Teacher Questionnaire

Name of student

Date of evaluation

Person completing form and position

Phone

Email address

This student has been scheduled for an evaluation of his/her learning profile at Kingfisher Learning. Any information you offer will help us optimally understand this individual as a learner. This form may be duplicated.

What might you wish to learn from this evaluation?

Do you currently have any concerns regarding this student? If yes, please describe.

Please describe this student's performance within your classroom setting, including areas of strength and weakness.

How would you describe this student's interactions with peers? With adults?

To develop the most relevant and appropriate recommendations, please list any programs, strategies, methods, materials, etc., that you have implemented, either successfully or unsuccessfully, with this student. Please comment on the effectiveness of instruction, differentiation, and/or accommodations you have offered.

Feel free to attach any work samples if desired.

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