Student Profile Packet
Date: _______________
Archdiocese of Indianapolis
Student Profile
Student: ________________________________________________ D.O.B. ____________Grade: ________
School: ___________________________________________________________________________________
Teacher(s): _______________________________________________________________________________
Is student eligible for Title 1 Services at your school? ____Yes ____No
Student Strengths: _________________________________________________________________________
__________________________________________________________________________________________
The student is experiencing difficulty in the following areas:
_____ Academic _____ Behavioral _____ Social Emotional _____ Other
The following areas appear to be contributing factors:
_____ Classwork _____ Effort _____ Homework _____ Attention Span
_____ Time on Task _____ Other (please explain)
Attendance Information: Absences ______ Tardies ______ Recording Period __________
Additional Pertinent Information: ____________________________________________________________
__________________________________________________________________________________________
Academic Information:
Final grades from previous year:
_____ Reading _____ Math
_____ English
_____ Phonics
Current Grades: As of: _____________
_____ Spelling
_____ Science _____ Social Studies
_____ Reading _____ Math
_____ English
_____ Phonics
_____ Spelling
_____ Science _____ Social Studies
Standardized Test Scores: Attach the cumulative standardized test report from student file
Social Emotional Information:
Peer Interactions: ___________________________________________________________________________
__________________________________________________________________________________________
Motivational Level: _________________________________________________________________________
__________________________________________________________________________________________
Archdiocese of Indianapolis
Student Profile Packet
Archdiocese of Indianapolis
Academic Report
Student Name: ___________________
Date: ____________________
Please use the following code:
G = Good Performance A = Average Performance P = Poor Performance
If the skill is not observed, please leave item blank
Listening
Spoken Language
___Retention of information one-on-one
___Comprehension of class discussions
___Comprehension of word meanings
___Ability to follow directions
Comments: ___________________________________
___Appropriate vocabulary
___Ability to recall words
___Ability to convey ideas clearly
___Usage of correct syntax
___Willing to participate in discussions
Comments: ___________________________________
_____________________________________________
_____________________________________________
Reading
___Ability to rhyme
___Ability to distinguish between speech sounds
___Ability to blend phonemes
___Ability to segment phonemes
___Ability to use word attack skills
___Recognizes words on grade level
___Reads without omissions, additions, and reversals
___Fluent reader
___Ability to make inferences
___Ability to comprehend what is read
___Ability to retell and summarize
___Enjoyment of reading
___Discrepancy between listening comprehension and
reading comprehension (yes/no)
Comments: ___________________________________
_____________________________________________
Written Language
___Legible Handwriting
___Copying from board/book
___Ability to write without letter reversals
___Spelling skills
___Appropriate spacing and centering
___Ability to express ideas in writing
___Ability to write a complete sentence
___Ability to write a cohesive paragraph
___Discrepancy between oral and written ability
(yes/no)
Comments: ___________________________________
_____________________________________________
Behavior
___Ability to understand math concepts
___Ability to perform basic math operations
___Knowledge of basic math facts
___Ability to understand fractions
___Ability to understand algebraic concepts
___Ability to understand geometric concepts
___Ability to complete word problems
___Knowledge of money concepts
___Knowledge of time concepts
___Knowledge of measurement concepts
___Attendance
___Cooperation
___Motivation
___Attitude
___Ability to remain on task
___Organization
___Transitions from task to task
___Understands consequences
___Accepts responsibility
___Completes classwork
___Completes homework
___Study skills
___Peer relationships
Comments: ___________________________________
Comments: ___________________________________
_____________________________________________
_____________________________________________
Math
Archdiocese of Indianapolis
Student Profile Packet
Archdiocese of Indianapolis
Parent Report
Student Name: ___________________
Date: ____________________
Please complete and return to your child’s teacher by ___________________.
1. Strengths my child has – include interests, hobbies, possible career potentials, anything that
your child does that you appreciate and/or enjoy.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. Concerns for my child:
At school __________________________________________________________________
__________________________________________________________________________
At home ___________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3. Ways that I have found to motivate my child:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
4. Goals or expectations I have for my child:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
5. Please share any additional information that will help us further understand
your child.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3A of 9
Archdiocese of Indianapolis
Student Profile Packet
Informe de los Padres
Student Name: ___________________
Date: ____________________
Por favor complete esta información y devuélvala al maestro o la maestra de su hija/o antes del ____
1. Virtudes de mi hija/o – incluya sus intereses, hobbies, potencial para estudios futuros,
cualquier cosa que su hija/o haga que usted aprecia o disfruta.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. Asuntos que me preocupan en relación con mi hija/o:
En la escuela: ______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
En la casa: ________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3. Las maneras que he encontrado para motivar a mi hija/o son:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
4. Metas o expectativas que tengo para mi hija/o:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
5. Por favor comparta con nosotros cualquier otra información que nos pueda ayudar a
entender mejor a su hija/o.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3B of 9
Archdiocese of Indianapolis
Student Profile Packet
Date: _________
Archdiocese of Indianapolis
Student Report
Student Name: ___________________
Date: ____________________
Please complete and return to your teacher by ___________________.
