Fill - Free fillable Educator's Questionnaire PDF form

EDUCATOR’S QUESTIONNAIRE

1

Dr. Clive J. Schwartz

Developmental Pediatrics

clive.schwartz@utoronto.ca

Fax: 1-866-846-6939

EDUCATOR’S QUESTIONNAIRE

Date#: _____________________

Student name#: _____________________ Birth date: YYYY____MM____DD____

Present Grade level or placement:

Name of School: ______________________________________

Tel#: _____________________

Fax#: ____________________

School Email: _____________________

Address: ___________________________________________

_________________________________________

Principal: ____________________

Classroom teacher: ____________________

Questionnaire completed by: _______________

Date: _________________

Position: _______________________

Email: _____________________

EDUCATOR’S QUESTIONNAIRE

2

1. Please indicate this student’s present placement (include type of classroom, special

remedial support or special programming) and whether IPRC has been accessed or is planned.

___________________________________________________________________________

Does student receive in-class or withdrawal support?

_____ hrs. per day _____ hrs. per week

Name of E.A. or S.E.R.T. or other professional providing this support:

_______________________

2. To your knowledge who initiated the concern that prompted this referral to the doctor?

3. Please list this student’s strengths and difficulties?

STRENGTHS:

___________________________________________________________________________

________________________________________________________________________

___________________________________________________________________________

DIFFICULTIES:

___________________________________________________________________________

Please list any specific concerns and questions you would like answered to help you with this

student:

1.

2.

3.

4.

EDUCATOR’S QUESTIONNAIRE

3

How does she/he get along with adults and peers?

________________________________________________________________

Please indicate if any of the following reports are available and please attach copies:

In-school testing including PPVT

Psychological/ Psychoeducational report

Speech and Language Pathology report

Occupational Therapy report

Are you aware of any pending evaluation by the school team or board if this has not yet been

done?

Which of the following professionals are/have been involved with this student?

Involved

Professional (Name)

Educational Assistant

S.E.R.T.

Speech & Language Pathologist

Guidance Staff

Occupational Therapist

Psychometrist/Psychologist/Psychological

Associate

Social Worker

Special Education facilitator

EDUCATOR’S QUESTIONNAIRE

4

Student Performance: (For elementary school students) – Please estimate the areas are

of concern as you see them and what you suspect is this student’s level is relative to

curriculum expectations. This may be subjective and not necessarily based on any actual

achievement testing.

Major

Concern

Minor

Concern

No

Concern

Advanced

for age

Reading

Word recognition

Reading rate

Oral reading

Silent reading

Spelling

Accuracy

Writing

Punctuation

Legibility

Volume output

Written Language

Motor Skills

Arithmetic

Computation

Problem solving

Language

Word pronunciation

Comprehension

Instruction

Oral sentence structure and

fluency

General Knowledge

Creativity/imagination

Enthusiasm

EDUCATOR’S QUESTIONNAIRE

5

OBSERVATION

Not at

All

Just a

little

Pretty

Much

Very

Much

INATTENTION

Often fails to give close attention to details or makes

careless mistakes in schoolwork, work, or other

activities

Often has difficulty sustaining attention in tasks or

play activities

Often does not seem to listen when spoken to

directly

Often does not follow through on instructions and

fails to finish schoolwork, chores, or duties in the

workplace (not due to oppositional behavior or

failure to understand instructions)

Often has difficulty organizing tasks and activities

Often avoids, dislikes, or is reluctant to engage in

tasks that require sustained mental effort (such as

schoolwork or homework)

Often loses things necessary for tasks or activities

(eg, toys, school assignments, pencils, books, or

tools)

Is often easily distracted by extraneous stimuli

Is often forgetful in daily activities

HYPERACTIVITY

Often fidgets with hands or feet or squirms in seat

Often leaves seat in classroom or in other situations

in which remaining seated is expected

Often runs about or climbs excessively in situations

in which it is inappropriate (in adolescents or adults,

may be limited to subjective feelings of restlessness)

Often has difficulty playing or engaging in leisure

activities quietly

Is often "on the go" or often acts as if "driven by a

motor"

Often talks excessively

IMPULSIVITY

Often blurts out answers before questions have been

completed

Often has difficulty awaiting turn

Often interrupts or intrudes on others (eg, butts into

conversations or games)

EDUCATOR’S QUESTIONNAIRE

6

Does this student have access to a writing aid/computer?

Does this student have satisfactory keyboarding skills and is he/she utilizing software such as

Kurzweil, WordQ Inspiration/Smart Ideas or Dragon etc?

Does this student have any special interests or talents?

How serious do you feel that this problem is at this time?

ANY ADDITIONAL COMMENTS ON THIS STUDENT AND/OR THE FORMAT OF THIS

QUESTIONNAIRE?

Thank you!

Please fax completed questionnaire to 1-866-846-6939 or

scan and email to drcjs@me.com

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Fillable Educator's Questionnaire

Fill Online, Printable, Fillable, Blank Educator's Questionnaire Form

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