Classroom Teacher Input Form

Full Individual Evaluation (FIE)

* Indicates a required field. Please complete all sections as thoroughly as possible. Your input is an important part of understanding this student's needs.

General Information

Date *

Your Name *

Student's Name *

Grade / Class Period *

Is the student an emergent bilingual? *

Yes No

Do you have concerns regarding the student's attendance? *

Yes No

Do you have concerns regarding the student's behavior? *

Yes No

Do you have concerns regarding the student's academic performance? *

Yes No

Do you have concerns regarding the student's fine or gross motor skills? *

Yes No

Have you been able to communicate with the parent(s) regarding your concerns? *

Yes No

Classroom Observations & Supports

Describe interventions (such as RTI) you have previously implemented for this student: *

Describe accommodations you have previously implemented for this student: *

List two or three things the student enjoys (activities, characters, items, etc.): *

Describe the student's overall attitude toward school and the learning environment: *

Describe what success looks like for the student in the area(s) of concern and what supports were needed to get there: * e.g. Student is able to decode CCVC words in isolation when working with a single initial consonant blend and one-on-one teacher support.

Rating Scales

Using the scale below, please rate the student's skills in each area as observed in the classroom. Mark only one rating per row.

Scale: 1 — Major concern 2 — Some concern 3 — Average 4 — Above average 5 — Significantly above average

Communication	1 Significantly Below Average (major concern)	2 Below Average (some concern)	3 Average (no concern)	4 Above Average	5 Significantly Above Average

Speech Intelligibility / Pronunciation of Sounds
Voice Quality
Comprehension of Word Meanings
Following Oral Instructions
Comprehension of Classroom Discussions
Remembers Information Just Heard
Use of Adequate Vocabulary
Use of Adequate Grammar for General Understanding
Expresses Self Fluently When Called On to Speak
Relates a Sequence of Events in Order (telling a story)
Organizes and Relates Ideas and Factual Information
Use of Socially Appropriate Language
Able to Express Needs and Wants

Social & Emotional	1 Significantly Below Average (major concern)	2 Below Average (some concern)	3 Average (no concern)	4 Above Average	5 Significantly Above Average

Generally Cooperates with Teacher Requests
Adapts to New Situations Without Getting Upset
Accepts Responsibility for Own Actions
Makes and Keeps Friends at School
Works Cooperatively with Others
Has an Even, Usually Happy Disposition
Is Pleased with Good Work
Initiates Activities Independently
Responds Appropriately to Praise and Correction
Resists Becoming Discouraged by Difficulties or Minor Setbacks
Maintains Attention to Teacher
Maintains Attention to Task
Maintains Attention to Class Discussion
Use of Socially Appropriate Language
Exemplifies Adequate Attention to Complete Routine Tasks
Organization
Adherence to Classroom Routines
Awareness of the Needs/Wants of Others
Excessively High Energy
Excessively Low Energy
Difficulty Following Directions
Defiance / Non-compliance
Distractibility
Impulsivity
Respectfulness
Interactions with Peers During Academic Activities
Interactions with Peers During Non-academic Activities

Academic	1 Significantly Below Average (major concern)	2 Below Average (some concern)	3 Average (no concern)	4 Above Average	5 Significantly Above Average

Ability to Begin Tasks Independently
Ability to Maintain Attention to Task
Timely Completion of Tasks
Completion of Tasks
Effort on Assignments/Tasks
Overall Work Quality
Basic Reading Skills (letter names and sounds, decoding)
Reading Fluency
Reading Comprehension
Oral Expression
Written Expression
Handwriting
Math Calculation
Math Problem Solving (word problems)
Listening Comprehension
Spelling

Writing	1 Significantly Below Average (major concern)	2 Below Average (some concern)	3 Average (no concern)	4 Above Average	5 Significantly Above Average

Pencil Grip
Letter Formation
Letter Spacing
Word Spacing
Writing on Line
Use of Punctuation and Capitalization
Sentence Structure
Organization of Ideas

Additional Comments or Concerns

Please share anything else you would like the evaluation team to know about this student: