Monroe County Schools RtI

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Monroe County Schools
RtI Form 9
RtI Parent Questionnaire
Personal Information
Child’s Name ___________________________________ Date_______________________________
DOB _______________________ Gender______________
Address ________________________________________________________________________________
________________________________________________________________________________
Phone Number ________________________________
Name of Person Completing Questionnaire _____________________________________________
Relationship to Child ______________________________________
Who does child live with? ______________________________________________________________
Mother’s Name____________________________________Occupation________________________
Father’s Name ____________________________________Occupation________________________
Does your child have siblings? __________ yes ____________no
If yes, How many? (list gender(s) and age(s)
_____________________________________________________________________________________
____________________________________________________________________________________
Birth History
Were there any complications during pregnancy? (If yes, Explain) _________________________
_______________________________________________________________________________________
______________________________________________________________________________________
Was Child born prematurely? Yes ___________ No___________
If yes, how many weeks or months? _____________________________________________________
Were there any problems during labor or after birth? Yes ______________ No_______________
If yes, explain. _________________________________________________________________________
______________________________________________________________________________________
Response to Instruction
Updated August 2011
Monroe County Schools
RtI Form 9
Developmental History
How old was your child when he/she talked? _____________________
How old was your child when he/she crawled? ____________ walked? ____________________
At what age was your child’s potty trained? _____________________
Did your child have any problems sleeping through the night? _________________________
At what age did they sleep through the night?________________________________
Does your child have hearing or vision problems? __________________________________
Did your child have ear infections as an infant or toddler? _______________ How often?
__________________________________________________________________________________
Family History
Do any family members have a history of learning problems? Be specific.________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do any family members have any medical problems? Be specific. _______________________
_____________________________________________________________________________________
_____________________________________________________________________________________
About Your Child
What are some of child’s interests? ______________________________________________________
_______________________________________________________________________________________
Likes___________________________________________________________________________________
Dislikes________________________________________________________________________________
Does your child have any allergies?________________ Please specify.________________________
_______________________________________________________________________________________
Does your child take any medications? Yes _____________________ No______________________
If yes, please explain. __________________________________________________________________
Response to Instruction
Updated August 2011
Monroe County Schools
RtI Form 9
Has your child ever received any special services? Yes_____________ No
__________________
_______________________________________________________________________________________
Did your child attend Pre-school? Yes__________ No_____________
If yes, Where? ________________________________________________________________________
How was his/her preschool experience? _________________________________________________
______________________________________________________________________________________
Socialization
Attention
_________Plays well with others
________Easily Distracted
_________Included by peers in activities
________Makes eye contact
_________Works well in a group
________Forgets Directions
_________Prefers to play alone
Behavior
Speech
________Excitable
_______Speaks in clear easily understood
phrase or sentences
________Very Active
_______Expresses wants and needs
_______Needs instructions repeated
________Does not Follow Requests
________Unable to accept limits
________Disinterested in people
________Interactive well with peers
Self Help
________Needs assistance with toileting
________Needs assistance with feeding
________Needs assistant with dressing
________Hits
________Kicks
________Bites
________Unaware of danger
________Quiet or Withdrawn
________Fearful
Comments:_______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Response to Instruction
Updated August 2011
Monroe County Schools
Response to Instruction
RtI Form 9
Updated August 2011
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