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
Spelling
Writing
Arithmetic
Language
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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