ESL Step 3 – Form C
DATE: ____________________
Student’s Name _____________________________________
Parents/Guardians ___________________________________
Address ____________________________________________
Phone (s) ___________________________________________
Interviewer(s) ____________________________________________________________________________________________
ESL FAMILY AND INSTRUCTIONAL HISTORY
TEACHER’S REASON(S) FOR CONCERN: _______________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
A.
Family & Cultural Factors
1. What is the family’s native country?
2. Why did the family immigrate to the U.S.?
3. Did the entire family immigrate together? If they did
not, specify the order and when each family member
came to U.S. and who, if any, remain in the native
country.
4. What was each parent’s occupation in their native
country? What job does each parent have in the U.S.?
5. Are there any differences in the child’s activities,
behavior, and attitude compared to when they lived in
their native country?
6. What is each parent’s educational level?
7. Who lives in the student’s home? What language or
languages does each person in the home use to
communicate with the child? If more than one
language is used, specify the percent of time used in
English and the native language for each person in the
home.
8. Is the child’s level of acculturation different from that
of his/her parents? If so, does this result in added
stress or additional responsibilities for the child?
9. Does the family watch television programs and listen to
radio stations that are in the native language? English?
Both? Other?
10. Does anyone assist the child with school work in their
native/first language?
11. Are there concerns about the child’s development?
How does this student compare to his/her siblings with
respect to stages of development?
12. Has the student had any significant illnesses or injuries?
If so, how were these addressed?
13. Are there any other concerns (academic, social,
behavior, attitude, etc.)?
B. Family Mobility
14. Has the family moved within a state or across state
lines? Name the different locations and the amount
of time at each location.
15. Has the family visited or returned to their native
country? If so, how often and for how long?
16. How many different schools has the child attended?
What was the length of stay at each school?
17. On average, how many school days does the student
miss per year due to traveling between locations?
C.
Preschool Experiences
18. Who was/were the child(s) primary caregivers? What
language(s) did they speak to the child?
19. Did child receive any preschool educational services
(i.e. Head Start or Private Center)? If no, proceed to
next section. If yes, ask the following questions:
20. For how long did the child receive these preschool
educational services?
21. Were the preschool services offered in the child’s
native language, in English, or in both languages?
22. Did personnel in these preschool settings note any
concerns about this child? If yes, please describe:
D.
Educational History in Native Country
23. Did the child start his/her formal schooling in the
United States? If yes, proceed to next section, if no,
ask the following questions:
24. How many years did the child attend school in native
country?
25. How is school structured in the child’s native country?
Ask parents to describe a typical school day in their
native country. Was the school that the child
attended in their native country located in an urban
or rural area?
26. What do we know about the language system used in
the native country? For example, does it have a
written form and is it read from a left to right basis or
vice-versa?
27. Did the child regularly attend school in native
country?
28. Did the student evidence any academic difficulties/
problems while attending school in the native
country?
29. Do parents have written documentation about student
performance in school in native country? Have these
been translated and reviewed?
ESL Step 3 – Form C
E.
Student Performance and Language Considerations
30. What ESL services has the child received
(program, type, materials, duration, etc.)?
31. What specific instructional interventions has the
teacher used with the child?
32. How long were these interventions implemented?
33. What were the results of these interventions?
34. At what instructional level does the child perform
in his/her first or native language and in English?
(reading, math, etc.) Are the suspected areas of
difficulty noted in both the child’s native
language and in English?
35. What work samples have been collected for this
student across time?
36. What is the child’s current level CALP/BICS in L1?
L2?
37. Does the child’s performance improve when
provided instructional assistance in his/her native
language?
38. Compare the student’s attitude during ESL
program services versus general education?
39. How well does the child communicate in his/her
first or native language and in English across
different settings (home, classroom, playground,
neighborhood, community)?
40. Does the child evidence common language
patterns, differences and characteristics
frequently noted in second language learners?
41. How does the child feel about acquiring English?
F. Other Information
42. Other Information
ESL Step 3 – Form C
ESL Step 3 – Form D
ESL School-Based Team Summary Report
Based on current data, the English Second Language School-Based Team has determined the following factors
have been ruled out as primarily attributing to the child’s learning and/or behavior problems.
Please check all factors that have been ruled out:
□
□
□
□
Limited English Proficiency – Step 1
Socio-Cultural Differences (Level of Acculturation) – Step 1
Instruction/materials not appropriate for ELL – Step 2
Lack of Opportunity (Inconsistent schooling, mobility, etc.) – Step 3
Recommendations:
______
The student is progressing appropriately and referral for further evaluation is not necessary
at this time.
______
Additional information is needed.
Please describe: _________________________________________________________________
________________________________________________________________________________
______
Additional intervention(s) to be implemented for the next _____weeks. (minimum 3 weeks)
______
Referral to the Student Support Team (SST).
______
Other:
Please describe: _________________________________________________________________
________________________________________________________________________________
Signature
______________________________________________
Date
__________________
Administrator
______________________________________________
__________________
Building ESL Teacher
______________________________________________
__________________
Classroom Teacher
______________________________________________
__________________
Referring Teacher
_________________________________________________________
School Psychologist or Speech Pathologist
_______________________