Form E
Baldwin County Public School System
Section 504 of the Rehabilitation Act
Form E (Teacher Input Form) is being used to:
Determine Initial Eligibility Determine Continued Eligibility Update Current 504 Plan
Please complete the following teacher observation information and return this form within five (5) days to
enable the Section 504 Team to conduct a Section 504 evaluation for the above-named student.
1 2 3 4 5 N 1 2 3 4 5 N
Reading Skills Tests
Math Skills Follows Oral Directions
Written Expression Follows Written Directions
Spelling Organizational skills
Classroom Work Attention Span
Homework Timeliness to Class
Behavioral Characteristics
Check observed behavioral characteristics which might adversely affect this student’s learning.
Shyness Needs Constant Encouragement
Rejected by Peers Quarrelsome
Irritable Anxious
Distractible Aggressive
Moody Disruptive
Daydreams Withdrawn
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Student Name: School: Grade:
Teacher’s Name: Subject Matter: Date:
Teacher Observations
Based on your knowledge and observation, please rate this student’s performance in the following areas as compared to his or her
non-disabled peers. For each skill, mark: 1=Poor 2=Below Average 3=Average 4=Above Average 5=Superior
N=Not Observed
Pre-Referral Actions Taken Results
Sent Reports Home
Talked with Counselor
Rearranged Seating
Preferential/Isolated Seating
Ignored Behavior
Referred to Administrator
Contracts
Assignment Notebook
Tutoring
Alternative Assignments
Additional Time for Assignments
Small Group Instruction
Cooperative Learning
Peer Tutoring
Parent Conference
Other
Teacher Input Form
