Student:       Grade:       ID#:       Date:       Teacher:       Subject:      

Richardson ISD
Teacher Data Form and Documentation of Interventions

Rate this student as he/she compares to classmates using the following scale:
1. low performance or does not demonstrate desired skill
2. below average performance or inconsistent demonstration of desired skill
3. average performance or consistent demonstration of desired skill
4. above average performance or demonstrates mastery of skill
n/a – does not apply to this student due to age, placement, etc.

Receptive language skills are average to above average Expressive language skills are average to above average
Articulation skills are average to above average Motor skills are average to above average
Academic skills are average to above average

n/ Please comment on
ACADEMIC DATA 1 2 3 4 a main concerns for each area
Comprehends word meanings Comments:      
Receptive

Follows oral directions

Comprehends classroom discussion
Demonstrates immediate auditory recall
Uses adequate vocabulary for age / grade Comments:      
Uses adequate grammar for general understanding
Expressive

Expresses self independently

Expresses self when questioned
Sequences events in order: 2 3 4 5 steps
Organizes and relates ideas / factual information
Sound pronunciation in comparison to peers Comments:      
Articulation

Articulation improvement upon modeling/repetition

Speech Intelligibility in comparison to peers
Student awareness of articulation ability
Gross motor coordination compared to peers Comments:      
Motor skills

Fine motor coordination (writing) compared to peers

Copies information from board / overhead
Exhibits motor planning skills
Reads aloud on grade level Comments:      
Answers comprehension questions on grade level
Composes complete sentences
Composes paragraphs / compositions
Expresses thoughts/ideas fluently in writing
Academic

Uses correct punctuation (Beg / end of sentences)

Uses correct spelling
Performs correct math process for stated problems
Adds / Subtracts on grade level
Multiplies / Divides on grade level
Can complete word problem using correct process
Demonstrates inferential / abstract thinking
Retains instruction from week to week

Teacher Data
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Documentation of Academic Interventions and Accommodations Tried
How long has
1 = Little or No Improvement accomm.
2 = Moderate Improvement been in
LA M Sci SS Academic Accommodations: 3 = Significant Improvement place?
Preferential Seating 1 2 3      
Provide privacy folder to reduce distractions 1 2 3      
Provide mentor 1 2 3      
Allow adequate / extended time for responses 1 2 3      
Assign task into workable segment 1 2 3      
Use visual aids 1 2 3      
Provide timelines, checklists, calendars 1 2 3      
Providing taped texts, or allowing taping of lectures 1 2 3      
Highlighted / color coded materials / overlays 1 2 3      
Whisper phones 1 2 3      
Advanced organizers (thinking maps) 1 2 3      
Adjust homework to student level to reinforce concepts 1 2 3      
Provide supplemental study guides / guided outlines 1 2 3      
Vary activities (auditory, visual, tactile) 1 2 3      
Simplify vocabulary / important concepts 1 2 3      
Emphasize critical information 1 2 3      
Individual learning objectives and feedback 1 2 3      
Allow redo of assignment or test 1 2 3      
Oral administration / oral response 1 2 3      
Extended time (defined) 1 2 3      
Shortened or segmented assignments 1 2 3      

How long has

1 = Little or No Improvement intervention
2 = Moderate Improvement been in
LA M Sci SS Academic Interventions: 3 = Significant Improvement place?
Small group instruction 1 2 3      
Positive reinforcement / incentives / recognition 1 2 3      
Provide repetition of key concepts 1 2 3      
Task Analysis (give steps of activity / process / task) 1 2 3      
Provide audio tapes / materials / manipulatives / cues 1 2 3      
Provide leveled reading materials 1 2 3      
Provide peer tutor for instructional assistance 1 2 3      
Additional instruction and practice on concepts 1 2 3      
Pre-teach content vocabulary 1 2 3      
Provide tutorials / extended day 1 2 3      
Provide 1 to 1 instruction / in-class individualized 1 2 3      
instruction
Computer assisted instruction 1 2 3      
Differentiated instruction (e.g. cooperative learning groups, 1 2 3      
reading groups)
Direct instruction of note or test taking skills 1 2 3      
Other:       1 2 3      

