The Nicholls Group

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Thank you for taking the time to complete this information. It is critical that we have your professional input. We appreciate your involvement.

Please tell us your impression of the following characteristics of this student:

Is a poor listener:
Yes No Don't Know

Can concentrate for only a short time
Yes No Don't Know

Frequently seems to be looking around or staring off into space
Yes No Don't Know

Forgetful in daily activities
Yes No Don't Know

Excellent imagination
Yes No Don't Know

Loses materials (books, pencils, passes, etc.)
Yes No Don't Know

Daydreams often: seems to be in own world
Yes No Don't Know

Impulsive, rushes through tasks
Yes No Don't Know

Has trouble concentrating in group work
Yes No Don't Know

Receives inconsistent grades or test scores
Yes No Don't Know

Annoys or bothers others
Yes No Don't Know

Seems to have too much energy
Yes No Don't Know

Body in motion most of the time
Yes No Don't Know

Fidgety-keeps moving hands or tapping feet
Yes No Don't Know

Behavior is variable and hard to predict
Yes No Don't Know

Gets into trouble without really meaning to
Yes No Don't Know

Is a troublemaker; stirs things up
Yes No Don't Know

Class clown
Yes No Don't Know

Is moody
Yes No Don't Know

Is a worrier
Yes No Don't Know

Often cheerful, pleasant, well meaning
Yes No Don't Know

Is often sad
Yes No Don't Know

Is often very quiet
Yes No Don't Know

Is often tired
Yes No Don't Know

Speaks unclearly, stutters, stammers
Yes No Don't Know

Complains of not feeling well
Yes No Don't Know

Asks to leave the room frequently
Yes No Don't Know

Not chosen for teams or groups
Yes No Don't Know

Well liked by peers
Yes No Don't Know

Seems disconnected, confused
Yes No Don't Know

Disorganized, unprepared, can’t find time
Yes No Don't Know

Please give us your impressions of this student's skills in the following areas:

Other academic areas

Does this student receive any of the following services: (Check all that apply)

Specialized Reading Instruction

Speech/Language Services Recovery

Specialized Math Instruction

Learning Resource Classroom

Occupational Therapy

Self-Contained Classroom

Please share any other information you feel is important for us to know about this student:

Please e-mail ([email protected]) with any important documents you believe we should review for the student you are grading (handwriting samples, class work, test scores, etc.,) Thank you!

Teacher Form

Educational Information

Academic Skills Assessment

Reading

Math

Written Language

Other academic areas