New Fall 2015

ADSIS R EFERRAL
Jacqueline Brown

Learner Performance Review Form

R. L. Stevenson Elementary

Use this form for learners who are experiencing

difficulty in school and may require additional help and
support.

Part A - Learner Information

Learner's Legal Name:______________________________ School:
_____________________________
Teacher:________________________________________________________ Grade:_________
ELD Status :________________________
Birth Date:_____________
Gender:_________
Enrollment Date:______________________________ Previous
School:__________________________
Parent or Guardian:___________________________ Home Phone:____________________________
Address: ___________________________________________ Work
Phone:_________________________
Street

Zip

Part B - Referral Initiation Information

Date of Referral: ______________________ Referral Initiated By: _________________________________________
Position:____________________________School:____________________________Phone:_____________________
Date Parent Notified of Referral: ____________________

______ Conference ______ Phone Call

Information Reported by Parents (attach notes if needed):

Part C Record Review

Cumulative Folder Review
Is there a History
of?

Health Review
Is there a History
of?
Visual Concerns
Hearing Concerns
Medications
Other Heath Concerns
Possible Chemical Health
Concerns

Grade/Dat
e

Special Education/IEP
Attendance Concerns
Title One/SNAP
ELD/Bilingual Services
Retention
Behavior Concerns
504 plan

Other Considerations/Circumstances

Grade/Dat
e

Notes:

(Family, living, financial, etc.)

Part D - Academic/ Diagnostic Assessments

MAP/NWEA/MCA Scores and STEP Level:
*Required information for all referrals. You must administer appropriate subtests for that subject area,
print scores, and submit score sheets with referral form. Please give levels for the previous years (2 years
prior) if possible as well as the current years level.*

STEP Level
Grade: ____
Previous Year

Fall

Winter

Spring

Fall

Winter

Spring

Fall

Winter

Spring

Date

Level

Date

Level

Date

Level

Grade/Year
DNA Level

Grade: ____
Previous Year

Grade/Year
DNA Level

Grade: ____
Current Year

Grade/Year
DNA Level

MCA Scores
Grade: ____
Previous Year

Reading
Math
Writing

Grade: ____
Previous Year

Reading
Math
Writing

Grade: ____
Current Year

Reading
Math
Writing

Part E - Student Personal Profile

Personality Profile (Check all that apply)

Adventurous
Leader
Follower
Comedian
Organized
Focused
Athletic
Spontaneous
Affectionate
Artistic/creative

Energetic
Motivated
Resourceful
Responsible
Social
Detail-oriented
Consistent
Reserved
Caring
Polite

Student Interests/Motivators
1.

4.

2.

5.

3.

6.

Self-confident
Sensitive
Serious
Creative
Patient
Laid back

Notes about Student Personal Profile:

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Part F - Student Performance Profile

Academic Skills
Check If
Concern
Applies

Rate (1 =
most
concern)

_______

READING
Phonological Awareness

_______

Alphabetic Principle

_______

Sight word Vocabulary

_______

Decoding Skills

_______

Comprehension (literal)

_______

Comprehension (inferential)

_______

Oral Reading Fluency

_______

MATH
Number Sense: 1:1 Correspondence with objects

_______

Number Identification

_______

Counts from ____ to ____

_______

Number Order

_______

_______

Basic Math Facts (circle)

Addition
Subtraction Multiplication Division
Skip Counting (2s, 5s,10s)

_______

Time

_______

Money

_______

Fractions

_______

Decimals

_______

One-step Word Problems

_______

Multiple Step Word Problems

Check If
Concern
Applies

Rate (1 =
most
concern)

*Please

_______

WRITTEN EXPRESSION
Spelling

_______

Legibility/Handwriting

_______

Spacing

_______

Capitalization

_______

Punctuation

_______

Sentence Construction

_______

Paragraph Formation

_______

Written Content

attach writing and work samples*

Notes about most concerning Academic Skills:

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Sensory Processing
Rate (1 =
Check If
most
Applies
concern)
Note: This is an overall
rating of the greatest sensory concerns. Each
Tactile
subsection isnt separate in rating. Avoids casual touch from classmates or teacher
_______
sensory

_______

Becomes silly or annoyed when touched

_______

Craves excessive physical contact with others

_______

Distressed by messy hands or face-glue, glay, paints, sand, food, etc.

_______

Dislikes or craves certain textures materials, paper, toys, etc.

