"504 Eligibility Data Classroom Teacher Feedback Template - Cedar Rapids Community Schools"

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504 Document
504 Eligibility Data – Classroom Teacher Feedback
The student named below has been referred for a possible 504 Plan based on the specified
impairment. Please provide the requested information based on your knowledge of the student’s
performance in your classroom. Please bring this documentation with you to the Section 504
eligibility meeting scheduled for ____________.
Student __________________________
Impairment ___________________________
Academic Characteristics: Indicate by placing an “X” in front of the areas in which the student
has difficulty:
Oral reading
Spelling
Reading Comprehension
Math calculations
Basic reading skills
Math reasoning
Written expression
Legible writing
Other: _____________________________________________________________________
Modifications or Adjustments: Indicate by placing an “X” in front of the modifications or
adjustments that have been made for this student:
Modified instructional methods
Modified instructional pacing
Modified instructional materials
Behavioral planning or contracting
Parent conferences
Environmental modifications
Other: _______________________________________________________________________
Teacher Observation: Based on your knowledge and observations of this student, please rate 1-5
his/her performance in the following areas: (1 = satisfactory, 5 = unsatisfactory). Please use the
back of the page to explain your ratings if necessary.
1
Classroom work
1
Homework completion
1
1
1
Tests/quizzes
1
Following verbal directions
1
1
1
Following written directions
1
Attention span
1
1
1
Organizational skills
1
Peer relations
1
1
Other: _______________________________________________________________________
Place an “X” on the scale below to indicate the extent to which you think the specified
impairment limits this student’s ability to learn:
______________________________________________________________________________
Negligibly
Mildly
Moderately
Substantially
Extremely
Person(s) completing this form:____________________________Date:___________
E
504 Document
504 Eligibility Data – Classroom Teacher Feedback
The student named below has been referred for a possible 504 Plan based on the specified
impairment. Please provide the requested information based on your knowledge of the student’s
performance in your classroom. Please bring this documentation with you to the Section 504
eligibility meeting scheduled for ____________.
Student __________________________
Impairment ___________________________
Academic Characteristics: Indicate by placing an “X” in front of the areas in which the student
has difficulty:
Oral reading
Spelling
Reading Comprehension
Math calculations
Basic reading skills
Math reasoning
Written expression
Legible writing
Other: _____________________________________________________________________
Modifications or Adjustments: Indicate by placing an “X” in front of the modifications or
adjustments that have been made for this student:
Modified instructional methods
Modified instructional pacing
Modified instructional materials
Behavioral planning or contracting
Parent conferences
Environmental modifications
Other: _______________________________________________________________________
Teacher Observation: Based on your knowledge and observations of this student, please rate 1-5
his/her performance in the following areas: (1 = satisfactory, 5 = unsatisfactory). Please use the
back of the page to explain your ratings if necessary.
1
Classroom work
1
Homework completion
1
1
1
Tests/quizzes
1
Following verbal directions
1
1
1
Following written directions
1
Attention span
1
1
1
Organizational skills
1
Peer relations
1
1
Other: _______________________________________________________________________
Place an “X” on the scale below to indicate the extent to which you think the specified
impairment limits this student’s ability to learn:
______________________________________________________________________________
Negligibly
Mildly
Moderately
Substantially
Extremely
Person(s) completing this form:____________________________Date:___________