Teacher Support 4th Grade Referral Form

Teacher Support 4th-Grade Referral Form

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District *

Teacher Name *

First

Last

Email *

Grade *

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, multi-step verbal instructions during class activities?

Yes
No
Sometimes

LC- Does the student actively participate in group discussions by answering and asking questions?

Always
Sometimes
Rarely

LC-Does the student ask for clarification or rephrase instructions they don't fully understand?

Always
Sometimes
Rarely

LC- How would you rate the student’s ability to infer meaning from spoken information?

Excellent
Good
Fair
Poor

LC- Can the student retell or summarize information from a lecture or discussion in detail?

Yes
No
Sometimes

OE- Does the student use complete sentences and appropriate structure when speaking?

Always
Sometimes
Rarely

OE- Can the student clearly express their opinions or thoughts during class discussions?

Yes
No
Sometimes

OE- How well does the student engage in discussions with peers, respecting opinions and maintaining relevance?

Very Well
Moderately Well
Needs improvement

OE-Does the student show an understanding of advanced vocabulary for their grade level?

Yes, Consistently
Sometimes
No, Rarely

MC- Can the student solve multi-step word problems involving all four operations (addition, subtraction, multiplication, and division)?

Yes
No
Sometimes

MC- Does the student demonstrate understanding of multiplication and division facts up to 10x10?

Yes, Consistently
Sometimes
No, Rarely

MC- How well does the student apply math concepts to solve real-world problems?

Very Well
Moderately Well
Needs Improvement

MC- Can the student accurately identify numbers and write numbers up to grade-level expectations?

Yes
No
Sometimes

MC- How would you rate the student’s understanding of place value in large numbers?

Excellent
Good
Fair
Poor

R- Can the student read grade-level texts with fluency and comprehension?

Yes
No
Some

R- How well does the student understand and use text structures (e.g., compare/contrast, cause/effect)?

Very Well
Moderately Well
Needs Improvement

R- Can the student decode and understand multi-syllabic words?

Yes
No
Sometimes

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 through written responses or projects?

Yes
No
Sometimes

W- Can the student write a well-organized paragraph or short essay with supporting details?

Yes
No
Sometimes

W- How well does the student maintain neat handwriting with proper size and spacing?

Very Well
Moderately Well
Needs Improvement

W- How well does the student use figurative language and descriptive vocabulary in writing?

Very Well
Moderately Well
Needs Improvement

W- Can the student write complex sentences with correct grammar and punctuation?

Yes
No
Sometimes

W- Does the student demonstrate an understanding of advanced grammar concepts 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 Teacher Support team should know?

File Uploads (Optional)

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Upload Any Relevant Student Files or Artifacts #2

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Upload Any Relevant Student Files or Artifacts #3

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