TEACHER QUESTIONNAIRE

 

 

Student Grade

 

Date Teacher Subject(s) Period(s)

Directions: Please rate the student on the following behaviors that might indicate information processing difficulties. Each section represents one component of information processing. Italic print is for students who are deaf or hard-of-hearing.

 

 

 

Acquisition: accurately gaining, receiving and/or perceiving information

Usually

Sometimes

Seldom

Links new information to that previously learned

Acquires information by hearing

Acquires information by seeing

Acquires information by reading

Acquires information by touching

Acquires information through multi-sensory approach

Can discriminate visually

Can discriminate using auditorily

Acquires information through signed/cued communication modality at a level of proficiency to acquire grade level or age appropriate

• academic development

• social development

• emotional development

o

o

o

o

o

o

o

o

 

 

o

o

o

o

o

o

o

o

o

o

o

 

 

o

o

o

o

o

o

o

o

o

o

o

 

 

o

o

o

 

 

 

 

Organization: structuring information, i.e., categorizing, sequencing, etc.

Usually

Sometimes

Seldom

Has an organized locker or desk

Brings needed materials to class

Completes assignments

Turns in completed assignments organized and on time

Uses planning skills, planning aids, etc.

Aligns work spatially

Sequences information

Prioritizes information

Label, categorizes, associates information

Sequence sentences to explain; give directions or relate information

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

 

Teacher Questionnaire Page 2

 

 

Name_______________________________________ Date_________________________________

 

 

Manipulation: the process of applying, using, or altering information

Usually

Sometimes

Seldom

Applies learned information to new situations

Infers information

Summarizes information

Interprets information

Writes sentences of varying length and complexity

Analyzes and solves problems of varying complexity

Interprets social cues

Differentiates details from key concepts

Uses appropriate language (vocabulary) for specific academic, social and environmental situations

Uses known vocabulary/concepts to build or expand vocabulary/concept knowledge)

Conveys information (converse) in a variety of settings for a variety of purposes

Uses/comprehends figurative language in appropriate setting (idioms, slang, metaphors, similes, sarcasm, irony)

Has the skills to use an interpreter/transliterator

Uses amplification device(s) to facilitate participation in school and after school activities

o

o

o

o

o

o

o

o

o

o

o

o

 

o

o

o

o

o

o

o

o

o

o

o

o

o

o

 

o

o

o

o

o

o

o

o

o

o

o

o

o

o

 

o

o

 

 

 

 

Storage: adding information to existing information

Usually

Sometimes

Seldom

Follows two to three step directions

Immediately recalls information

Retains prior information learned

Grasps word meaning

Grasps sentence meaning

Recognizes information over a period of time

Recalls information over a period of time

Generalizes from one topic to another

Correctly uses concept words having multiple meanings

Uses variety of ways to explain, clarify or revise their communication of a specific topic

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

 

Teacher Questionnaire - Page 3

 

Name______________________________________ Date____________________________

 

 

Retrieval: locating or recalling stored information

Usually

Sometimes

Seldom

Responds in acceptable amount of time

Develops strategies to help recall information

Can name or label

Recalls sounds associated with letters and words

Identifies key consonants, vowels and syllables by lipreading

Retrieves known vocabulary concepts to build or expand vocabulary

Counts and calculates automatically

Recalls sequential steps for tasks

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

 

 

 

Expression: communicating information

Usually

Sometimes

Seldom

Communicates information verbally/manually

Communicates information through writing

Communicates information through gestures

Communicates information through body language, non-verbal, etc.

Responds appropriately to verbal/manual communication

Responds appropriately to nonverbal communication

Asks questions related to content

Answers questions related to content

Participates in class discussions

Uses appropriate nonverbal behaviors in conversation (body language, facial expressions, gestures, eye contact, distance from speaker/listener)

Has skills to negotiate desires and appropriately asserts these in communication interactions

o

o

o

o

o

o

o

o

o

o

 

o

o

o

o

o

o

o

o

o

o

o

 

o

o

o

o

o

o

o

o

o

o

o

 

o

 

 

Please answer the following questions:

 

1. How does the student learn best? (copying, rehearsing, using fingers, using hearing, using vision, etc.) Does the student use this method in all subject areas?

 

 

 

2. At what point does the student’s method of learning lose its effectiveness?

 

 

 

3. Describe the student’s ability to communicate information?

 

 

OBSERVATION

 

 

 

Student Grade Date Class Teacher Pupil/Teacher Ratio Observer Beginning Time Ending Time

Setting (describe)

Task (describe)

Check the level of the student’s problem:

Information Processing

No problem

Some problem

Significant

problem

Not observed

Follows directions (S)

Remembers visual materials (S)

Remembers auditory materials (S)

Has materials (O)

Begins task promptly (O)

Completes assignment (O)

Uses planning skills (O)

Understands visual material (A)

Comprehends (R)

Recalls information (R)

Responds in time (R)

Uses strategies to recall (R)

Writes legibly (E)

Participates (E)

Demonstrates fluency (E)

Applies information (M)

Makes inferences (M)

Interprets information (M)

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

 

(A) Acquisition (M)Manipulation (O)Organization (S)Storage (R)Retrieval (E)Expression

 

1. Indicate how the observed behavior relates to the student’s academic functioning.

 

 

 

2. Does the general education teacher think that the observation is representative of typical processing skills for the student in the classroom?

