1. Section 1A Classroom Teacher/Counselor School Administrator Classroom Teacher/Interventionist Classroom Teacher/Interventionist NOTE: Complete social emotional/behavior checklist only if needed Classroom Teacher/Interventionist Classroom Teacher/Interventionist NOTE: Complete checklist for Pre-K students only if needed *Complete Behavioral Analysis Form C for behavior Students in General Education Section 1B Section 2A & 2B Tier II 4. Appendix A 5. Appendix D 6. Appendix F Hearing & Vision Screening JPSD Teacher Narrative Parent Interview Questionnaire 1. Section 1A Classroom Teacher/Counselor School Administrator Classroom Teacher/Interventionist Classroom Teacher/Interventionist Classroom Teacher/TST NOTE: Skip IEP section Classroom Teacher/Interventionist NOTE: Complete social emotional/behavior checklist only if behavior is identified as deficit area. Classroom Teacher/Interventionist Students in General Education Section 1B Section 2A & 2B Tier III Section 3A Section 3B & 3C 6. Appendix A 7. Appendix D Facts, Behavior Intervention Plan 1. Section 1A Classroom Teacher/Counselor School Administrator Classroom Teacher/TST/IEP Team * NOTE: Include IEP section Template Classroom Teacher/ TST/IEP Team Classroom Teacher/Interventionist *Note: Complete only if 3rd grade student applying for Good Cause Exemption Students in Special Education Section 1B Section 3B & 3C Intensive Interventions K-4 Appendix D Appendix E Students with Dyslexia Section 1A Section 1B Section 2A & 2B Section 3A Section 3B & 3C Appendix C Classroom Teacher/Counselor School Administrator Classroom Teacher/Interventionist Classroom Teacher/Interventionist Classroom Teacher/TST Teacher and Parent English Language Learners (ELL) Section 1A Section 1B Appendix B Classroom Teacher/Counselor School Administrator ELL Teacher
Section 1A: Pre-K Student Profile Student Name: MSIS Number/ID: School/Site: District: Date of Teacher: Gender: Race: Parent/Guardian Name Email: Street Address: College and Career Readiness Anchor Standards Performance Instructions: Indicate the total number of performance standards that were indicated as code 1 (needs development) in each domain on the College and Career Readiness Anchor Standards Observation Checklist for Four Year Old Children. Behavior Instructions: Check if documentation is applicable & available. Attendance School Year Days Present / Absent List last 3 schools attended and dates. Special Population Instructions: if applicable to student. Special Education / IEP 504 ELL (complete Appendix B) Speech/Language Other: Kindergarten Readiness Assessment Scores Instructions: Fill in the chart below based on student scores on the MKAS2 Assessment. Screener(s) Instructions: Indicate the name of each screener used in the classroom and the screener’s recommended cut score. Indicate the date of the screener and the student’s score. --------------------------------------------------------------------- --------------------------------------------------------------------- Hearing/Vision Screener Form Completed By: Date of Completion:
Appendix A: Social/Emotional Worksheet Instructions: Classroom teachers or counselors should complete this checklist to aid in the collection of information to determine if student is in need of Tier II or Tier III behavioral interventions NOTE: This worksheet is not a behavioral screener. For behavioral screening resources, visit . STUDENT IS DISRUPTIVE IN CLASS: fidgets is overly active does not remain in seat talks out of turn disturbs others when they are working constantly attention overly aggressive with others (i.e., physical fights) belligerent towards teachers and others in authority defiant or stubborn impulsive can’t wait his/her turn acts without thinking of the consequences STUDENT IS WITHDRAWN: shy, timid has difficulty making friends sits alone in cafeteria does not join in classroom group activities overly conforms to appears to daydream or be out of touch with the class has difficulty expressing feelings STUDENT IS ANXIOUS: appears depressed rarely smiles appears to be tense appears frightened or worried easily does not trust others reports fears or phobias (such as fear of coming to school) SOCIAL/EMOTIONAL BEHAVIORS: lacks self-confidence says “can’t do” even before attempting reacts poorly to disappointment is overly sensitive to disappointment depends on others clings to adults pretends to be ill has poor grooming or personal hygiene STUDENT HAS: been on runaway status been caught stealing at school left class without permission cursed school personnel threatened to harm school personnel or wished school personnel harm been suspended for fighting attempted suicide received tobacco violations at school received drug/alcohol violations at school CLASSROOM INTEREST: High Average Low Other, Please Specify CLASSROOM PARTICIPATION: almost always frequently occasionally seldom CLASSROOM PREPAREDNESS: always brings necessary supplies usually brings supplies seldom comes to class with supplies never comes to class with supplies MOTIVATION: completes homework completes about half of the assignment tends to give up easily has difficulty getting started on assignments TO THE BEST OF YOUR KNOWLEDGE: This student is involved with the court system. This student is in counseling. This student is on medication. Appendix B: Language Service Plan (for Students Instructions: This form should be completed by the individual and the classroom teacher.