_______

Distracted by clothing or shoes

_______

Chews or sucks on clothing, hands, pencils, other objects

_______

Craves or avoids hot or cold item, water play, art supplies

_______

Disturbed by vibration such as air conditioner or trucks

_______

Tactile stims tapping, rubbing, squeezing, hanging

_______

Squints, blinks, or rubs eyes frequently

_______

Makes poor eye contact

_______

Struggles with reading

_______

Has difficulty with eye-hand coordination beading, writing, drawing

_______

Difficulty copying from the board

_______

Distracted by glare, bright light, fluorescent lighting

_______

Distressed when lights are dimmed or by the dark

_______

Struggles to follow moving objects or people

_______

Poor ball skills catching and/or throwing

_______

Easily overloaded by crowded visual fields

Vision

_______

Visual stims hand flaps, flick fingers in front of eyes, spins objects
Vestibular/
Balance

_______

Avoids changes in head position

_______

Seems clumsy, moves awkwardly

_______

Excessively cautious on stairs

_______

Slumps in chair/sits in W-position on floor/needs support for floor sitting

_______

Touches furniture or walls when walking

_______

Rocks in chair, wraps legs around chair legs

_______

May fall out of chair or onto another student during floor time

_______

Fidgets consistently

_______

Seems restless or always on the go

_______

Seems lethargic or hard to wake up

_______

Gets dizzy easily

_______

Avoids or craves moving playground equipment or riding on bus/in car

_______

Difficulty using playground equipment slides, swings, ladders, sandbox

_______

Vestibular stims spinning, rocking, jumping

_______

Distressed by loud noises (fire drill, whistles)

_______

Disturbed by sounds such as singing and musical instruments

_______

Complains that everything/everyone is too loud

_______

Speaks with a very loud voice

Auditory

_______

Speaks with an unusually quiet voice

_______

Doesnt seem to hear you

_______

Has difficulty filtering out noise and focusing on teachers voice

_______

Frequent outbursts in gym and recess

_______

Frequent outbursts in cafeteria or Team & Family

_______

Seems to learn more easily in one-on-one situations than in a group

_______

Auditory stims hums, repeats, makes odd noises

_______

Poor body awareness doesnt know where body parts are

_______

Bumps into classmates, furniture, walls

_______

Difficulty grading force breaks crayons, pencil points, toys

_______

Accidentally spills when opening containers, pouring, or drinking

_______

Drops items on floor, slams doors although not angry

_______

Crashes and falls on purpose

_______

Lies down on floor at inappropriate times

_______

Complains about smells

_______

Complains about tastes

_______

Doesnt seem to notice strong odors glue, markers, food

_______

Picky eating or very self-limited diet

_______

Acts out at snack time or in cafeteria

_______

Mouths or licks objects and people

Proprioception

Smell and Taste

_______

Smells objects and people

Behavior,
Learning,
Social Issues

_______

Craves predictability

_______

Engages in repetitive play

_______

Doesnt understand concept of personal space

_______

Has difficulty joining group activities

_______

Has difficulty with transitions between activities

_______

Difficulty initiating and completing tasks

_______

Struggles with sequencing activities

_______

Poor organization, loses things frequently

_______

Easily overwhelmed or frustrated

_______

Frequently tunes out or withdraws

_______

Frequently acts out or tantrums

Notes about most concerning Sensory Processes:

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Social/Emotional Behavior Concern Checklist

Check If
Applies

Rate (1 =
most
concern)

_______

Out of seat

_______

Playing with objects during instruction

_______

Making noises during class

_______

Excessive questions during class

_______

Talking with peers during class

_______

Calling out during class

_______

Excessive activity level

_______

Impulsive acting out

_______

Non-compliance with requests (direct defiance)

_______

Non-compliance with requests (negotiation)

_______

Non-compliance with requests (passive)

_______

Arguing

_______

Lying

_______

Invading others personal space

_______

Teasing peers/bullying behavior

_______

Stealing

_______

Temper tantrums

_______

Disrespectful/inappropriate language

_______

Destruction of property

_______

Threatening others

_______

Poor work independence

_______

Careless work completion

_______

Passive-off task (short attention span)

_______

Constant complaining/whining

_______

Crying

_______

Daydreaming

_______

Work avoidance

_______

Excessive requests to leave classroom

_______

Poor peer relationships

_______

Poor adults relationships

_______

Easily distracted

_______

Negative self-statements

_______

Withdrawn/depressed mood

_______

Excessive sleepiness

_______

Moodiness/irritability

_______

Falling frequently

_______

Chewing/eating objects

_______

Physical aggression towards peers

_______

Physical aggression towards adults

Notes about most concerning Social/Emotional Behavior Concern:

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Communication/Language
Rate (1 =
Check If
most
Applies
concern)
Note: Please compare to same age/same language peers.

