EDUCATIONAL SCHOOL REPORT

To be completed by the School student is presently enrolled

St. Paul’s Lutheran School                                                      Date                                                   

Attn:  David Masengarb, Principal

330 W. Highland Drive

Chicago Heights, IL  60411

Student Name                                                                          Present Grade              Date of Birth                                    

School Name                                                              School Street Address                                                          

City                                                       State                Zip Code                Telephone (       )                                  

SCHOOL ACHIEVEMENT:  Please submit a copy of the latest report card.

Has this student ever been retained?  Yes                    No                   

Will this student be promoted at his present level of achievement?  Yes                   No                   

ATTENDANCE:  Number of days absent in past year.                      Number tardy                     

SPECIAL SERVICES:

Does/has this student receive(d)/require(d) any form of modified lessons?  Yes                          No                   

If yes, indicate all modifications:  presentation                 environment                time demands              materials          use of groups and peers        use of teacher aide                

Additional comments:                                                                                                          

Does this student receive/require Special Education Services?   Yes                    No                   

Does this student receive/require Speech Therapy Services?  Yes                    No                   

Does this student have an individualized Education Program (IEP)?  Yes                    No                 

Does this student have an Intervention Plan in place?  Yes          No               

Has the student been recommended for a case study?  Yes                   No                 

Has the student been recommended for an educational evaluation?  Yes                    No                   

Has it been determined that the child has a learning disability?  Yes                           No                   

Has it been determined that the child has a behavior disorder?  Yes                           No                   

Has it been determined that the child has Attention Deficit Disorder?  Yes                    No                   

Does the child require remedial mathematics?  Yes                    No                   

Does the child require remedial reading?  Yes               No                 

Does/did the child attend Title 1 Classes?  Yes                           No                   

PSYCHOLOGICAL EVALUATION:

Has a psychological evaluation ever been given?  Yes                   No                    Test Date                           

Has a psychological evaluation ever been recommended?  Yes                No                   

Does/has student ever receive(d) counseling?  Yes                    No                   

SPECIAL INFORMATION:

Effort:  working to capacity                        Good              Fair                  Poor                None              

Areas of Strengths:                                                                   Areas of Weaknesses:                                                 

(OVER)

Has this student ever received a vision referral?  Yes        No                   Corrective lenses?  Yes                   No                    

Has this student ever received a hearing referral?  Yes                    No                           Hearing aid?  Yes           No         

CONDUCT:

Has this student been suspended?  Yes                    No                   

If yes, please explain.                                                                                                   

Does the student display inappropriate behaviors in the classroom              gym                 hallway                and/or on the playground                  ?

If yes, please describe.                                                                                                

How does the student react to success?                                                                                                               

How does the student react to failure?                                                                                                                   

What behaviors/attitudes are displayed toward authority?                                                                                           

Are leadership qualities displayed?  Yes                    No                   

Peer relationships:  Excellent          Good                Fair                   Poor               

Acceptance of consequences/criticism:  Excellent                      Good              Fair                  Poor              

ACHIEVEMENT TESTING:  Attach a copy of test data from the most recent testing.

In your opinion, are these scores indicative of the student’s ability?  Yes                   No                 

If no, please explain.                                                                                                   

ADDITIONAL COMMENTS:

Please feel free to provide additional information about this student that you feel would provide us with a more rounded picture of the child’s ability, performance, conduct, and potential.

How long have you known this student?                                 

Signature                                                                                                         Title                                                    

REMINDER:  Attach a copy of the latest report card and the achievement test data from the latest testing date.