Fillable FacReferform Faculty Referral Form

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FacReferform Faculty Referral Form

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Mt San Jacinto Community College District
Learning Skills Program
San Jacinto 951-487-3490 Menifee 951-639-5491
Indicators of Learning Disabilities
Referral/Information Form
(To be completed by Instructor/Counselor)
Student:_______________________________________ Date:__________ Semester:__________
Referred By:____________________________________ Dept.:____________________________
Course:__________________________________________________________________________
Please give completed form to student to bring to Learning Disabilities Specialist
or send to ldspecialist@msjc.edu
Please check those behaviors you have observed:
A. Areas of strength for this student
Organizing
Problem solving
Note-taking
Reasoning/Logic
In-class communications with me and/or others
Memory for information just heard/read
Memory over time
Attention/concentration
Attendance
Following written directions
Following verbal directions
Classroom/group participation
Attends to and follows lecture
Test scores
Written work (spelling, grammar, punctuation, syntax, conceptual composition)
Other (please specify) ____________________________________________________
B. Areas of marked difficulty or weakness for this student
Reading
Spelling
Math calculations
Math concepts
Paying attention, concentrating and/or sitting still
Writing skills: paragraph development, sentence structure or mechanics
Comprehension of lecture and/or class discussions
Comprehension of written material
Following directions
Note-taking
Verbal expression and/or word finding ability
Finishing tests, in-class assignments on time
Completion and/or submission of homework assignments
Organization/prioritization/study habits
Short and/or long-term memory
Amount of time spent studying compared to other students and to results
Copying information from the board
Ability to benefit from peer study and/or tutoring
Other (please specify)____________________________________________________
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FacReferform Faculty Referral Form

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Completed 16 November 2019

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