From: ______________________________ Date:____________________________

To: ______________________________

I am concerned about __________________________’s progress in my class,

(student’s name)

specifically

__________________________________________________________________.

(describe concerns)

I need your input to help me understand him/her better and make a plan. Please complete this form and return it to me by _______________. Thank you.

(date)

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Staff Input Form

What are this student’s strengths?

What is not happening that should be? ___________________________________________________________________

What is happening that shouldn’t be? ___________________________________________________________________

___________________________________________________________________

To which adult does this student have a strong connection? ___________________________________________________________________

Teacher rates this student’s performance in classroom or setting. Put check mark indicating S=Struggles to meet expectations M=Meets expectations E=Exceeds expectations N=not observed

S M E N
Reading skills Math skills Listening skills Written expression Spelling Classroom work Homework Tests/Quizzes Follows oral directions Follows written directions Organizational skills Attendance	___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

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S M E N
Participation Fine Arts abilities Physical/motor skills Pays attention/concentrates Has needed school items Maintains approp. activity level Completes tasks Waits turn Works cooperatively with peers Remains seated Stays on task Complies with rules Shows respect for adults Adapts to change Accepts responsibility Makes and keeps friends Displays even disposition	___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Strategies/Interventions/Accommodations already made or tried:

__Modified instructional methods, pacing or materials

__One-on-one instruction

__Provided after school help

__Connected student with peer tutor

__Provided visual information to accompany oral

__Modified classroom setting/arrangement

__Allowed extra time for assignment completion

__Developed behavioral contract

__Determined daily/weekly goals with student

__Sent homework/assignment list home

__Sent weekly progress reports home

__Contacted parent or held conference(s)

__Consulted with support professional (name or role: ____________________)

__Other (specify) _______________________________________________

If an EST referral is made to address this student’s needs, would you be interested

in participating in the meeting? (usually a Monday 3-4 pm) 1 Yes 1No