Lower School (K-5) Teacher Questionnaire
This questionnaire is designed to assist us in determining if/how this student might fit into our classroom and school environment. Your responses will be kept confidential and will not become a part of the student's permanent records. Thank you in advance for answering the questions below and assisting us in the application process.
Student Information:
Student's Name
*
First Name
Last Name
Student's Current School
*
Grade Applying For
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Student's Current Grade:
*
Pre-Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Teacher's Information:
Teacher's Name
*
First Name
Last Name
Teacher's Phone Number
*
-
Area Code
Phone Number
Teacher's Email
*
example@example.com
Approximately how often has this child been absent this school year?
*
1
2
3
4
5
Frequently (12+ days)
Rarely (Less than 4 days)
1 is Frequently (12+ days), 5 is Rarely (Less than 4 days)
Approximately how often has this child been Tardy this school year?
*
1
2
3
4
5
Frequently (12+ days)
Rarely (Less than 4 days)
1 is Frequently (12+ days), 5 is Rarely (Less than 4 days)
Additional comments on attendance:
How academically prepared is this child for the grade in which they are applying?
*
1
2
3
4
5
Not Prepared
Exceptionally prepared
1 is Not Prepared, 5 is Exceptionally prepared
Please explain your rating:
*
How well does this child manage himself/herself behaviorally?
*
1
2
3
4
5
Poorly
Exceptionally
1 is Poorly, 5 is Exceptionally
Please explain your rating:
*
How well does this child interact socially with peers?
*
1
2
3
4
5
Poorly
Exceptionally
1 is Poorly, 5 is Exceptionally
Please explain your rating:
*
Has this child required any formal disciplinary action (Detention, expulsion, suspension)?
*
Yes
No
If yes, Please explain:
How supportive and involved are this child's parents?
*
1
2
3
4
5
Not Involved
Highly Involved
1 is Not Involved, 5 is Highly Involved
Please explain your rating:
*
Please rate the child's English proficiency:
*
1
2
3
4
5
Poor
Exceptional
1 is Poor, 5 is Exceptional
Please explain your rating:
*
Does this student have an IEP, 504 Plan or Recieve Title I, Title III (ELL), counselor visits, etc?
*
Yes
No
If yes, please explain:
Please provide other comments that can help us determine if this can be a mutually beneficial fit:
*
Submit
Should be Empty: