Date sent: Date received: TEACHER S QUESTIONNAIRE Request for admission Vanguard Elementary Level This document is to be completed by the classroom teacher and and/or the Special Education Specialist Name of Student Student s address Date of birth Code of Difficulty Permanent Code Grade level Name of school board Name of school School telephone number School address Name of principal Name of teacher Name of special education coordinator Parents Application for admission to Vanguard was initiated by: Parents School Parents School - School board If other please specify: Name, Position, Telephone Number Reason for referral: 5935, chemin de la Côte-de-Liesse, Saint-Laurent (Québec) H4T 1C3 - Tel.: 514.747.5500 / Fax: 514.747.2831
ACADEMIC HISTORY Services received LANGUAGE OF INSTRUCTION TYPE OF CLASS ADDITIONAL SERVICES YEARS SCHOOL HISTORY Start with the most recent year Grade Level English French Regular Special Class Speech and Language Social Work Occupational Therapy Psychology Other NAME OF TEACHERS AND PROFESSIONALS INVOLVED WITH THE STUDENT Name Position Telephone Number VANGUARD ELEMENTARY LEVEL Teacher s Questionnaire 2
I. ACADEMIC REVIEW - Oral language skills Mother Tongue: Other Languages spoken at home: 1. EXPRESSIVE LANGUAGE 1.1 FORM: When the student expresses him/herself: Check if applicable - s/he has difficulty in articulating and/or organizing sounds. - s/he has difficulty organizing words and sentences..... - s/he stutters or hesitates abnormally...... - s/he has difficulty using appropriate grammar and syntax.. 1.2 CONTENT: The student: - has a limited vocabulary for his/her age..... - has difficulty expressing his/her thoughts...... - has difficulty with word-finding..... 1.3 USAGE: The student: - has difficulty recognizing his/her audience.... - uses language which is not precise. - does not provide adequate information...... - uses empty words such as thing and stuff... 1.4 The student participates in communication activities Frequently Sometimes Never 2. RECEPTIVE LANGUAGE 2.1 LISTENING: The student appears to have difficulty: - understanding (asks to repeat, observes others in order to know what to do ) 2.2 ATTENTION: The student has difficulty: - being attentive (is absorbed by his/her own thoughts, is distracted by outside noise ).. 2.3 UNDERSTANDING: The student has difficulty: - understanding verbal directions... - understanding the vocabulary used. - indicating his/her lack of understanding (does not ask for clarification).. 3. COMMENTS: VANGUARD ELEMENTARY LEVEL Teacher s Questionnaire 3
II. ACADEMIC REVIEW - Reads a variety of texts 1. LEVEL OF COMPETENCY Indicate the actual reading level of the student Cycle beginning middle end 2. DECODING STRATEGIES When the student has to recognize words in a meaningful situation, s/he has difficulty: Check if applicable - with phonemic awareness... - using sound/symbol correspondence. - recognizing short vowels... - recognizing long vowels. - dividing words into syllables. - determining words from context... - combining different strategies.. 3. COMPREHENSION STRATEGIES When the student reads various texts corresponding to his/her reading level s/he has difficulty: - reading with expression. - respecting punctuation.. - scanning for information - comprehending literal information - recognizing information which is more important... - making inferences.. - predicting what will come next.. - categorizing information - responding to questions by writing sentences (short answers).. - responding to essay type questions (paragraphs) - offering opinions... 4. SILENT READING When the student reads texts corresponding to his/her reading level, his/her reading pace is: slow average fast 5. a) What is the student s attitude toward reading? VANGUARD ELEMENTARY LEVEL Teacher s Questionnaire 4
b) What programs and/or approaches have been used with the student? c) Comments : VANGUARD ELEMENTARY LEVEL Teacher s Questionnaire 5