 

 

 

Other Comments:

HOME/FAMILY QUESTIONNAIRE/INTERVIEW

 

 

Name Parent(s) Birthdate Age Grade School Teacher(s)

Dear Family Member,

Please complete this form. The information you provide will be used in planning appropriate services for your child.

 

 

Rate your child’s performance at home on the following items

Good

Poor

Don’t

Know

Codes

for scoring

Ability to follow two to three step directions

Memory

Organizational skills

Planning skills

Understanding what he/she reads

Understanding what he/she sees

Understanding what he/she hears

Understanding what is signed/cued

Ability to learn a new game

Ability to recall events from the school day

Ability to recall events from a special event

Ability to read aloud

Ability to carry on a conversation

Handwriting skills

Ability to problem solve

Ability to explain something he/she learns

Ability to assemble or repair things

Artistic ability

Knows basic math facts

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

O

S

O

O

A

A

A

A

R

R

R

E

E

M

M

M

M

R

R

 

 

1. In your opinion, what can the school staff do to help your child at this time?

 

 

2. Share strengths and special abilities your child has that the school staff should know.

 

 

3. Describe the way your child learns best. (Include your child’s linguistic and communication needs if your child is deaf or hard-of-hearing.)

 

 

 

Form completed by Date

THANK YOU VERY MUCH FOR YOUR HELP!

 

STUDENT QUESTIONNAIRE/INTERVIEW

 

 

Student Grade Date

Directions: Circle the word that best describes you. Items may be read to the student.

ACQUISITION

1. I remember things without having to have to them repeated.

2. I learn new things easily.

3. I understand what I read.

4. I understand what is signed/cued

5. I understand what someone tells me.

6. I understand my class work.

 

Usually

 

Usually

Usually

Usually

Usually

Usually

 

Sometimes

 

Sometimes

Sometimes

Sometimes

Sometimes

Sometimes

 

Seldom

 

Seldom

Seldom

Seldom

Seldom

Seldom

MANIPULATION

7. I can find more than one way to answer a question.

8. I can explain what I learn to my parents or friends.

 

Usually

Usually

 

Sometimes

Sometimes

 

Seldom

Seldom

 

 

ORGANIZATION

9. I turn my assignments in on time.

10. My locker/desk is in order.

11. I run out of space when I am writing.

12. When I write papers, I get information before I begin writing.

13. I make notes or an outline before I write.

14. I edit or change my writing at least once before handing my paper to the teacher.

15. When I do a math story problem, I think about the information before I do the work.

16. I can tell a story in order of events.

17. I know how to study for a test.

 

Usually

Usually

Usually

Usually

 

Usually

Usually

 

Usually

 

Usually

Usually

 

Sometimes

Sometimes

Sometimes

Sometimes

 

Sometimes

Sometimes

 

Sometimes

 

Sometimes

Sometimes

 

Seldom

Seldom

Seldom

Seldom

 

Seldom

Seldom

 

Seldom

 

Seldom

Seldom

 

Student Questionnaire - Page 2

 

Name____________________________________ Date_______________________

 

 

STORAGE

18. After hearing /seeing new information, I learn it by saying it again to myself.

19. I spell words by seeing the word in my mind.

20. I spell words by sounding out the letters.

 

Usually

 

Usually

Usually

 

Sometimes

 

Sometimes

Sometimes

 

Seldom

 

Seldom

Seldom

RETRIEVAL

21. I know my basic addition facts.

22. I know my basic multiplication facts.

23. I use pictures when I do a math problem.

24. I remember things from the past.

25. I remember specific information I have studied for a test.

26. I like to play games that are timed.

27. I do things at a fast rate of speed.

 

Usually

Usually

Usually

Usually

Usually

 

Usually

Usually

 

 

Sometimes

Sometimes

Sometimes

Sometimes

Sometimes

 

Sometimes

Sometimes

 

Seldom

Seldom

Seldom

Seldom

Seldom

 

Seldom

Seldom

 

EXPRESSION

28. I can tell you how to get around the building.

29. I like to: read aloud

draw

give oral reports

do an experiment

show how to do something

write

do math problems

 

Usually

Usually

Usually

Usually

Usually Usually

Usually

Usually

 

 

Sometimes

Sometimes

Sometimes Sometimes

Sometimes

Sometimes

Sometimes

Sometimes

 

Seldom

Seldom

Seldom

Seldom Seldom

Seldom

Seldom

Seldom

 

 

 

30. How do you learn new information best?

 

 

 

Comment:

 

 

THANK YOU VERY MUCH!