Student's Name:
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Teacher's Name:
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School:
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Grade:
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School Address:
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School Telephone:
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Describe the student's positive qualities and learning strengths.
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Describe areas of concern and the student's learning weaknesses.
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Describe any problems the student might be having in school (academic or social).
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Comment on the student's behavior or potential.
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What strategies/interventions have been tried? What were the outcomes?
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Does the student require additional testing time when compared with other students?
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Yes
No
Other
If "yes", how much additional time does the student require to complete multiple-choice test items?
25%
50%
100%
None
Other
How much additional time does the student require to complete other question types (short answer, essay, math problems, etc.)?
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25%
50%
100%
None
Other
Please note the specific question types from above.
Does the student use extended time effectively?
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Yes
No
Other
If "yes", does it benefit the student's learning outcome?
Yes
No
Other
If "no", why is the accommodation not effective??
Describe how the student gets along with classmates.
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Describe any unusual or bizarre behavior.
Indicate the student's achievement level in your class: (Please list academic subject and the level/grade)
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Is the student receiving any special education services or has the student been referred for these services? Please describe.
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