Smart Inclusion Tracking and Evaluation (Pre-Questionnaire)
Your evaluation of various “inclusion targets” is required so that we can assess the impact of Smart Inclusion on student engagement, participation,
communication and learning. You will be asked to complete ONE form for the ONE student for whom the SEA equipment was purchased. If you
have other special needs students you would like to report on, please do so by additional completing forms for them as well. You should have
consents for all students for whom a form is completed. Information from all evaluations will be collated for reporting purposes. Students,
schools, and teachers will not be identified by name in any reporting. We are asking any staff able to report on students LAST YEAR to have
input into this questionnaire. We need information from those who would have the best knowledge of the student LAST YEAR. Thank
you.
Complete the student information box below
Please attach the final IEP from the previous school year (2007-2008) and the final report card from last year (2007-2008).
Return all by FAX (613) 925-3244 or Courier to: Alison Inglis at the Frankville office.
Student:
PRE Evaluation - Date completed___________________________
School:
Current Teacher:
Grade (this year):
Current Education Assistant(s):
DOB:
Please proceed to the next set of questions
If you have ANY questions about, or need ANY clarification of, questions asked please contact
alison.inglis@ucdsb.on.ca or alexandra.dunn@ucdsb.on.ca
Please read each question carefully and provide a response FOR THE PREVIOUS SCHOOL YEAR 2007-2008 as your response-point.
This requires you to “report retrospectively” and provide estimates/impressions for the entire school year last year. A space for
additional comments is provided.
Question
Percentage of time the
student was in the
classroom during the
school day last year
(instructional time only;
310 minutes – excludes
nutrition/recess breaks).
Circle One –>
Response
1. No time spent in class (0%)
2. A small part of the day
(1-10% = up to 30 minutes, total for day)
3. Some parts of the day
(11-39% = between 31 and 120 minutes, total for day)
4. Several parts of the day
(40-60% = between 121 and 190 minutes, total for day)
5. Many parts of the day
(61-75% = between 191 and 232 minutes, total for day)
6. Most of the day
(76-95% = between 233 and 295 minutes.
7. Almost all day
(more than 295 minutes, total for day).
Percentage of time
student was engaged in
activities -social,
academic, etc. (e.g.
looking, listening,
responding) last year.
1. 0% of the time (never engaged)
2. up to 10% of the time (limited engagement)
3. 11 to 50% of the time (some engagement)
4. 51 to 79% of the time (engaged a lot of the time)
Circle One – >
5. 80 to 100% of the time (engaged most or all of the time)
Comments
Question
Response
Were there significant
disruptive incidents over
the course of the school
year, last year?
_____Behaviour has not ever been seriously
disruptive (Go to next question).
Disruptive incidents are
defined as those that
require removal of student
from classroom and/or
removal of other students
from the class and/or
significant interruptions to
learning of others.
______Disruptive incidents were an issue last
year. Describe (circle one):
1. A few serious disruptive incidents
throughout the year (1-4).
2. Many serious disruptive incidents
throughout the year (monthly).
3. A significant number of disruptive incidents
throughout the year (weekly).
4. Behaviour was extremely difficult to manage
(serious incidents almost daily).
Comments
Information about the student’s level of participation in the classroom last year, with peers and with programming, is needed. Levels of
participation may include:
“Competitive”: Student participates in the same educational activities with, and at the same time as, peers. Adaptations/accommodations to access
curriculum may be used as needed. Academic expectations are the same as those of peers. Progress is evaluated similarly to peers.
“Active”: Student participates in the same educational activities with, and at the same time as, peers (i.e., literacy activities during literacy block). Some
adaptations to access curriculum are used as needed, and some modifications are made to the curriculum - academic expectations are different from those of
peers. Progress is evaluated according to individualized standards.
“Involved”: Student pursues individualized goals through activities that are woven into educational activities of peers, and involves interaction with peers
during those activities (i.e., student hands out math manipulatives to peers to meet social, communication, and fine motor goals) = modified goals and
objectives to meet individual needs in cross-curricular domains. Progress is evaluated according to individualized standards.
“None”: Student participates in different educational activities than those that the rest of the class is involved in. Peer interaction is limited to very little or
none. Academic expectations may range from the same as those of peers (though the student is not involved with peers or pursuing the expectation at the
same time as peers), to highly individualized and very different from those of peers.
