Carbon Lehigh
Intermediate Unit #21
4210 Independence Drive
Schnecksville, PA 18078-2580
Focus
Lead
Serve
Robert J. Keegan, Jr.
Executive Director
Communicate
610-769-4111
800-223-4821
TDD 610-769-1151
Fax 610-769-1290
www.cliu.org
Collaborate
Improve
TEACHER INPUT FORM
STUDENT REEVALUATION – MDS/BEHAVIORAL CURRICULUM
STUDENT:
EXCEPTIONALITY:
BIRTHDATE:
DATE:
AGE:
TEACHER:
PROGRAM/GRADE:
BUILDING:
HOME DISTRICT:
PLANNED COURSE AREA
Communication Skills (Make sure to include information from ABLLS Sections C-J)
IEP Goals: (if there are specific goals)
Materials Used
Present Skill Levels – description of skills in classroom/community, grade levels
Recommendations for IEP
Social/Behavior Skills (Make sure to include information from ABLLS Sections L-N)
IEP Goals: (if there are specific goals)
Materials Used
Present Skill Levels – description of skills in classroom/community, grade levels
Recommendations for IEP
“CLIU is a student-centered education agency committed to Excellence through Service.”
The Carbon Lehigh Intermediate Unit is an equal opportunity employer and does not discriminate on the basis of race, color, religion, national origin, age, marital status, sex or nonrelevant handicap in activities, programs, or employment practices. For information regarding civil rights or grievance procedures contact Mr. John B. Houser, Section 504 Coordinator,
or Mrs. Kim Talipan, Title IX and ADA Coordinator at the Carbon Lehigh Intermediate Unit, Education Park, 4210 Independence Drive, Schnecksville, PA 18078-2580, 800-223-4821.
Motor Skills (Make sure to include information from ABLLS Sections Y, Z)
IEP Goals: (if there are specific goals)
Materials Used
Present Skill Levels – description of skills in classroom/community, grade levels
Recommendations for IEP
Self Help/Daily Living (Make sure to include information from ABLLS Sections U, V, W,
X/LCCE Domains I and II)
IEP Goals: (if there are specific goals)
Materials Used
Present Skill Levels – description of skills in classroom/community, grade levels
Recommendations for IEP
Functional Academics
Reading/Language Arts (Make sure to include information from ABLLS Section Q)
IEP Goals: (if there are specific goals)
Materials Used
Present Skill Levels – description of skills in classroom/community, grade levels
Recommendations for IEP
Math (Make sure to include information from ABLLS Section R)
IEP Goals: (if there are specific goals)
Materials Used
Present Skill Levels – description of skills in classroom/community, grade levels
Recommendations for IEP
Written Language (Make sure to include information from ABLLS Sections S, T)
IEP Goals: (if there are specific goals)
Materials Used
Present Skill Levels – description of skills in classroom/community, grade levels
Recommendations for IEP
Community Skills
IEP Goals: (if there are specific goals)
Materials Used
Present Skill Levels – description of skills in classroom/community, grade levels
Recommendations for IEP
Vocational/Work Skills (Make sure to include information from LCCE Domain III)
IEP Goals: (if there are specific goals)
Materials Used
Present Skill Levels – description of skills in classroom/community, grade levels
Recommendations for IEP
Leisure/Recreation (Make sure to include information from ABLLS Section K)
IEP Goals: (if there are specific goals)
Materials Used
Present Skill Levels – description of skills in classroom/community, grade levels
Recommendations for IEP
PARTICIPATION IN REGULAR EDUCATION
Subject/Activities
Comments
Recommendations for IEP
GENERAL OBSERVATIONS TO INCLUDE STRENGTHS AND NEEDS OF THE
STUDENT:
SPECIALLY DESIGNED INSTRUCTION WHICH HAS BEEN SUCCESSFUL:
The following specially designed instruction has been successful:
Behavior Management Program
Stimuli Reduction
Modeling
Daily Schedule
Errorless Learning Techniques
Physical Prompts
Small Group Instruction
Functional Curriculum
Verbal Cues
Strategic Seating
Alternative Skills Instruction
Manipulatives
Staff Proximity
Frequent Home/School Contact
Partial Participation
Positive Reinforcement
Peer Tutoring
Repeated Practice
Adjusted Language Level
Community Based Instruction
Other _____________
Computer Assisted Instruction
Multi-modal Techniques
Other _____________
Assistive Technology
Task Analysis
Other _____________
One to one Instruction
Least to Most Prompts
MEDICAL CONCERNS:
OTHER ISSUES:
GENERAL RECOMMENDATIONS:
Teacher Input Form – Student Reevaluation – MDS-Behavioral Curriculum.doc