Federalsburg Elementary School

302 S. University Avenue Federalsburg, MD 21632

410-754-9054 Fax 410-754-5504
http://federalsburgelelmentary.weebly.com/
Yolanda Holloway, Principal
Todd Nichols, Assistant Principal

Request for Assistance

Student’s Name: _________________________________ Grade: ________ Date: ______________

Teacher’s Name: _________________________________ IEP: Yes No

Please identify your child’s strengths.

(Some possible strengths include: academic interest, social skills, hobbies, sports, etc.)

1.____________________________________ 2.__________________________________

3.____________________________________ 4.__________________________________

Problem Behaviors: (Please check all areas of concern)

Verbally Harasses Others Disrupts Class Activities Noncompliant

Difficulty Completing Work Withdrawn Tardy / Attendance

Inattentive Other: ___________________________________

Academic Concerns:

All Academic Areas Math Reading Writing Study Skills

Organization Homework Other:__________________________________

Why do you believe your child is engaging in problem behavior?

(Please check primary function if known)

Adult Attention Peer Attention Escape from difficult work / tasks

Escape from adult / peer attention Gain access to preferred activity / item