School District of the Menomonie Area
TIER II - Needs Assessment
This information should be made available to school staff on a “need to know” only basis and should
be considered confidential.
Student Name:
Today’s date:
Staff Members Completing Form:
Gender:
Date of Birth:
Grad Year:
PRIMARY BEHAVIORS
Academic &
Attendance
OBSERVED
COMMENTS/EVIDENCE
Usually/
Always
Sometimes
Rarely/
Never
Usually/
Always
Sometimes
Rarely/
Never
1. Attends school regularly
2. Completes assignments
regularly
3. Is on time for classes/
school
4. Academic performance
in READING is at grade
level
5. Academic performance
in WRITTEN
EXPRESSION is at grade
level
6. Academic performance
in MATH is at grade level
Behaviors
Comments/Evidence
1. Follows rules
2. Can manage own
impulses
3. Takes responsibility for
own actions
4. Show respect for self
and others
5. Seeks
assistance/attention
appropriately
6. Attends to classroom
activities appropriately
7. Reacts to
conflict/frustration
appropriately
8. Shows respect for own
and others’ property
9. Have there been any
recent significant changes
in this students’ behavior?
Relationships in
School
Usually/
Always
Sometimes
Usually/
Always
Sometimes
Rarely/
Never
Comments/Evidence
1. Appropriately initiates
and maintains age
appropriate relationships
2. Can acknowledge &
understand others
perspectives
Emotional
Rarely/
Never
Comments/Evidence
1. Displays healthy affect
(check concerns):
⃞ Angry
⃞ Depressed
⃞ Aggressive
⃞ Withdrawn
⃞ Anxious
⃞ Manipulative
⃞ Crying
⃞ Other
2. Shows ability to solve
personal problems
3. Communicates moods
and feelings appropriately
4. Sees self in positive light
Health/Physical
1. Maintains appropriate
hygiene and grooming
2. Has basic needs met
appropriately
3. Maintains good health
(check concerns)
⃞ Alcohol Use
⃞ Other Drug Use
⃞ Tobacco Use
⃞ Eating Disorder
⃞ Rested
4. Speech Language skills
are developmentally
appropriate
5. Motor skills are
developmentally
appropriate (list concerns:
gross motor, fine motor).
6. Student accesses health
care and service when
needed
Usually/
Always
Sometimes
Rarely/
Never
COMMENTS/EVIDENCE
7. If student is on
medication, is it taken as
prescribed?
8. Vision and hearing have
been screened?
Family
Usually/
Always
Sometimes
1. Family is involved in
student’s education
2. Family attends school
conferences
3. Family maintains
informal contact
4. Family attends school
events
5. Family utilizes
community resources
6. Family recognizes
students’ strengths
7. What are the family’s
greatest strengths?
8. Have there been any
recent significant changes
in this students’
environment? (e.g. death
in family, illness, divorce,
employment, foster care,
legal issues, etc.)
9. Have parents/guardians
been contacted?
Questions/ Concerns that need to be addressed:
Rarely/
Never
COMMENTS/EVIDENCE
Language: ________________________________________________
Math: ______________________________________________________
Retentions: ___________________________Grade retained:__________
Accelerations:_________________________________________________
Grade or Content accelerated:___________________________________