III. ACADEMIC REVIEW - Writing Skills 1. Indicate the student s actual performance level in writing skills Cycle beginning middle end 2. Handwriting The student is: Check if applicable - right handed. - left handed... - uses printing - uses cursive... - has difficulty with letter formation. - has difficulty with graphic organization - has difficulty with speed of writing - has difficulty copying.. 3. Spelling The student: - uses inventive spelling... - has difficulty using the phonetic elements.. - has difficulty remembering the word as a whole (global sight) - has difficulty remembering the spelling of plurals or suffixes.. - has difficulty transferring taught information... 4. When modifying a sentence or producing a written text, the student has difficulty : - using words appropriate to his/her intention.. - presenting enough information. - presenting the information using sentences, punctuation, correct grammar - organizing the information coherently. 5. What is the student s attitude toward writing? 6. What approaches or programs were used this year? 7. Comments : VANGUARD ELEMENTARY LEVEL Teacher s Questionnaire 6
IV. ACADEMIC REVIEW Mathematics 1. Indicate the actual level of the student s mathematical ability Cycle beginning middle end 2. Indicate the nature of the student s difficulties with mathematics: Check if applicable - difficulty seeing patterns. - difficulty memorizing numbers. - difficulty comprehending concepts, the meaning of operations. - difficulty memorizing rote facts. - difficulty solving problems. 3. Numeration The student can read and write numbers having: 1 digit 2 digits 3 digits 4 digits 5 digits and up The student understands place value for numbers having: 1 digit 2 digits 3 digits 4 digits 5 digits and up The student understands decimals to the: 10ths place 100ths place 4. The student can solve the following operations : - addition facts to 10 addition with regrouping - subtraction facts to 10 subtraction with regrouping - multiplication (1 digit by 1 digit) multiplication with regrouping - division (one divisor) division with remainders long division 5. The student has difficulty with problem solving due to: - problems in reading... - identifying what is pertinent.... - identifying which equation is required... - validating his solution... 6. What is the student s attitude toward math? VANGUARD ELEMENTARY LEVEL Teacher s Questionnaire 7
7. What program and materials were used this year? What were the results? 8. Which techniques were beneficial? 9. Comments: VANGUARD ELEMENTARY LEVEL Teacher s Questionnaire 8
CROSS-CURRICULAR COMPETENCIES Legend : (1) Often (2) Sometimes (3) Rarely (P) Progressing 1. Intellectual Competencies Check appropriate box 1 2 3 P - demonstrates independence in seeking solutions - is receptive to proposed strategies.. - transfers strategies to new situations.. - checks his/her work independently. - recognizes his/her strengths and weaknesses. - utilizes his/her imagination... 2. Methodological Competencies - follows visual and oral instructions 1 2 3 P in a group. individually... - maintains his/her attention to complete the task in a group. individually... - shows interest (asks questions or shares information)... - makes sure assignment is understood before beginning (seeks clarification). - completes assignments in the allotted time... - works in an organized fashion.. - presents a completed assignment which is neat and organized 3. Personal and Social Competencies 1 2 3 P - controls his/her movement and noise in the class - calmly waits his/her turn before speaking and acting.. - accepts the consequences for his/her words and actions.. - respects the rules - in class.. - during the lunch period.. - during transitions. - in group activities s/he contributes in a positive manner - speaks politely, using appropriate language, with adults - with whom s/he has frequent contact.. - with whom s/he has occasional contact.. - seeks assistance in an appropriate manner... - respects individual differences.. - in conflict situations is able to control him/herself verbally. - in conflict situations is able to control him/herself physically.. - resists undue peer pressure... - initiates contact with others... VANGUARD ELEMENTARY LEVEL Teacher s Questionnaire 9
OTHER DIFFICULTIES Check those factors that may be linked to the learning difficulties of this student Autonomy Impulsivity Limited concentration Memory Motivation Organization Immaturity Distractibility Agitation Easily fatigued Lack of effort Anxiety Short attention span Slow in carrying out tasks Language Low self esteem Other Relevant Comments : What recommendations would you make to better help this student? This questionnaire was completed by: Title : Telephone: Signature : Date : Please return this questionnaire to: Vanguard School Admissions Elementary Level 5935, chemin de la Côte-de-Liesse Saint-Laurent (Québec) H4T 1C3 Your cooperation is appreciated! VANGUARD ELEMENTARY LEVEL Teacher s Questionnaire 10