Name ____________________________Age ____ Date Student Enrolled__________ Grade_____
Date Classroom Teacher Completed Form__________ Teacher_____________ School ___________
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Rating Scale |
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Below |
Above |
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Skill/Behavior |
Critical |
Average |
Average |
Average |
Superior |
Comments |
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Academic Skills* |
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Reading |
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Math |
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Language |
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Other |
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Learning Rate |
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Fine Motor Coordination |
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Gross Motor Coordination |
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Speech Articulation |
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Language |
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Grammar |
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Syntax |
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Receptive |
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Expressive |
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Initiative |
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Cooperation |
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Leadership |
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Creativity |
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Hearing |
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Vision |
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Problem Behaviors |
Rating Scale |
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Serious Problem Mild |
No |
Comments |
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Task Completion |
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Withdrawal |
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Aggression |
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Dependency |
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Anxiety/Fearfulness |
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Lying/Stealing |
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Response to Authority |
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Other |
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Yes |
No |
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Regular Attendance Frequent Excused Absences (illness, disease, accident) |
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*Critical = approximately 2 years or more below grade level
Superior = approximately 2 years or more above grade level
**Refer to back of form for responses to critical/superior ratings
Identification of
Exceptional and Chronic Health Problem Students
Page 2
Response (if critical or superior areas are marked)
o
Informal consultation with regular class teachero
Child Study Teamo
K-3 Academic assistanceo
LEP consultation/direct serviceo
Speech/language consultation/direct serviceo
Name submitted to gifted program teacher_________________________________________________________________
Chronic Health Problem:
_____________________________________ ________________________
Staff Signature Date