Teacher First Assessment Form - Schooling Assessment

Teacher Assessment form for the First Doctor consultation

Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year.

Step 1 of 6

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School Name*
School currently attending.
Teachers's Name*
First Last
Teacher's Email*
Enter Email Confirm Email
School Email*
Enter Email Confirm Email
Child's Name*
First Last
Grade*
Please enter a number from 00 to 12.
Today’s Date*
Date Format: DD slash MM slash YYYY
Additional information about type of class
Normal stream. Remedial. Or specialised class
Please indicate in months time you have been able to evaluate the behaviours:
Please enter a number from 1 to 12.

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Strengths: What are this student's strengths?*
Education plan: If this student has an education plan, what are the recommendations? Do they work?*
Accommodations: What accommodations are in place? Are they effective?*
Class Instructions: How well does this student handle large-group instruction? Does s/he follow instructions well? Can s/he wait for a turn to respond? Would s/he stand out from same-sex peers? In what way?*
Individual seat work: How well does this student self-regulate attention and behaviour during assignments to be completed as individual set work? Is the work generally completed? Would s/he stand out from same-sex peers?In what way?*
Transitions: How does this student handle transitions such as going in and out for recess, changing classes or changing clothing.*
Conflict and Aggression: – Is s/he often in conflict with adults or peers? How does s/he resolve arguments? Is the student verbally or physically aggressive? Is s/he the target of verbal or physical aggression by peers?*
Academic Abilities: We would like to know about this student's general abilities and academic skills.*
Self-help skills, independence, problem solving, activities of daily living*
Please comment on any concerns.
Motor Skills (gross/fine): Does this student have problems with gym, sports, writing? If so, please describe.*
Written output: Does this student have problems putting ideas down in writing? If so, please describe.*
Primary Areas of concern: What are your major areas of concern/worry for this student? How long has this/these been a concern for you?*
Impact on student: To what extent are these difficulties for the student upsetting or distressing to the student him/ herself, to you and/or the other students?*
Impact on the class: Does this student make it difficult for you to teach the class?*
Medications: If this student is on medication, is there anything you would like to highlight about the differences when s/he is on?*
Parent involvement: What has been the involvement of the parent(s)?*
Are the problems with attention and/or hyperactivity interfering with the student's learning? Peer relationships?*
Has the student had any particular problems with homework or handing in assignments?*
Is there anything else you would like us to know? If you feel the need to contact the student's clinician during this assessment please feel free to do so*

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	Never	Occasional	Often	Very Often	Not Applicable
1.Fails to give attention to details or makes careless mistakes in schoolwork
2. Has difficulty sustaining attention to tasks or activities
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand).
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
8. Is easily distracted by noises or other stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining seated is expected
12. Runs about or climbs too much when remaining seated is expected
13. Has difficulty playing or beginning quiet play activities
14. Is “on the go” or often acts as if “driven by a motor”
15. Talks excessively
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his or her turn (waiting in line)
18. Interrupts or intrudes on others (eg, butts into conversations/games)
19. Loses temper
20. Actively defies or refuses to comply with adult’s requests or rules
21. Is angry or resentful
22. Is spiteful and vindictive
23. Bullies, threatens, or intimidates others
24. Initiates physical fights
25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others)
26. Is physically cruel to people
27. Has stolen items of value
28. Deliberately destroys others’ property
29. Is fearful, anxious, or worried
30. Is self-conscious or easily embarrassed
31. Is afraid to try new things for fear of making mistakes
32. Feels worthless or inferior
33. Blames self for problems; feels guilty
34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”
35. Is sad, unhappy, or depressed

	Excellent	Above average	Average	Somewhat a Problem	Problematic
36. Reading
37. Mathematics
38. Written expression

	Excellent	Above average	Average	Somewhat a Problem	Problematic
39. Relationship with peers
40. Following directions
41. Disrupting class
42. Assignment completion
43. Organizational skills

	Well Below Grade Level	Some what Below	At Grade Level	Some what above	Well Above	Not Applicable
Reading: Decoding
Reading: Comprehension
Reading: Fluency
Writing: Handwriting
Writing: Spelling
Writing: Written syntax (sentence level)
Writing: Written composition (text level)
Mathematics: Computation (accuracy)
Mathematics: Computation (fluency)
Mathematics: Applied mathematical reasoning
Classroom Performance: Following directions/instructions
Classroom Performance: Organisational skills
Classroom Performance: Peer relationships
Classroom Performance: Classroom Behaviour