Teacher Form

Teacher Form
Form Name
EDUCATIONAL INFORMATION
Student's Name
Today's Date

MonthDayYear
Date
Teacher's Name
Subject
Is a poor listener

YesNoDon't Know
Can concentrate for only a short time

YesNoDon't Know
Frequently seems to be looking around or staring off into space

YesNoDon't Know
Forgetful in daily activities

YesNoDon't Know
Excellent imagination

YesNoDon't Know
Loses materials (books, pencils, passes)

YesNoDon't Know
Daydreams often: seems to be in own world

YesNoDon't Know
Impulsive, rushes through tasks

YesNoDon't Know
Has trouble concentrating in group work

YesNoDon't Know
Receives inconsistent grades or test scores

YesNoDon't Know
Annoys or bothers others

YesNoDon't Know
Seems to have too much energy

YesNoDon't Know
Body in motion most of the time

YesNoDon't Know
Fidgety-keeps moving hands or tapping feet

YesNoDon't Know
Behavior is variable and hard to predict

YesNoDon't Know
Gets into trouble without really meaning to

YesNoDon't Know
Is a troublemaker; stirs things up

YesNoDon't Know
Class clown

YesNoDon't Know
Is moody

YesNoDon't Know
Is a worrier

YesNoDon't Know
Often cheerful, pleasant, well meaning

YesNoDon't Know
Is often sad

YesNoDon't Know
Is often very quiet

YesNoDon't Know
Is often tired

YesNoDon't Know
Speaks unclearly, stutters, stammers

YesNoDon't Know
Complains of not feeling well

YesNoDon't Know
Asks to leave the room frequently

YesNoDon't Know
Not chosen for teams or groups

YesNoDon't Know
Well liked by peers

YesNoDon't Know
Seems disconnected, confused

YesNoDon't Know
Disorganized, unprepared, can’t find time

YesNoDon't Know
ACADEMIC SKILLS ASSESSMENT

Reading

	Exceptional	Above Average	Average	Below Average	Significantly Below
Vocabulary
Comprehension
Phonetics/Decoding
Fluency
Oral

Math

	Exceptional	Above Average	Average	Below Average	Significantly Below
Calculation
Math Facts
Story or word problems
Fluency

Written Language

	Exceptional	Above Average	Average	Below Average	Significantly Below
Spelling
Sentence structure/grammar
Creative writing
Handwriting
Organization

Other Academic Areas

	Exceptional	Above Average	Average	Below Average	Significantly Below
Science
Foreign Language
Social Studies
Art
Physical Education

Does this student receive any of the following services (Check all that apply)

504 planIEPCounselingSpecialized Reading InstructionSpeech/Language Services RecoverySpecialized Math InstructionLearning Resource ClassroomOccupational TherapyPhysical TherapySelf-contained ClassroomOther

What do you note as this student’s strengths? Please list.

	Strengths
1.
2.
3.

Please share any other information you feel is important for us to know about this student:
Please e-mail (info@thenichollsgroup.com) with any important documents you believe we should review for the student you are grading (handwriting samples, class work, test scores, etc.,) Thank you!
Should be Empty:

Teacher Form

EDUCATIONAL INFORMATION

ACADEMIC SKILLS ASSESSMENT