Teacher Data
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Rate this student behaviorally as he/she compares to classmates using the following scale:
N = the behavior is never observed
S = the behavior sometimes occurs
O = the behavior often occurs
A = the behavior almost always occurs

Please mark the top five behavior concerns in the far left column
BEHAVIORAL DATA N S O A Please comment on main concerns
Attends class regularly Comments:      
Adapts to new situations without getting upset
Complies with adult requests
Accepts responsibility for own actions
Responds appropriately to praise and correction
Student is motivated to do well
Initiates activities independently
Exhibits age-appropriate attention span
Completes tasks on time
Demonstrates age-appropriate organizational skills
Appears to have an even / happy disposition
Appears pleased with good work
Resists becoming discouraged at minor setbacks
Works cooperatively in small groups
Respects adult and peers
Makes and keeps friends at school
Participates in a shared conversation
Understands age-appropriate humor
Perseverates on topics
Blurts out off-topic comments
Appears fearful or anxious
Exhibits overactive behavior
Impulsive; does not consider the consequences before acting
Is negative or oppositional
Engages in physical fighting with other students
Is verbally aggressive towards other students
Is argumentative with adults / staff
Other:      

Documentation of Behavioral Interventions and Accommodations Tried

1 = Little or No
Improvement How long has
2 = Moderate Improvement accomm. been in
Behavioral Accommodations: 3 = Significant Improvement place?
Seat student near instruction to allow for redirection to task 1 2 3      
Use verbal cues or prompts 1 2 3      
Use visual cues or prompts 1 2 3
Provide close supervision 1 2 3      
Increased alertness to triggers that lead to misbehavior 1 2 3      
Quick intervention at first sign of problem 1 2 3      
Assign a task for redirection (passing out papers, errand) 1 2 3      
Build rapport with student 1 2 3      
Use diffusing statements (I see you are angry, I need you to use 1 2 3      

Teacher Data
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words)
Give incremental feedback during multi-step tasks 1 2 3      
Other:       1 2 3      

1 = Little or No
Improvement How long has
2 = Moderate Improvement intervention
Behavioral Interventions: 3 = Significant Improvement been in place?
Reward for approximations of desired behavior 1 2 3      
Direct instruction ( Listening Skills Rules Routines Coping      
1 2 3
Skills)
High frequency reinforcement (Positive rewards at a rate of 4:1 over negative 1 2 3      
interactions)
Use a timer for visual reminder of start/stop times 1 2 3      
Redirect in a non-emotional manner & allow time for initiation of      
1 2 3
compliance with request before giving second redirection or warning
Tell the student what “to do” as opposed to what “not” to do 1 2 3      
Proximity control with redirection using silent cues when possible 1 2 3      
Implement behavior chart or contract that show acceptable behavior incidents 1 2 3      
Wait until student is calm before imposing negative consequences 1 2 3      
Assist the student in getting started by demonstrating how to work the first      
1 2 3
item
Redirect and discuss problems or concerns privately; not lecture      
1 2 3
format
Give directions in clear and concise, matter-of-fact manner 1 2 3      
Limit suspensions and removals from class (since it encourages work      
1 2 3
avoidance)
Offer choices within teacher defined limits 1 2 3      
Restitution (repair the work environment) 1 2 3      
Cool down area within the classroom outside classroom 1 2 3      
Process incidents with student by helping him/her verbalize what the problem      
was, what was expected of him/her, how his/her decision affected the outcome, 1 2 3
and what he/she might have done differently
Use “When... Then” statements 1 2 3      
Other:       1 2 3      

Additional comments / concerns:

     

Teacher Data
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Please return this form to: _____________________

Teacher Data
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