Subject areas, and
participation level for each
subject area, last year.
Subject: ______________________________
Subject: ______________________________
Participation Level(circle one):
Participation Level(circle one):
A – Competitive
B – Active
C – Involved
D - None
A – Competitive
B – Active
C – Involved
D - None
Subject: ______________________________
Subject: ______________________________
Participation Level(circle one):
Participation Level(circle one):
A – Competitive
B – Active
C – Involved
D - None
A – Competitive
B – Active
C – Involved
D – None
Continued next page…
Continued next page…
Continued…….
Subject areas, and
participation level for each
subject area, last year.
Subject: ______________________________
Participation Level(circle one):
A – Competitive
B – Active
C – Involved
D - None
Subject: ______________________________
Participation Level(circle one):
A – Competitive
B – Active
C – Involved
D - None
Other areas? Comments?
Question
Amount of additional direct
assistance required during
the day last year to
interpret/understand
lesson/task (over and
above usual assistance that
is often provided to all
students)
Check One –>
Response
____Direct assistance was required almost all of the
time to interpret/understand lesson/task (almost all
hours of the day)
____A lot of assistance - direct assistance was
required up to 75% of the time to
interpret/understand lesson/task
____Some assistance - direct assistance was required
up to 50% of the time to interpret/understand
lesson/task
____A bit of assistance - direct assistance was
required up to 25% of the time to
interpret/understand lesson/task
____No (or very minimal) direct assistance was
required.
Amount of additional direct
assistance required during
the day last year to
complete work or task
(over and above usual
assistance that is often
provided to all students)
____Direct assistance was required almost all of the
time to complete work/task (almost all hours of the
day)
____A lot of assistance - direct assistance was
required up to 75% of the time to complete work/task
____Some assistance - direct assistance was required
up to 50% of the time to complete work/task
Check One –>
____A bit of assistance - direct assistance was
required up to 25% of the time to complete work/task
____No (or very minimal) direct assistance was
required.
Comments
Question
Percentage of time
communication
opportunities were
present last year for the
student during academic
activities (i.e., chance to
take a turn, engage with
peers, provide an answer,
etc.)
Response
1. 0% of the time - no communication opportunities
were present.
2. up to 10% of the time - limited communication
opportunities were present.
3. 11 to 50% of the time - some communication
opportunities were present.
4. 51 to 79% of the time - frequent communication
opportunities were present.
Circle One –>
5. 80 to 100% of the time - communication
opportunities were present much or all of the time.
Percentage of time that the
student’s communication
responses were
successful last year
during academic activities
(i.e., student engages in the
communication
opportunities – see
previous - when they are
presented)
1. 0% of the time – there were no successful
communication responses.
Circle One –>
5. 80 to 100% of the time – most or all communication
responses were successful.
2. up to 10% of the time - there were limited successful
communication responses.
3. 11 to 50% of the time - there were some successful
communication responses.
4. 51 to 79% of the time - there were frequent
successful communication responses.
Comments
Question
Percentage of successful
social communication
attempts during the school
day last year (e.g.
greeting, manners)
Circle One –>
Response
1. 0% – there were no social communication attempts.
2. up to 10% of the time - there were limited social
communication attempts.
3. 11 to 50% of the time - there were some social
communication attempts.
4. 51 to 79% of the time - there were frequent social
communication attempts.
5. 80 to 100% of the time –social communication was
attempted most or all of the time.
Quality of work/tasks
undertaken last year e.g.
marks, meeting
expectations…..
Comments/Describe (use extra sheets if necessary):
Most significant
achievements for the
student last year …..
Comments/Describe (use extra sheets if necessary):
What were the most
challenging aspects related
to achievement for the
student last year …
Comments/Describe (use extra sheets if necessary):
Comments
How would you describe
this student’s social
experiences at school, last
year?
___ Socialized with many peers.
___ Socialized with one or two peers.
___ Rarely socialized with peers.
i.e., social experiences
would include playing with
peers, talking with peers
about things other than
school work, eating lunch
as part of a peer group, etc.
Additional comments/observations:
Additional comments (use extra sheets if necessary):
Person(s) who completed this questionnaire________________________________________________________________________________
Thank you for taking the time to provide this information!
Please attach the final 2007-2008 version (last year)
of the student’s IEP and June 2008 report card
Return all by FAX (613) 925-3244 or Courier to: Alison Inglis at the Frankville office