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
Student __________________________________________________________________________
DOB ___________________
In the first column check those to be implemented. Teacher(s) shall rate results 1-4 in the second column. 1 = makes problem worse 2 = no change 3 = helps somewhat 4 = very successful Include examples of student’s work. Interventions Accommodations for Setting __ __(01) Assign preferential seating __ __(08) Post or provide visual cues and/or markers __ __(02) Alter physical room environment (Details Attached) __ __(09) Change location to increase physical access __ __(03) Reduce/minimize distractions __ __(10) Use flexible/special purpose grouping __ __(04) Provide home/school communication (Details Attached) __ __(11) Stand near student when giving directions/redirection __ __(05) Assign peer tutors/work buddies/note takers or scribe __ __(12) Use notebook for assignments/materials/homework __ __(06) Modify student’s schedule __ __(13) Small group/Individualized instruction/testing (Circle) __ __(07) Other: __________________________ Accommodations for Presentation/Response __ __(01) Use graphic organizers as teaching/learning tools __ __(15) Use virtual/multisensory modes to reinforce instruction __ __(02) Provide outlines and notes of key material/highlight material __ __(16) Provide photocopies of teacher/peer notes __ __(03) Use teacher-initiated signal to redirect attention __ __(17) Provide assistance/cues for homework and transitions __ __(04) Prioritize tasks/assist with pacing (e.g., lists/desktop notes) __ __(18) Provide daily assignments __ __(05) Break tasks and procedures into sequential steps __ __(19) Provide practice activities and immediate feedback __ __(06) Use rehearsal mnemonic devices __ __(20) Teach concrete concepts before abstract concepts __ __(07) Limit number of concepts introduced at one time __ __(21) Do not count off for spelling when grading content __ __(08) Modify assignments (e.g. vary length, limit number of items) __ __(22) Assignments/tests read aloud __ __(09) Color code material __ __(23) Computer-assisted instruction, when available __ __(10) Increase amount of white space or spacing on page __ __(24) Allow use of computer as alternative to writing tasks __ __(11) Alter format of instructional content (e.g., multi. choice/essay) __ __(25) Alter format of materials on page (e.g., font/spacing/color) __ __(12) Provide options for student to obtain information and demonstrate knowledge through use of (e.g. alternate projects, interviews, oral reports, dramatization) Specify ______________________________________________________________________________ __ __(13) Appropriate format for instructional/supplemental materials (e.g. Braille, audio, digital, large print) Specify________________ __ __(14) Other: ________________________________________________________________________________________________ Accommodations for Time Demands __ __(01) Increase time allowed for class-work and/or tests __ __(06) Increase time allowed for homework and projects __ __(02) Provide timelines for completing tasks in chunks __ __(07) Require reduced number of responses to achieve grade __ __(03) Allow breaks during work periods or between tasks __ __(08) Limit amount of work required/length of assignments __ __(04) Give frequent, short quizzes and avoid long tests __ __(09) Other______________________________________ __ __(05) Provide assistance/cues for transitions between classes, lockers, home et al. (Specify) ________________________________ Accommodations/Provisions for Behavior Concerns __ __(01) Assure that curriculum is appropriate and necessary accommodations have been implemented __ __(02) Establish procedures and routines to help complete activities __ __(09) Positive Behavior Support Program (Specify Tier) ____ __ __(03) Reinforce appropriate behavior __ __(10) Use token economy reinforcement strategies __ __(04) Determine reason for behavior and teach replacement skills __ __(11) Offer systematic program to increase self-esteem __ __(05) Visits with counselor or other service personnel __ __(12) Structured social skills training/formal instruction __ __(06) Develop, implement, and monitor a structured behavior intervention plan (BIP) Note: Required for students who exhibit recurrent problematic behavior and/or have repeated suspensions. (Behavior Intervention Plan Attached) __ __(07) Minimize triggers (Specify) _______________________________________________________________________________ __ __(08) Other: ________________________________________________________________________________________________ Assistive Technology __ __(01) Manipulatives __ __(08) Digital Recorder __ __(02) Organizers __ __(09) Colored reading filters/overlays __ __(03) Highlighters/Markers __ __(10) Adapted grips, pencils, utensils, other tools (Circle) __ __(04) Cellular Phone (Specify Purpose) _______________________ __ __(11) Calculators __ __(05) Text to Speech to Text Device __ __(12) Electronic Scribe/Recorder __ __(06) Digital/Electronic Books __ __(13) FM System __ __(07) Word processor with talking spellchecker, grammar checker, word prediction, et al (Specify feature and purpose below) ___________________________________________________________________________________________________________ Tests/Quizzes __ __(01) Prior Notice of Tests __ __(02) Increased time for written projects __ __(03) Preview test material or procedures __ __(04) Pace long-term projects __ __(05) Modified test format (Specify) ________________________ __ __(06) Objective tests __ __(07) Hands-on assessments/projects __ __(08) Alternate options for demonstrating learning
__ __(09) Increased time for completion __ __(10) Allow student to write on tests __ __(11) Provide test study guide or material __ __(12) Shortened tests __ __(13) Rephrase test content/simplify wording __ __(14) Limited multiple choice __ __(15) Tests read aloud __ __(16) Require fewer responses to achieve grade