All responses and student/child information will be held confidential and used only for the purposes of gathering background knowledge.
1) Introduce the student by writing their name, age, grade, their identified exceptionality / placement and one interest.
_______________________________________________________________
_______________________________________________________________
2) Does the student have any disorders or other health impairments? If yes,
please specify on the space below.
_______________________________________________________________
3) When was the student’s last Individualized Education Plan (IEP) meeting?
_______________________________________________________________
4) What area do you see a need for direct and specific support?
Academics Behavior Both
5) Specify by circling the student’s strongest academic subject area(s).
Math Reading/Language Arts Science Social Studies P.E. Electives
6) Specify by circling the student’s weakest academic subject area(s).
Math Reading/Language Arts Science Social Studies P.E. Electives
7) Based upon your experience with the student, what type of learner is he/she?
Auditory Visual Kinesthetic Reading/Writing Observational
Mixture of _________________________________________________________
8) With the space provided below, list any concerning behaviors that you observed.
_________________________________________________________________
9) Please specify by circling when these behaviors occur.
Morning Afternoon Night Dismissal Arrival Transition Other_________
10) Are there any triggers/stimuli that may cause this behavior to occur? If yes, please
in the space below.
Yes No
________________________________________________________________
For the purpose of this case, you can print out the questionnaire, type your responses, and and scan it to my email or email me the responses in the corresponding format.
amays001@fiu.edu