TEACHER INPUT FORM IEP/ER

Student:

Grade:

Teacher:

Subject:

Program
:
STUDENT'S GRADE TO DATE:

IEP Teacher of Record:

Due By:

Parent/staff requested that student be evaluated.

Every three years, students in Special Education may have their program re-evaluated. Your information will be integrated
and summarized in a Re-Evaluation Report. The parents will receive the information during a team meeting.

PLEASE RATE THE STUDENT IN THE FOLLOWING AREAS AND RETURN THIS FORM TO:
1. RATE OF RETENTION AND ACQUISITION: Please rate the above student in the following areas and explain.
Rate of acquisition of New Material (check one):
Need for Repetition and Review (check one):

High
Seldom

Average
Occasionally

Low
Frequently

2. AREAS OF CONCERN: Please check only those that apply.

Homework:
Classwork:
Participation:
Behavior
Test Results:
Attendance:

Mild
Mild
Mild
Mild
Mild
Mild

Moderate
Moderate
Moderate
Moderate
Moderate
Moderate

Severe
Severe
Severe
Severe
Severe
Severe

3. STRENGTHS AND NEEDS: Provide specific feedback about the student in each area, academic and behavior.
(e.g. Student struggles with math computation, specifically subtraction with regrouping in triple digit numbers;
Student must be asked an average of four times before following directions.
Academic

STUDY ORGANIZATIONAL SKILLS/WORK HABITS

Indicate s for a strength and w for a weakness
Class preparation
Organizational skills
Homework assignment completion
Classwork completion
Independent work completion
Cooperative/Group work
Accuracy of work completed
Creativity
Meets deadlines
Test taking skills
Other

Behavior

Additional Comments