Difficulty with voice modulation (e.g. harsh, raspy, etc.)

Difficulty with pronouncing sounds
Difficulty with naming people and objects
Difficulty staying on topic
Difficulty with explaining things (e.g. feelings, ideas) due to imprecise
language and limited vocabulary
Difficulty following instructions or directions
Difficulty with retelling what has just been said
Stuttering
Difficulty with sequencing events
Difficulty with using correct grammar in conversation
Uses shorter than average sentences/answering questions (who, what,
where, when, phrases, etc.)

Notes about most concerning Communication/Language Concern:

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Prioritized Concerns
Review the boxes you checked on the previous pages. Identify your top 1-3 concerns (1 = most important). When prioritizing, give
preference to skills/concerns that if improved, would improve the other skills/concerns.

1.

2.

3.

Part G - Previous Instructional/Managerial/Observational Strategies

Attempted

Strategy Idea List

Academic Strategy Examples

Parent conferences regarding problems

Use worksheets that require minimal writing
Provide a print outline
Use fill-in questions with space for a brief
response rather than a short essay
Provide instruction at students ability level
Testing accommodation (read aloud, small
group, scheduled breaks, etc.)
Outside agency referral/service
ELD referral

Schedule modification (additional breaks,

different choices, etc.)
Omit assignments that require copying

Daily assignment sheet

Special teaching/materials/program
accommodating teaching style and students
learning style
Mark the correct answers rather than the
incorrect ones
Use both oral and written directions
Have student repeat the directions for a task
Sequence work, with the easiest part first

Check progress and provide feedback often in

Behavioral Strategy Examples

Parent conferences regarding problems

Schedule modification
Documentation/charting behavior
Arrange a check-in time to organize the
day
Daily or weekly behavioral
contract/progress report sent home
Pair the student with a student who is a
good behavior model for class projects
Repeat and /or simplify directions
Modify classroom policies that may
discriminate against the student (e.g.
provide frequent breaks for the student
who cannot pay attention for long periods
of time)
Use nonverbal cues to remind the student
of rule violations
Amend consequences for rule violations
(e.g. reward a forgetful student for
remembering to sharpen a pencil in the
morning, rather than punishing the failure
to remember)
Reinforce (often) when a student displays
positive behavior
Develop an individualized behavior
strategy plan that is consistent with the
students ability and skills
Arrange for a student to leave the
classroom for designated safe place when
highly stressed
Develop a system or a code word to let a
student know when behavior is not
appropriate
Ignore behaviors that are not seriously
disruptive
Develop strategies for behaviors that are
annoying but not deliberate (e.g. place a
small piece of foam rubber on the desk of a
student who continually taps a pencil on
the desktop)
Sensory breaks

the first few minutes of the assignment

Break long-term assignments into small steps
with daily monitoring and frequent grading

Sensory objects throughout the room that

the student knows how when and how to
use
Increase the frequency and immediacy of
reinforcement

Decrease the amount of daily work for

students who perform poorly

Part H1 - Daily Recording of Academic Concern

*Please use this section to collect data. Take 3 weeks of data before submitting referral*

Concern

Date/Subjec
t

Example:

Day 1

Handwriting

9/18/11
Writing

Day 2
9/19/11
Writing

Day 3
9/20/11
Writing

Day 4
9/21/11
Writing

Day 5
9/22/11
Writing

Observation

Strategy

(What did you

see/notice
prior?)

(What did you

do/duration?)

Strategy Noticings

-Holding pencil with:

thumb, middle finger,
and pointer, hand
midway on the pencil
-Irregular letter size
-Unfinished words

Gave student a
pencil grip to help
with correct finger
and hand placement

Student was holding pencil in the correct position for 7

minutes out of the 60 minutes during the writing portion of
the day

-Holding pencil with:

thumb, middle finger,
and pointer, hand
midway on the pencil
-Irregular letter size
-Unfinished words
-Holding pencil with:
thumb, middle finger,
and pointer, hand
midway on the pencil
-Irregular letter size
-Unfinished words
-Holding pencil with:
thumb, middle finger,
and pointer, hand
midway on the pencil
-Irregular letter size
-Unfinished words
-Irregular letter size
-Unfinished words

Same as day 1

Same as day 1

Same as day 1

Student was holding pencil in the correct position for 15 of

the 60 minutes during writing

Same as day 1 but I

had the student hold
pencil grip in the
correct position
throughout the entire
day for practice.
Same day 4

Student was holding fingers correctly but students finger

grip is starting to move up on pencil and out of the correct
writing position frequently (a noticeable amount of time).

