up with new interventions to help the student.
Detailed Observations of Student in Class
Please provide any other observations on how above student performs in your class. Any specific areas of strength or struggle. Please detail below.
Name of Teacher completing the form:
Email Address of Teacher
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