At Risk Student Referral Form
(Created by the KHS Child Study Team-form is an electronic form for teachers to submit)
Please check all applicable statements in each section. The last section is a required response asking for
you to indicate any successful interventions/strategies
First Name:_________________ Last Name:____________ Grade:
Please verify the following has occurred: * Student achieves less than 50% of assignments in a two
week time period
____ Yes
____ No
Please verify the following has occurred: * Student has at least 9 tardies to class
____ Yes
____ No
Please verify the following has occurred: * Student has at least 3 absences from your class
____Yes
____No
Which of the following has the student met? * Check all that apply
____ Less then 50 % of assignments completed
____ More than 9 tardies
____ More than 3 absences
Observable Behaviors * Check all that apply
____Achieving Below Potential
____ Recent decline in grades or class participation
____ Attitude negatively affecting work ____ Always behind in class
____Frequently absent
____ Frequently asks to leave the room
____ Often asks to see the nurse
____Does not have a sense of belonging or connection to school
____Disrupts learning environment
____ Distracts others
____Will not complete class assignments ____Doesn't complete homework assignments
____Unprepared for class
____Apathetic
____Unresponsive to prompts ____ Hygiene
____Targets others
____Targeted by others
____Sudden change in weight
____ Inappropriate responses
Any additional behavior or observations. Please use the space below to provide additional
information regarding either the behavior or concerns.
Please check all strategies and interventions you have used to increase student success in your
classroom.
Classroom Structure
____ Define limits, rules, and task expectation ____Follow consistent routines
____ Structure environment
____ Limit distractions
____ Define Physical Space
____ Provide tasks to reduce over activity
____Provide safe areas to regain control
Curriculum Variables
___ Modify assignments
____Give concise instructions
___Provide instructions in multiple formats
____Provide multisensory cues and supports
___Check for understanding
____ Allow extra time to process information
___ Use physical prompts
Teacher Student Interactions
___Signal Nonverbally
____ Control by proximity
____Redirect
____ Allow time out
Parental Involvement
____P raise
____ Ignored behavior
____ Praise appropriate behaviors in others
____ Parent contacted
____ Schedule reports to parent
____ Confer with parent
____ Use home/school communication
____ Use home/school reward system
Were there any effective interventions/strategies? Please take a moment to indicate any successful
interventions or strategies:
Person Making ReferraL: