Cherokee Student Study Form

Cherokee Student Study Form - SST

Filled out prior and during SST - Student Study Meeting
COMPLETE AND SUBMIT PRIOR TO SST MEETING. BRING STUDENT CA60 AND ASSESSMENT DATA/WORK SAMPLES.
Date of Submission

MonthDayYear
Date
Student's Name

First NameLast Name
Current Grade Level
Current Teacher's Name

First NameLast Name
Classroom Teacher's Email
example@example.com
Additional Teacher's Email
example@example.com
Support/Health History
STUDENT SUPPORT: Indicate current/previous area of student support.

Speech/Language SupportSchool Social Work SupportResource Room SupportTeacher Consultant SupportCheck-In/Check-Out (CICO)504 PlanPlan for SuccessIRIPBilingual/ESL SupportOccupational Therapy (OT)Physical Therapy (PT)Private (out of school) TherapyESCE (if known)RetainedOther
Further Explanation (if needed)
HEALTH:

VisionHearingMedicationOther
Further Explanation (if needed)
Area(s) of Concern
Academic Concerns - identify specific skills/standards
Most Recent FastBridge Benchmark Score and Date
Most Recent Reading NWEA (Grades 3-5) RIT, Percentile and Date
Most Recent Math NWEA (Grades 3-5) RIT, Percentile and Date
Any other data points to be considered:
Work Habit Concerns:

ResponsibilityOrganizationWork CompletionIndependent WorkMotivation/InitiativeCollaborationOther
Behavior Concerns - identify specific internal or external behavior concerns (SRSS assessment data)
Medical Concerns - suspected and/or diagnosed concerns
Attendance Concerns:

NoYesOngoingOther
Accommodations

Indicate Classroom Accommodations, if applicable.
Modifications to Environment
Modifications to Presentation of Instruction
Modifications of Assignments
Modifications to Presentation of Evaluation
Organization Assistance
Behavior/Motivation Techniques
Other School-wide Supports
Describe Level of Success (most effective/least effective modifications)
Interventions

Indicate Academic, Behavioral, SEL Interventions, if applicable.
What are the name(s) and date ranges of interventions provided:
Indicate level of intervention success/Feedback from Interventionist:
Upload any supporting documents to be considered:

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Cherokee Student Study Form - SST

Support/Health History

Area(s) of Concern

Accommodations

Interventions

Completed DURING SST Meeting