ORLEANS PARISH SCHOOL BOARD SECTION 504 TEACHER INFORMATION QUESTIONNAIRE
Teacher_______________________________
Date_______________________
Student_______________________________
School________________________
DOB___________________Grade____________
Subject________________________
Please complete the following and return to the Section 504 Chairperson within ten (10) days for consideration of Section 504 eligibility. Teacher observation: Based on your knowledge and observation, please rate this student’s performance. (please circle). Poor Classroom work Homework Tests Reading performance Math performance Written performance Attendance Attention span
1 1 1 1 1 1 1 1
Fair
Good
Excellent
3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4
2 2 2 2 2 2 2 2
Emotional / Behavioral / Social: Indicate (+) strengths; (-) area of concern. __________Generally cooperates or is compliant with teacher requests __________Adapts to new situations without getting upset __________Accepts responsibility for own actions __________Works cooperatively with others his/her own age __________Resists becoming discouraged by difficulties or minor setbacks __________Consistently demonstrates behavior appropriate for his/her age
Discipline: Is discipline an area of concern? Yes _______
No_________
Current grade average(s) in your classroom: (Please give any applicable averages for this student in your class that would help explain this student’s work in your class: Test averages, assignment averages, homework grades, etc.) Attach appropriate work samples that document the area(s) of concern. Attach a written observation of the student documenting area(s) of concern. Page 1 of 2 Form 3 rev 8/13