1. Some things that I enjoy doing are: _____________________________________________
__________________________________________________________________________
2. Some things that I do very well are: ____________________________________________
__________________________________________________________________________
3. My favorite activity or subject at school is: _______________________________________
__________________________________________________________________________
4. At school I worry about:______________________________________________________
__________________________________________________________________________
5. At school I have difficulty with: ________________________________________________
__________________________________________________________________________
__________________________________________________________________________
6. At school I am embarrassed when: ______________________________________________
__________________________________________________________________________
7. My least favorite activity or subject at school is: ___________________________________
__________________________________________________________________________
8. At home I worry about: _______________________________________________________
__________________________________________________________________________
9. The best reward anyone can give me is: __________________________________________
__________________________________________________________________________
10.Five years from now I will be: _________________________________________________
__________________________________________________________________________
11. When I am an adult I will be: __________________________________________________
__________________________________________________________________________
4 of 9
Archdiocese of Indianapolis
Student Profile Packet
Archdiocese of Indianapolis
Behavior Report
Name _________________________________________ Age _______ Date _________________
Never
or rarely
Sometimes
Often
1. Fails to give close attention to details
0
1
2
2. Has difficulty sustaining attention in tasks
0
1
2
or leisure activities
3. Has difficulty organizing tasks and activities
0
1
2
4. Inconsistent listening skills
0
1
2
5. Fails to finish tasks
0
1
2
6. Makes careless mistakes
0
1
2
7. Homework is often missing or misplaced
0
1
2
8. Missing supplies necessary for tasks completion
0
1
2
9. Easily distracted
0
1
2
10. Fidgets with hand or feet or squirms
0
1
2
11. Leaves seat in situations in which remaining
0
1
2
seated is expected
12. Has difficulty engaging in leisure activities quietly
0
1
2
13. Acts as if “driven by a motor”
0
1
2
14. Talks excessively
0
1
2
15. Blurts out answers before questions have been
0
1
2
completed
16. Has difficulty waiting his/her turn
0
1
2
17. Interrupts or intrudes on others
0
1
2
18. Loses temper
0
1
2
19. Argues with others
0
1
2
20. Actively defies or refuses to comply with
0
1
2
requests or rules
21. Deliberately annoys people
0
1
2
22. Blames others for own mistakes or misbehaviors
0
1
2
23. Often is annoyed by others
0
1
2
24. Shows anger and resentment
0
1
2
25. Demonstrates spitefulness and vindictiveness
0
1
2
26. Poor peer relationships
0
1
2
27. Demonstrates anxiety or fearful reactions to
0
1
2
everyday situations
28. Reluctance or refusal to come to school
0
1
2
29. Repetitive unproductive behaviors
0
1
2
30. Additional Comments:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
5 of 9
Archdiocese of Indianapolis
Student Profile Packet
Archdiocese of Indianapolis
Student Behavior Chart
Student’s Name: ________________________________________________ School: ________________________________________________
Teachers: _______________________________________________________________ School Year: __________________________________
Date
Undesired Behavior
Setting
Antecedent
Staff Intervention
Student Response
Parent
Contacted/
Result
Archdiocese of Indianapolis
6 of 9
Student Profile Packet
Archdiocese of Indianapolis
Student Behavior Plan
Student’s Name: ________________________________________________
School: ________________________________________________
Teachers: _______________________________________________________________ Date: ________________________________________
Undesired Behavior
Desired Behavior
Student Plan of Action
Review Date:
__________________________
Parent Signature
__________________________
Student Signature
__________________________
Teacher Signature
_____________________
Date
_____________________
Date
_____________________
Date
7 of 9
Archdiocese of Indianapolis
Student Profile Packet
Date:
Archdiocese of Indianapolis
Documentation of Interventions
Review
Date
Interventions Attempted
By: _________________________
Differentiated Instruction
By: _________________________
Student: _____________________________________________________
***allow at least 4-6 weeks for monitoring outcomes
Date
Outcome
Team
Initiated
School: ____________________________________________
8 of 9
Archdiocese of Indianapolis
Student Profile Packet
Archdiocese of Indianapolis
Communication Log
Please document all conferences held to share concerns about this student.
Student:_____________________________________________________ School:____________________________________________________
DATE
PURPOSE OF CONFERENCE
PARTICIPANTS
9 of 9
IN-SCHOOL
PHONE
MEETING CONFERENCE/
RESULT
Archdiocese of Indianapolis