TEACHER/SCHOOL INFORMATION
This student has applied to participate in the Reading Clinic held at Millersville University from
July 11th until July 29th, 2016. A certified teacher completing his/her reading specialist
certification (or ESL certificate, if the child is an English language learner) will be working with
this student on an individual basis under the direction of a faculty supervisor. The information
that you provide will give us an early start in planning lessons tailored to the needs of this
student. Please return the completed form to us as soon as possible so that we can act upon
this child’s application. Return to:
Dr. Judith Wenrich
Department of Early, Middle and Exceptional Education
Millersville University
P.O. Box 1002
Millersville, PA 17551-0302
Student
__________________________ Grade Completing ______
Name of School ____________________________________________
School District ____________________________________________
**Please note that the Clinic is designed for students who are less than
proficient and are in need of intervention. Space is limited. Receipt of this
completed form is necessary for the student to be considered for clinic.
Date _____________
Name of Teacher Completing Form
______________________________
____ Classroom Teacher
____ Reading Teacher
____ Special Education Teacher
____ ESL Teacher
Please complete the questions that relate to your involvement with the student.
1. Is this student reading:
________ at grade level
________ below grade level
2. At what level is the student reading?
_____ Guided reading instructional level
_______ month/year given
Name of the guided reading leveling system used (e.g., Fountas & Pinnell, DRA 2)
____________________________________________
_____ Grade level of reading series ______________________ Name of reading series
3. Please provide any recent additional reading assessment information you may have.
Name of Test
Month/Year
Results: grade equivalent, percentile rank, etc.
(over)
4. Does this student receive ESL services?
_____ yes
If so, please indicate the child’s level
_____ Stage 1 or pre-conversational
_____ Stage 2 or beginning conversational
_____ Stage 3 or intermediate conversational
_____ Stage 4 or advanced conversational
_____ Stage 5 or approaching academic fluency
_____ no
What language is spoken in the home? _______________________________
What can you tell me about the parents’ ability to communicate with the school? How is this
best accomplished? Can you suggest the name and telephone number of an interpreter, if one
is required?
5. List any academic or other support programs that this student receives at school.
(e.g., Tier 2 or Tier 3 Intervention, Reading Recovery, speech therapy)
6. Does this student have an Individualized Education Plan (IEP)?
_____ yes
_____ no
7. What areas of specific need have you observed?
_____comprehension
_____ content area reading
_____vocabulary
_____ study skills
_____sight vocabulary
_____ motivation
_____phonics/decoding
_____ other
_____fluency
8. Comment on the student’s work habits and motivation.
Are there any behaviors/problems we should be aware of that may impede this student’s
learning?
9. How do you feel the reading specialist candidate can best help or motivate this student?
10. Please provide any additional comments that you feel may be helpful.
11. I would be willing to speak directly to this student’s reading clinician during the summer.
____________________________ phone number at which I could be reached
____________________________ email
Thank you for your cooperation. You may contact Dr. Judith Wenrich, Professor of Literacy
within the Department of Early, Middle and Exceptional Education and Director of the Reading
Clinic at Millersville University at (610) 301-8025 or judith.wenrich@millersville.edu as
necessary.