"Private/Home School Educational Information Form - the School Board of St. Lucie County"

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School Board of St. Lucie County
PSET 2: Private/Home School Educational Information
Student Name
Grade/School
DOB ____/____/____
SECTION ONE: OBSERVATIONS
Student’s Strengths: Check all that apply.
Artistic
 Positive Role Model
Motivated
Inner Direction
Perseverance
Friendly
Athletic
Positive Attitude
Confident
Independent
Trustworthy
Respectful
Flexible
Sense of Humor
Perceptive
Imaginative
Responsible
Dependable
Other:
Teacher Observations: Check all that apply.
Appears inattentive, easily distracted
 Poor fine motor control
 Poor understanding of vocabulary
 Use of poor judgment in social and interpersonal
 Poor gross motor control
 Difficulty following direction in sequence
relationships
 Withdrawn
 Slow to react to and follow directions
 Constantly seeks attention-especially from adults
 Low frustration tolerance
 Performs inconsistently from day to day
 Reverses or confuses letters-numbers-words
 Difficulty completing assignments  Leads or joins others in inappropriate
 Makes inappropriate responses to conversation
Difficulty expressing ideas
behavior
Frequently loses place when reading
Difficulty staying on the line
 Impulsive-talks out-difficulty waiting turn
 Engages in destructive and/or aggressive behavior
when writing
 Misinterprets verbal questions & directions
SECTION TWO: CURRENT LEVELS
Reading Curriculum used: _______________________________________ Student’s level ____________ Current grade A B C
D F
Math Curriculum used:__________________________________________ Student’s level ___________ Current grade A B C
D F
Writing Curriculum used: ________________________________________ Student’s level ____________ Current grade A B C
D F
Interventions Tried:
 Small group instruction focusing on _______________________________________________ Beginning on ___/___/___ to ___/___/___
Delivered by _______________________________________________
 In classroom
OR
 Pull out
 Individual instruction focusing on _________________________________________________ Beginning on ___/___/___ to ___/___/___
Delivered by _______________________________________________
 In classroom
OR
 Pull out
SECTION THREE: REASON FOR REFERRAL
Date of Parent Conference ____/____/____
Reason for Referral:
Team Members Present:
Teacher ________ __________________________________________ Parent ____________________________________________________
Administrator ______ ________________________________________ Parent ____________________________________________________
Other _____________________________________________________ Other _____________________________________________________
SECTION FOUR: PERMISSION TO SCREEN
In order to obtain further information about your child’s abilities, we need your permission to conduct sensory, cognitive, and academic
screenings with your child.
By signing below, I give permission for the educational screening of my child.
Parent and/or Guardian Signature ______________________________________________________________________ Date ____/____/____
School Official’s Signature __________________________________________________________________ Date ____/____/____
Created 9/2009 PSET2
STS0130
School Board of St. Lucie County
PSET 2: Private/Home School Educational Information
Student Name
Grade/School
DOB ____/____/____
SECTION ONE: OBSERVATIONS
Student’s Strengths: Check all that apply.
Artistic
 Positive Role Model
Motivated
Inner Direction
Perseverance
Friendly
Athletic
Positive Attitude
Confident
Independent
Trustworthy
Respectful
Flexible
Sense of Humor
Perceptive
Imaginative
Responsible
Dependable
Other:
Teacher Observations: Check all that apply.
Appears inattentive, easily distracted
 Poor fine motor control
 Poor understanding of vocabulary
 Use of poor judgment in social and interpersonal
 Poor gross motor control
 Difficulty following direction in sequence
relationships
 Withdrawn
 Slow to react to and follow directions
 Constantly seeks attention-especially from adults
 Low frustration tolerance
 Performs inconsistently from day to day
 Reverses or confuses letters-numbers-words
 Difficulty completing assignments  Leads or joins others in inappropriate
 Makes inappropriate responses to conversation
Difficulty expressing ideas
behavior
Frequently loses place when reading
Difficulty staying on the line
 Impulsive-talks out-difficulty waiting turn
 Engages in destructive and/or aggressive behavior
when writing
 Misinterprets verbal questions & directions
SECTION TWO: CURRENT LEVELS
Reading Curriculum used: _______________________________________ Student’s level ____________ Current grade A B C
D F
Math Curriculum used:__________________________________________ Student’s level ___________ Current grade A B C
D F
Writing Curriculum used: ________________________________________ Student’s level ____________ Current grade A B C
D F
Interventions Tried:
 Small group instruction focusing on _______________________________________________ Beginning on ___/___/___ to ___/___/___
Delivered by _______________________________________________
 In classroom
OR
 Pull out
 Individual instruction focusing on _________________________________________________ Beginning on ___/___/___ to ___/___/___
Delivered by _______________________________________________
 In classroom
OR
 Pull out
SECTION THREE: REASON FOR REFERRAL
Date of Parent Conference ____/____/____
Reason for Referral:
Team Members Present:
Teacher ________ __________________________________________ Parent ____________________________________________________
Administrator ______ ________________________________________ Parent ____________________________________________________
Other _____________________________________________________ Other _____________________________________________________
SECTION FOUR: PERMISSION TO SCREEN
In order to obtain further information about your child’s abilities, we need your permission to conduct sensory, cognitive, and academic
screenings with your child.
By signing below, I give permission for the educational screening of my child.
Parent and/or Guardian Signature ______________________________________________________________________ Date ____/____/____
School Official’s Signature __________________________________________________________________ Date ____/____/____
Created 9/2009 PSET2
STS0130