CEPS

Dean Hope Center For Educational & Psychological Services

Box 91/ TEACHERS COLLEGE/ COLUMBIA UNIVERSITY

NEW YORK, NY 10027
212-678-3262

School Data Elementary School Students

___________________________________ was for a reading evaluation at The Center for
Psychological and Educational Services at Teachers College, Columbia University. It is very
important that we school input as we conduct our evaluation. A signed parental consent is attached
for this purpose.
The assistance of the school is very much appreciated. When the Teacher Report is completed please
return to:___________________________________________________ at the address above.
It would be appreciated if the students classroom teacher or school psychologist would fill out this
data sheet. The attached teacher report needs to be filled out by the classroom teacher. Please attach
a copy of the most recent grade report and a copy of the most recent group test scores (cognitive
ability/achievement). Any additional relevant data would be helpful as well.
For Special Education Students: Please attach a copy of current IEP and include Teacher Reports
from special education teachers (special class, resource room, speech, O.T., etc.)
Data Sheet to be filled out by classroom Teacher or School Psychologist
Please describe the nature and frequency of any regular education support services which the student
receives (e.g. reading or math remediation):___________________________
________________________________________________________________________
Please describe nature and frequency of any special education services: ______________
________________________________________________________________________
Please describe any problems with school attendance: ____________________________
Is the school staff aware of any behavioral or emotional issues which may be interfering with
learning?
_________________________________________________________________________________
_______________________________________________________________
Are there any familial, social/economic, or cultural issues which may be interfering with learning?
_________________________________________________________________________________
_______________________________________________________________
Has the student has a pervious psycho educational/psychological/education evaluation? Please
indicate date/results.
_________________________________________________________________________________
_______________________________________________________________
Signature of person filling out data sheet___________________ Title_______________
Print Name___________________________________ Date__________________