Teacher Support-2nd 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 complex instructions that involve multiple steps accurately?

Yes
No
Sometimes

LC- Does the student contribute to class discussions with on-topic comments and questions?

Always
Sometimes
Rarely

LC-Does the student seek more information actively when confused about a detailed explanation or instruction?

Always
Sometimes
Rarely

LC- How would you rate the student's ability to summarize detailed information they've heard, including key details and conclusions?

Excellent
Good
Fair
Poor

LC- Can the student accurately recount detailed information or stories, including cause and effect relationships?

Yes
No
Sometimes

OE- Does the student use complex sentences and varied vocabulary when discussing familiar topics?

Always
Sometimes
Rarely

OE- Can the student express thoughts and opinions clearly and justify them with reasons?

Yes
No
Sometimes

OE- How well does the student engage in detailed conversations with peers and adults?

Very Well
Moderately Well
Needs improvement

OE- Does the student demonstrate an understanding of advanced vocabulary that is relevant to the subjects studied in class?

Yes, Consistently
Sometimes
No, Rarely

MC- Can the student accurately skip count to the current grade level expectations?

Yes
No
Sometimes

MC-Does the student demonstrate an understanding of addition facts?

Yes, Consistently
Sometimes
No, Rarely

MC-Does the student demonstrate an understanding of subtraction facts?

Yes, Consistently
Sometimes
No, Rarely

MC- Can the student accurately identify and write numbers from 1 to 120?

Yes
No
Sometimes

MC- How would you rate the students ability to understand place value concepts (i.e., ones, tens, hundreds)?

Excellent
Good
Fair
Poor

R- Can the student read complex sentences and simple paragraphs independently?

Yes
No
Some

R- How well does the student demonstrate an understanding of oral phonemic awareness skills (i.e. segmenting, blending, omitting, substituting sounds)?

Very Well
Moderately Well
Needs Improvement

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

Very Fluent
Moderately Fluent
Needs Improvement

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

Yes
No
Sometimes

R- Does the student demonstrate comprehension of texts by answering questions about story elements?

Yes
No
Sometimes

W- Can the student write their first 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- 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 (Does it make sense)??

Yes
No
Sometimes

W- Does the student use invented spelling instead of applying current phonetic skills?

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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