Student Information Form

Student:	Requesting Individual:
Student Testing Number:	General Ed. Teacher:
Gender:	Date of Birth:
Home school (public):	Current Grade:
Home school corporation:	Other (list, if applicable):
Ethnic Background:	If the parent made the request, ENTER THE DATE of the verbal or written request: (If the parent request was made in writing, please attach the dated written request.)
Parent/Guardian:	Does the student already have a 504 plan? Yes No If yes, please list the current area(s) of need:
Address:	Does the student already have an IEP for any disability area, including speech and language services? Yes No If yes, please list the current area(s) of disability:
City/Zip Code:
Cell Phone:
Emergency Number:	Home Phone:
Legal Custody Status:	Email:
Reason for Referral:

Note: If the requesting individual is the student’s parent/guardian, then this form should be completed by the parent/guardian in cooperation with the classroom teacher.

Educational Information

Describe student performance in the following areas (include intervention results, ISTEP, Acuity, etc.):

Student (ISTEP; INSPECT; etc.) Date Score/Passing Score	Compared to Peers (Examples can be quartiles, rank of student in class, etc.)
Reading:
Math:
Writing:
Language:
Articulation:
Social:
Motor skills:
Other:
Behavior (if an area of concern, please specify the behavior):
Attendance:
Has student been retained?	YES NO Grade:

What are the student’s strengths and learning preferences?

What specific barriers continue to exist in the learning environment that if removed might allow the student to be successful?

Representation:

Expression:

Engagement:

Identify specific, research-based interventions that have been implemented with the student and the results:

General Education Classroom Dates/Duration: Intervention: Data on effectiveness:	Additional Tutoring/Instructional Support Dates/Duration: Intervention: Data on effectiveness:
General Education Classroom Dates/Duration: Intervention: Data on effectiveness:	Additional Tutoring/Instructional Support Dates/Duration: Intervention: Data on effectiveness:
General Education Classroom Dates/Duration: Intervention: Data on effectiveness:	Additional Tutoring/Instructional Support Dates/Duration: Intervention: Data on effectiveness:
General Education Classroom Dates/Duration: Intervention: Data on effectiveness:	Additional Tutoring/Instructional Support Dates/Duration: Intervention: Data on effectiveness:

Relevant medical information:

Screening	Date	Results
Vision
Hearing
Diagnosis
Medications

For 504 Evaluation:

School 504 Coordinator Signature___________________________________________________Date______________________

Building Administrator/Designee Signature___________________________________________Date______________________

For Special Education Evaluation:

Date complete materials reviewed by school psychologist and building administrator:

We find the referral should proceed for special education evaluation Yes No

Date of follow-up with teacher on referral decision:

Date of response to parent request for evaluation, if applicable:

School Psychologist Signature___________________________________________________Date______________________

Building Administrator/Designee Signature________________________________________Date______________________