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