Teacher Questionnaire

Please complete this questionnaire to the best of your ability related to the student. Thank you

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READING
Decoding
Fluency
Comprehension
Writing
Math
Number Sense
Problem Solving
Academic
Uses class time efficiently
Works independently
Requires adult supervision to initiate work
Personal/Social/Behavior
Cooperates with adult (generally)
Interacts well with peers
Follows classroom/school rules
Accepts responsibility for behavior
Responds well to praise
Must be constantly supervised or directed
Seems withdrawn preoccupied
Defiant
Communicates and responds to peers appropriately
Misunderstands behavior consequences
Demonstrates skill in resolving conflict peacefully

Please use the following scales to complete these sections: Not Observed- behavior not observed in this child Mild- Behavior occasionally observed in this child Severe- Behavior almost always observed in this child

Visuospatial Processes
Shows right-left confusion or confusion with directions (up-down)
Difficulties with putting puzzles together
Auditory processes
Difficulty with sound discrimination
Difficulty with blending of sounds to form words
Omits sounds when reading or speaking
Learning and Memory Processes
Difficulty learning new verbal information
Difficulty learning new visual information
Difficulty integrating verbal and visual information
Forgets where personal items or school work were left
Limited knowledge of basic facts for places, events and people
Reasoning Processes
Quickly becomes frustrated and gives up easily
Difficulty figuring out how to start a complex task
Difficulty solving problems that she recently learned
Makes the same kinds of errors over and over, even after corrections
Attention/working memory processes
Seems to get overwhelmed with difficult tasks
Difficulty paying attention for a long period of time
Seems to lose place in an academic task (e.g. reading, writing, math)
Frequently asks for repetitions of instructions
Trouble following multiple step directions
Speed,Fluency, and Efficiency of Cognitive Processing
Takes longer to complete tasks than others the same age
Requires extra time to complete tests
Does not do well on timed tests
Difficulty recalling information accurately and quickly
Slow and deliberate reader
Maintains a clear and sustained focus on the main writing topic
Difficulty pulling basic math facts out of memory quickly

Thank you for taking the time to complete this document.