Teacher Survey Form
Student's Name Course(s) and Year(s) Taught
Accommodations/supports are/were provided based on an IEP, 504 plan, or Accommodations Plan?  Yes  No
In your course does/did the student… Never Sometimes Often
Always N/A
Get started on his/her own
Keep working despite distractions
Finish work on time
Request extra time for assignments
Request extra time for tests
Keep notes and papers organized
Follow verbal directions
Follow written directions
Need more support than his/her classmates
Bring appropriate materials
Try to solve problems before asking for help
Evaluate his/her own performance
Become easily upset
Interrupt others
Act impulsively, either verbally or physically
Have difculty working in group settings
Please identify current strategies or interventions you are using to address the student’s problem areas.
Other information that supports the student's need for ACT testing with accommodations or EL supports:
Teacher Name (please print)
Teacher Signature Date
© 2019 by ACT, Inc. All rights reserved. SV09001.CJ0723 Note: When completed by a teacher, the contents of this document are condential.