Teacher Feedback Survey

Today’s Date: ____________________ Name of Teacher: ______________

Student Initials: __________________ Subject: ______________________

Please check the following boxes that applies the student:

Excellent Adequate Needs Unsatisfactory
Improvement
Attendance/punctuality ¨ ¨ ¨ ¨
Work completion ¨ ¨ ¨ ¨
Group work ¨ ¨ ¨ ¨
Ability to work ¨ ¨ ¨ ¨
independently
Organization ¨ ¨ ¨ ¨
Following verbal ¨ ¨ ¨ ¨
instructions
Following written ¨ ¨ ¨ ¨
instructions
Attitude toward ¨ ¨ ¨ ¨
learning
Peer interactions ¨ ¨ ¨ ¨
Attention/focus ¨ ¨ ¨ ¨
Note taking ¨ ¨ ¨ ¨
Ask for help ¨ ¨ ¨ ¨
Homework ¨ ¨ ¨ ¨
Test taking ¨ ¨ ¨ ¨

1. What concerns would you like to have addressed during this evaluation?
 Teacher Feedback Survey

2. What are the student’s academic strengths?

3. What are the student’s personal strengths?

4. What are the student’s needs?

5. What grade does the student currently have?

 Teacher Feedback Survey
6. Current interventions/accommodations/support given to student:

7. Current assessments/test/unit exams/testing data (if available):

8. How is the student’s interactions with teachers/staff?

9. Describe the student’s interaction with other peers:

 Teacher Feedback Survey
10. What is the student’s work habits and motivation?

11. Are there any particular behaviors that are of concern? Please describe what happens
typically before and after the problem behavior occurs.

12. Have you used any reinforcements? What has worked/what hasn’t?

13. Any other comments?