PDR Teacher Report Form
re: _____________________________________________
Child

										         6+

Dear Teacher(s),

A request has been made for this child to be evaluated at Randall Children’s Hospital, Pediatric Development & Rehab. Your view of the child is of paramount importance to us in obtaining a comprehensive evaluation. 

If this child is receiving special education, please ask those staff to assist you in completing this form. In addition, we would appreciate it if you would contact the Special Education Director to release the most recent evaluations (e.g. psychological, education, etc.) as well as the child’s current I.E.P.

We appreciate your completing this form, which is of much help to us in understanding this child. We suggest you keep a copy for your records. 
	
Please have complete and return to:

	Attention: Clinical Intake 
			Randall Children's Pediatric Development & Rehab (PDR)
2801 N. Gantenbein, Suite 2225
	Portland, OR 97227
 	Fax 503-413-4719

Sincerely,

PDR Clinical Intake

Child’s Name: ______________________________________                 DOB: _____________

School:		Grade: ________________	

School Address:			

Counselor and/or Principal (please print):			

Teacher(s) (please print):			

Date entered in this school:		Today’s Date:	

Type of Class:		Traditional		Open Classroom		Inclusion classroom
	Self-Contained Special Education 	   ESL/Bilingual	Other (specify): 			
Number of children in class: __________________

Number of teachers in class:		One		Two		Team Teaching 

Special Education and Related Services – Please check the services and amount received:
    No services
504 Plan:         No            Yes________________________________
IEP/Special Ed:	No	Referred for testing
Yes – if yes, please list disability: ________________________________

	 Days per week	minutes per session
Title I Reading 		 			
Title I Math 		 			 
Teacher’s Aide 		 		
Special Ed. Resource 		 		
Speech & Language		 		
Occupational Therapy 		 		
Physical Therapy		 		
Adaptive Physical Ed.		 		
Counseling Services		 		
Vocational Programming				 
Other 				 

I.  Classroom Performance
Do you have concerns regarding this child’s? 
1. Expressive Language:	No		Yes  If yes, describe:

2. Language Comprehension:		No		Yes  If yes, describe:  	

3. Fine Motor:	No	Yes  If yes, describe:	

4. Gross Motor:	No	Yes  If yes, describe:	

Please comment on this child’s: 
1. Social skills
a) Relationships with adults:	

b) Peer relationships: 	

2. Attention abilities: 	

3. Behavior: 	

4. Learning style: 	

Describe this child’s effort, attitude, and interest in school:	

 If the child is failing, describe his/her attitude toward this failure to achieve:	

Do you notice a difference in this child’s behavior depending on situation (e.g., academic work vs. recess, mathematics vs. reading, group vs. individual)?	

Do you feel this child has any special creative ability, talent or assets?		

II. School History

Please complete the following to the best of your knowledge, beginning with the child’s current placement:

Name of School	Dates Attended	Grade/Type of Class	Support Services 
(e.g., speech therapy, resource) and Frequency	

				

				

				

				
Does the child’s record give indications of prolonged or frequent absences, especially during the primary grades? Cite reason:	

Has the child ever repeated a grade?	No	Yes: which grade(s):______________

Was retention ever recommended but rejected by the parent? 	No	Yes
If yes, why? 	

III. Previous Testing

Intelligence Tests — Group or Individual

Name of Test and Form	Date of Testing	Grade at Testing	I.Q.	Verbal	Performance	

						

						

						

Please attach a copy of this student’s most recent report card and IEP if applicable.

Achievement Test Data

A copy of the actual test record is preferred. Otherwise, please indicate whether grade equivalent, percentile, stanine, etc., is used.

Name of Test	Grade	Word
Reading	Reading Comprehension	Spelling	Math	Language	

							

							

							

Last Vision Screening:	Date:		Result:	

Last Hearing Screening:	Date:		Result:	

IV. Current Academic Levels

Please attach a copy of the progress report. Otherwise, please indicate the summary of Current Grading:
Circle the appropriate number: 
(1) excellent, (2) above average, (3) average, (4) below average, (5) failing compared to class average. 

	Excellent	Average	Failing	Excellent	Average	Failing
Arithmetic	1 -    2 -    3 -    4 -    5 	Language	1 -    2 -    3 -    4 -    5 

Spelling	1 -    2 -    3 -    4 -    5 	Social Studies	1 -    2 -    3 -    4 -    5 

Handwriting	1 -    2 -    3 -    4 -    5 	Science	1 -    2 -    3 -    4 -    5 

Reading	1 -    2 -    3 -    4 -    5 	Phys. Ed.	1 -    2 -    3 -    4 -    5 

A.	Reading: 
What is your estimate of this child’s current reading grade level?	

What particular problems have you observed?
1. Oral		

2. Reading sight words		

3. Phonetic skills		

4. Comprehension		

B.  Arithmetic: 
What is your estimate of this child’s current mathematics grade level?	

What particular problems have you observed?

1.  Computation		

2.  Problem solving	

C.  Handwriting: 
What style handwriting does this child use?  Check one:
		Manuscript		Transitional		Cursive

How would you describe the quality of this child’s handwriting (size, formation)?	

D.  Spelling: 
What particular problems have you observed?	

E.  Written Language Skills:
How would you describe this child’s written language skills (i.e. ability to compose sentences, paragraphs, etc.)?	
Strengths:		
	
Weaknesses:		

F.  Seatwork (all areas):
Describe the quality and frequency of completion of seatwork:	
	
If seatwork is poor, state possible reasons:	

Do you think child will need to repeat present program?	

Do you think child is in need of resource services?	

Do you think child is in need of increased resource services?	
Inclusion Model	Resource Room Model	Both Models

Do you think child is in need of a self-contained special education placement?	

Please include anything else you would like us to know about this child:	

Current Date: 	

Name & Title of individual completing this form: