WESTMORELAND INTERMEDIATE UNIT
102 Equity Drive  Greensburg, PA 15601
NON-PUBLIC SCHOOL SERVICES – TEACHER INPUT FORM
Student’s Name:________________________________
Grade: ________ Subjects taught:__________________
Teacher: _________________________________
Date Completed:___________________________
1) What is the specific reason(s) for this referral? Please give examples of student’s behavior or academic issues.
How do you feel this affects the child’s performance in other areas?
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2) Student Strengths and Weaknesses
Please indicate weaknesses with W, strengths with an S, and NA if not applicable.
___independent reading assignments
___oral reading assignments
___following oral instructions
___following written instructions
___grasping new skills
___mastery of prerequisite skills
___completing homework assignments
___test taking skills
___note taking skills
___attendance
___behavior
___organizational skills
___perception skills
___transfer skills (copying from board, etc…)
___Other_________________________
___Other_____________________________
Comments: __________________________________________________________________________________
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3) Student Performance (Please check appropriate level for each)
 Student is performing
_______ at his/her potential
_______ above
_______ below
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Student is working
_______consistently in academic efforts
_______ inconsistently
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Student’s motivation is
_______average
_______ high
_______ low
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Student’s overall grade is
_______
Teacher Input Form 1
4) What content area(s) are a particular problem for this student?
5) Homework by the student is completed:
_____almost always
_____Sporadically
_____Almost Never
6) What is the student’s learning style?
_____auditory
_____visual
_____Multisensory
7) Adaptations/Modifications that have been tried in the classroom(academic and/or behavioral):
Please add additional adaptations/modifications if necessary.
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Adaptation/modification used:_____________________________________________________________
Frequency:
____daily
Effectiveness: ____high

____monthly
____low
____other
Adaptation/modification used:______________________________________________________________
Frequency:
____daily
Effectiveness: ____high

____weekly
____medium
____weekly
____medium
____monthly
____low
____other
Adaptation/modification used:_______________________________________________________________
Frequency:
____daily
Effectiveness: ____high
____weekly
____medium
____monthly
____low
____other
Please list all current modifications/adaptations that are in use:_____________________________________
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8) Please list any strengths or weaknesses you have observed with the student in an academic setting.
Strengths (including academic, social, emotional, behavioral, etc…):
Weaknesses (including academic, social, emotional, behavioral, etc…):
9) Are there any special skills or interests that the child possesses? (Art, Music, Hobbies, Sports, etc…) Please list.
Teacher Input Form 2
10) How is the child socially – does he/she interact appropriately with others? Does he/she have friends? How
does he/she work within a group? How do they work independently? Does the child respect other people’s
property? Do they respect their own property/belongings? (Please give examples)
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11) Does the student voluntarily engage in classroom activities? If not, what do you perceive to be the
problem? (Is he/she preoccupied? Daydreaming? Shy? Is the material too difficult?, etc…)
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12) Behavioral Characteristics Noted:
The Student….
Is overly active
Displays general awkwardness
Exhibits frequent reversals (reading or writing)
Is underachieving in reading
Is underachieving in mathematics
Is underachieving in spelling
Displays poor printing, writing, or drawing
Shows confusion about instruction
Demonstrates aggressive/explosive behavior
Has difficulty initiating/sustaining relationships
Displays short attention span
Accepts adult authority
Has poor school/parent relationship
Exhibits withdrawn behavior
Exhibits low self-esteem
YES
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NO
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13) Is there any other information you would like to provide for this evaluation? Additional concerns?
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Teacher Input Form 3