Teacher Support- 1st Grade Referral Form

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District *

Grade *

Teacher Name *

First

Last

Email *

Student Name *

First

Last

Areas of Concern *

Listening Comprehension
Oral Expression
Math Calculation
Reading
Written Expression
Behavior

Student Currently Participates in the following services

Title Reading
Title Math
Speech/Language Therapy
Motor RTI
Intervention Group
Other

LC-Can the student follow two-step verbal instructions accurately?

Yes
No
Sometimes

LC- Does the student provide relevant responses during class discussions?

Always
Sometimes
Rarely

LC-Does the student ask for clarification when they don't understand part of a story or instruction?

Always
Sometimes
Rarely

LC- How would you rate the student's ability to summarize simple stories or class instructions they've heard?

Excellent
Good
Fair
Poor

LC- Can the student retell a familiar story accurately using sequence words (e.g., first, then, last)?

Yes
No
Sometimes

OE- Does the student use complete sentences incorporating basic conjunctions (and, but) when speaking?

Always
Sometimes
Rarely

OE- Can the student clearly explain a personal experience or recent event?

Yes
No
Sometimes

OE- How well does the student engage in group discussions using appropriate turn-taking skills?

Very Well
Moderately Well
Needs improvement

OE- Does the student understand and use grade-appropriate vocabulary in conversations?

Yes, Consistently
Sometimes
No, Rarely

MC- Can the student accurately count by ones to the current grade level expectation?

Yes
No
Sometimes

MC- Does the student demonstrate an understanding of addition facts at the current grade level expectation?

Yes, Consistently
Sometimes
No, Rarely

MC- Does the student demonstrate an understanding of subtraction facts at the current grade level expectation?

Yes, Consistently
Sometimes
No, Rarely

MC- Can the student accurately identify numbers from 1 to the current grade level expection?

Yes
No
Sometimes

MC- Can the student accurately write numbers from 1 to the current grade level expection?

Yes
No
Sometimes

R- Can the student read words featuring the current phonetic skills?

Yes
No
Some

R- How well does the student demonstrate oral phonemic awareness skills (i.e., segementing sounds, blending sounds to make words)?

Very Well
Moderately Well
Needs Improvement

R- Can the student fluently read current first grade sight words?

Very Fluent
Moderately Fluent
Needs Improvement

R- How fluent is the student in reading aloud short passages appropriate for their grade level?

Very Fluent
Moderately Fluent
Needs Improvement

R- Does the student demonstrate comprehension of texts by answering questions about the story's main events?

Yes
No
Sometimes

W- Can the student write their first and last name independently?

Yes
No
Sometimes

W- How well does the student use correct letter formation?

Very Well
Moderately Well
Needs Improvement

W- How well does the student use appropriate letter size and spacing in their writing?

Very Well
Moderately Well
Needs Improvement

W- How well does the student use descriptive language and details to express their ideas in writing?

Very Well
Moderately Well
Needs Improvement

W- Can the student write words featuring the current phonetic skills?

Yes
No
Sometimes

W- Can the student write simple sentences with proper capitalization and punctuation?

Yes
No
Sometimes

W- Does the student demonstrate an understanding of basic grammar and sentence structure in their writing?

Yes
No
Sometimes

B- How often does the student exhibit disruptive behavior that interrupts the learning environment?

Rarely (once a week or less)
Occasionally (2-3 times a week)
Frequently (daily or multiple times a day)

B- How does the student respond to typical classroom behavior management strategies (e.g., verbal reminders, time-out, reward systems)?

Positively (responds well and shows improvement)
Inconsistently (sometimes responds, sometimes does not)
Negatively (does not respond or behavior worsens)

B- How does the student interact with peers during group activities or playtime?

Appropriately (engages well and follows social norms)
Inconsistently (sometimes interacts well, other times struggles)
Inappropriately (often has conflicts or isolates themselves)

B- To what extent does the student's behavior affect their academic performance?

Minimal impact (rarely affects their ability to complete tasks)
Moderate impact (occasionally affects task completion and focus)
Significant impact (frequently prevents them from completing tasks and focusing)

B- How often does the student require one-on-one attention from the teacher to manage their behavior?

Rarely (can manage with minimal teacher intervention)
Occasionally (needs teacher intervention 2-3 times a week)
Frequently (requires constant or daily teacher intervention)

Is there anything else the SIT team should know?

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