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Paradise Valley Unified School District • Phoenix, Arizona
SCREENING FORM – VALORACIÓN INICIAL
SCREENING MUST BE COMPLETED WITHIN 45 C
ALENDAR DAYS OF ENROLLMENT
TO BE COMPLETED BY PARENT/GUARDIAN AT TIME OF REGISTRATION
LOS PADRES DEL ALUMNO LLENAN ESTA SECCIÓN
Student Name [Nombre del alumno] Date of Birth [Fecha de nacimiento] Age [Edad] Grade [Grado] School [Escuela]
Male [Masculino]
Female [Femenino]
Last Grade Attended [Último grado al que asistió] Year Attended [Año en que asistió] Last School Attended [Última escuela a la que asistió]
Student Home Address [Dirección de la casa del alumno] City [Ciudad] Zip [Zona Postal] Home Phone [Teléfono de casa]
Ethnicity Language Spoken at Home Language Spoken by Student First Spoken Language of Student
[Grupo étnico] [Idioma que se habla en casa] [Idioma que habla el alumno] [Primer idioma que habló el alumno]
PARENT/GUARDIAN SIGNATURE: DATE:
[FIRMA DE UNO DE LOS PADRES O TUTOR LEGAL]:
TO BE COMPLETED BY SCHOOL NURSE
ACUITY
Snellen Test SPOT
VISION SUBTEST NEUROMATURATIONAL/DEVELOPMENTAL
Distance: Wears Glasses: Yes No
Ocular Alignment Pass Fail Dominance: Hand ____ Eye ____ Leg ____
Both Eyes: Right Eye: Left Eye: Pass Color Deficiency Pass Fail
Fail
HEARING
Pure Tone Impedance OAE
Fine Motor: Pass Fail
Near: Wears Glasses: Yes No
Right Ear: Pass Fail
Gross Motor: Pass Fail
Both Eyes: Right Eye: Left Eye: Pass
Left Ear: Pass Fail
Tactile/Kinesthetic: Pass Fail
Fail
HEIGHT WEIGHT
EDUCATIONALLY RELEVANT HEALTH INFORMATION:
NURSE
TO BE COMPLETED BY CLASSROOM TEACHER
1. VISION 6. COMMUNICATION
Yes No Yes No
Holds book too close or too far Difficulty understanding directions
Squints or has trouble seeing board Difficulty expressing ideas
Has trouble with eyes Difficulty expressing needs
Has weak note taking skills Difficulty producing speech sounds
Other: Other:
2. SOCIAL or BEHAVIORAL 7. HEARING
Yes No Yes No
Displays externalizing behaviors (fighting, assaulting, vandalizing) Does not respond to name, directions, or questions in class
Displays internalizing behaviors (fears, phobias, depression, withdrawn) Frequently asks for information to be repeated or asks, "What?"
Has difficulty with unstructured environments or transitions between Has significantly delayed language
activities Has frequent earaches
Has difficulty developing or maintaining peer or adult relationships Seems not to pay attention
Displays inappropriate types of behavior or feelings under normal
Other:
circumstances
8. TRANSFER STUDENT RECORDS REVIEW
Other:
Last grade attended: Year attended:
3. MOTOR SKILLS
Yes No
Last school attended:
Has short attention span
Date records requested: Received:
Problems with gross motor development (clumsy or awkward)
Problems with fine motor skills (reaching, grasping, manipulation of
Date records reviewed: Reviewer:
objects)
History of early intervention or special education? Yes No
Other:
History of poor performance or progress in school? Yes No
4. COGNITIVE or ACADEMIC
Yes No
Learns very slowly compared to peers
NO PROBLEM AT THIS TIME
Attention problems (short attention span, focused on less relevant
stimuli)
PROBLEM NOTED: See Administrative Action below.
Below grade level in reading:
Below grade level in writing:
TEACHER
Below grade level in math:
SIGNATURE: DATE:
Difficulty acquiring, retaining, recalling, manipulating information
Other:
9. ADMINISTRATIVE ACTION
Yes No
Yes No
5. ADAPTIVE DEVELOPMENT
Parents notified in 10 school days if concerns were noted: Date
Poor self care skills related to personal hygiene, dress, maintaining
Current IEP/Special Education Records Received/Reviewed
personal belongings
Referred for Teacher Assistance Team: Date
Poor social skills related to working cooperatively with peers, social
Referred for 504 Plan: Date
perceptions, response to social cues, or socially acceptable language
Lack of school coping behaviors related to attention to learning tasks,
Other:
organizational skills, questioning behavior, following directions, and
monitoring time use
ADMINISTRATOR
Other:
TO BE COMPLETED BY SPEECH LANGUAGE PATHOLOGIST
If student has been screened by the Speech-Language Pathologist, please indicate results:
Typical developmental errors
SPEECH-LANGUAGE
Original: Teacher Assistance Team (if possible intervention needed)