Student was holding pencil firmly and seemly in the correct

position for a portion of the day. Still noticing student is
having trouble not moving fingers up on pencil grip.

Strategy Adjustment
(What can you do different?)
Give student a pencil that is smaller than usual with the same grip. The pencil being short may help direct the grip and also may help enhance fine
motor skills

Concern

Date/Subjec
t

Observation

Strategy

(What did you

see/notice
prior?)

(What did you

do/duration?)

Strategy Noticings

Day 1

10

Day 2

Day 3

Day 4

Day 5

Strategy Adjustment
(What can you do different?)

Concern

Date/Subjec
t

Observatio
n
(What did you
see/notice
prior?)

Strategy

Strategy Noticings

(What did you

do/duration?)

Day 1

Day 2

Day 3

Day 4

Day 5

Strategy Adjustment
(What can you do different?)

11

Concern

Date/Subjec
t

Observation
(What did you
see/notice
prior?)

Strategy

Strategy Noticings

(What did you

do/duration?)

Day 1

Day 2

Day 3

Day 4

Day 5

12

Part H2 - Daily Recording of Behavioral Concern

*Please use this section to collect data. Take 3 weeks of data before submitting referral*
Concern Date/Time
Antecedenc Behavior (What did you
Noticings
e
see?) Consequence
(What
(Concern solved,
happened
reprimanded, sent out, in
prior?)
trouble, escape the request
of task, got peer attention)
Example:

Day 1
Physical
aggression
hitting

Day 2

Day 3

Day 4

9/18/11
Math

9/19/11
Writing

9/20/11
Math

9/21/11
Core Knowledge

-Group work
-3 students in group
(K, R, & S)
-K resistant to group
work and didnt
participate

Behavior: K hits Rebecca

-K resistant to group
work and didnt
participate

Behavior: K throws pencil at S and hits

desk with fists

Consequence: Removal of K from the

classroom to calm body down.

9/22/11
MM

Same as day 1

Consequence: Removal of K from the

classroom to calm body down.
-Group work
-3 students in group
(K, R, & S)
-K resistant to group
work and didnt
participate

Same as day 1

Same as day 1

-K resistant to group
work and didnt
participate

Behavior: K gets frustrated at J and hits

chair with fist on the ground during some
group work time.

When calm K returned to room. K

seemed a bit tense and was very quiet
for the remaining portion of core
knowledge.

Consequence: Removal of K from the

classroom to calm body down.

Day 5

When calm K returned to room. K

seemed less red and less tense when
coming back to the classroom. K was
able to continue work with the rest of
the class.

-K resistant to
participate in MM
activity

Behavior: K kicked feet against the

ground and shoved elbow into H who is
directly on Ks right.
Consequence: Removal of K from the
classroom to calm body down.

H didnt seem to be a direct target, just

who was closest. When calm K
returned to room. K seemed a bit tense
and was very quiet for the remaining
portion of core knowledge.

Strategy/Outcome Adjustment
(What can you do different?)
K doesnt get the privilege of any group work activities throughout the day for 1 week. Student must work independently for 1 week without any sort of
hitting OR aggression to earn that privilege back.

Concern

Day 1

Day 2

Day 3

Date/Time

Antecedenc
e

Behavior (What did you

see?) Consequence

(What
happened
prior?)

(Concern solved,
reprimanded, sent out, in
trouble, escape the request
of task, got peer attention)

Noticings

Day 4

Day 5

Strategy/Outcome Adjustment
(What can you do different?)

Concern

Date/Time

Anteceden
ce

Behavior (What did you

see?) Consequence

(What
happened
prior?)

(Concern solved, reprimanded,

sent out, in trouble, escape the
request of task, got peer
attention)

Noticings

Day 1

Day 2

Day 3

Day 4

Day 5

Strategy/Outcome Adjustment
(What can you do different?)

Concern

Date/Time

Antecedenc
e

Behavior (What did you

see?) Consequence

(What

(Concern solved,

Noticings

happened
prior?)

reprimanded, sent out, in

trouble, escape the request
of task, got peer attention)

Day 1

Day 2

Day 3

Day 4

Day 5

Part I - Observations from Other Student Support Providers/Specialists

Partner Teacher:
Comments (concerns/strategies tried):

Date:

Student Support Provider/Specialist:

Comments (concerns/strategies tried):

Date:

Student Support Provider/Specialist:

Comments (concerns/strategies tried):

Date:

Student Support Provider/Specialist:

Comments (concerns/strategies tried):

Date: