New Fall 2016

CAT R EFERRAL
Jacqueline Brown

Learner Performance Review Form

Fridley Public Schools

Use this form for learners who are experiencing difficulty in

school and may require additional help and support.

Part A - Learner Information

Learner's Legal Name:______________________________ School: _____________________________
Teacher:________________________________________________________ Grade:_________
ELD Status :________________________ Birth Date:_____________ Gender:_________
Enrollment Date:______________________________ Previous School:__________________________
Parent or Guardian:___________________________ Home Phone:____________________________
Address: ___________________________________________ Work Phone:_________________________
Street

Zip

Part B - Referral Initiation Information

Date of Referral: ______________________ Referral Initiated By: _________________________________________
Position:____________________________School:____________________________Phone:_____________________
Date Parent Notified of Referral: ____________________

______ Conference ______ Phone Call

Information Reported by Parents (attach notes if needed):

Part C Record Review

Health Review

Cumulative Folder Review

Is there a History of?

Is there a History of?

Visual Concerns
Hearing Concerns
Medications
Other Heath Concerns
Possible Chemical Health
Concerns

Grade/Date

Special Education/IEP
Attendance Concerns
Title One/SNAP
ELD/Bilingual Services
Retention
Behavior Concerns
504 plan

Other Considerations/Circumstances

Grade/Date

Notes:

(Family, living, financial, etc.)

Part D - Academic/ Diagnostic Assessments

MAP/NWEA/MCA Scores and STEP Level:
*Required information for all referrals. You must administer appropriate subtests for that subject area, print
scores, and submit score sheets with referral form. Please give levels for the previous years (2 years prior) if
possible as well as the current years level.*

STEP Level
Grade: ____
Previous Year

Fall

Winter

Spring

Fall

Winter

Spring

Fall

Winter

Spring

Date

Level

Date

Level

Date

Level

Grade/Year
DNA Level

Grade: ____
Previous Year

Grade/Year
DNA Level

Grade: ____
Current Year

Grade/Year
DNA Level

MCA Scores
Grade: ____
Previous Year

Reading
Math
Writing

Grade: ____
Previous Year

Reading
Math
Writing

Grade: ____
Current Year

Reading
Math
Writing

Part E - Student Personal Profile

Personality Profile (Check all that apply)
Adventurous

Energetic

Self-confident

Leader

Motivated

Sensitive

Follower

Resourceful

Serious

Comedian

Responsible

Creative

Organized

Social

Patient

Focused

Detail-oriented

Laid back

Athletic

Consistent

Spontaneous

Reserved

Affectionate

Caring

Artistic/creative

Polite

Student Interests/Motivators
1.

4.

2.

5.

3.

6.

Notes about Student Personal Profile:

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Part F - Student Performance Profile

Academic Skills
Check If
Concern
Applies

Rate (1 =
most
concern)

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Check If
Concern
Applies

Rate (1 =
most
concern)

READING
Phonological Awareness
Alphabetic Principle
Sight word Vocabulary
Decoding Skills
Comprehension (literal)
Comprehension (inferential)
Oral Reading Fluency
MATH
Number Sense: 1:1 Correspondence with objects
Number Identification
Counts from ____ to ____
Number Order
Basic Math Facts (circle)
Addition Subtraction Multiplication Division
Skip Counting (2s, 5s,10s)
Time
Money
Fractions
Decimals
One-step Word Problems
Multiple Step Word Problems

WRITTEN EXPRESSION
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Spelling

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Legibility/Handwriting

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Spacing

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Capitalization

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Punctuation

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Sentence Construction

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Paragraph Formation

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Written Content

*Please attach writing and work samples*

Notes about most concerning Academic Skills:

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Sensory Processing
Check If
Applies

Rate (1 =
most
concern)

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Note: This is an overall rating of the greatest sensory concerns. Each sensory
subsection isnt separate in rating.

Tactile
Avoids casual touch from classmates or teacher
Becomes silly or annoyed when touched
Craves excessive physical contact with others
Distressed by messy hands or face-glue, glay, paints, sand, food, etc.
Dislikes or craves certain textures materials, paper, toys, etc.
Distracted by clothing or shoes
Chews or sucks on clothing, hands, pencils, other objects
Craves or avoids hot or cold item, water play, art supplies
Disturbed by vibration such as air conditioner or trucks
Tactile stims tapping, rubbing, squeezing, hanging
Vision
Squints, blinks, or rubs eyes frequently
Makes poor eye contact
Struggles with reading
Has difficulty with eye-hand coordination beading, writing, drawing
Difficulty copying from the board
Distracted by glare, bright light, fluorescent lighting
Distressed when lights are dimmed or by the dark
Struggles to follow moving objects or people
Poor ball skills catching and/or throwing
Easily overloaded by crowded visual fields
Visual stims hand flaps, flick fingers in front of eyes, spins objects
Vestibular/
Balance

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Avoids changes in head position

Seems clumsy, moves awkwardly
Excessively cautious on stairs
Slumps in chair/sits in W-position on floor/needs support for floor sitting
Touches furniture or walls when walking
Rocks in chair, wraps legs around chair legs
May fall out of chair or onto another student during floor time
Fidgets consistently
Seems restless or always on the go
Seems lethargic or hard to wake up
Gets dizzy easily
Avoids or craves moving playground equipment or riding on bus/in car
Difficulty using playground equipment slides, swings, ladders, sandbox
Vestibular stims spinning, rocking, jumping
Auditory
Distressed by loud noises (fire drill, whistles)
Disturbed by sounds such as singing and musical instruments
Complains that everything/everyone is too loud
Speaks with a very loud voice
Speaks with an unusually quiet voice
Doesnt seem to hear you
Has difficulty filtering out noise and focusing on teachers voice
Frequent outbursts in gym and recess
Frequent outbursts in cafeteria or Team & Family
Seems to learn more easily in one-on-one situations than in a group
Auditory stims hums, repeats, makes odd noises
Proprioception
Poor body awareness doesnt know where body parts are

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Bumps into classmates, furniture, walls

Difficulty grading force breaks crayons, pencil points, toys
Accidentally spills when opening containers, pouring, or drinking
Drops items on floor, slams doors although not angry
Crashes and falls on purpose
Lies down on floor at inappropriate times
Smell and Taste
Complains about smells
Complains about tastes
Doesnt seem to notice strong odors glue, markers, food
Picky eating or very self-limited diet
Acts out at snack time or in cafeteria
Mouths or licks objects and people
Smells objects and people
Behavior,
Learning, Social
Issues

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Craves predictability
Engages in repetitive play
Doesnt understand concept of personal space
Has difficulty joining group activities
Has difficulty with transitions between activities
Difficulty initiating and completing tasks
Struggles with sequencing activities
Poor organization, loses things frequently
Easily overwhelmed or frustrated
Frequently tunes out or withdraws
Frequently acts out or tantrums

Notes about most concerning Sensory Processes:

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Social/Emotional Behavior Concern Checklist

Check If
Applies

Rate (1 =
most
concern)

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Out of seat
Playing with objects during instruction
Making noises during class
Excessive questions during class
Talking with peers during class
Calling out during class
Excessive activity level
Impulsive acting out
Non-compliance with requests (direct defiance)
Non-compliance with requests (negotiation)
Non-compliance with requests (passive)
Arguing
Lying
Invading others personal space
Teasing peers/bullying behavior
Stealing
Temper tantrums
Disrespectful/inappropriate language
Destruction of property
Threatening others
Poor work independence
Careless work completion
Passive-off task (short attention span)
Constant complaining/whining
Crying
Daydreaming
Work avoidance
Excessive requests to leave classroom
Poor peer relationships
Poor adults relationships
Easily distracted
Negative self-statements
Withdrawn/depressed mood
Excessive sleepiness
Moodiness/irritability
Falling frequently
Chewing/eating objects
Physical aggression towards peers
Physical aggression towards adults

Notes about most concerning Social/Emotional Behavior Concern:

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Communication/Language
Check If
Applies

Rate (1 =
most
concern)

Note: Please compare to same age/same language peers.

Difficulty with voice modulation (e.g. harsh, raspy, etc.)

Difficulty with pronouncing sounds
Difficulty with naming people and objects
Difficulty staying on topic
Difficulty with explaining things (e.g. feelings, ideas) due to imprecise
language and limited vocabulary
Difficulty following instructions or directions
Difficulty with retelling what has just been said
Stuttering
Difficulty with sequencing events
Difficulty with using correct grammar in conversation
Uses shorter than average sentences/answering questions (who, what,
where, when, phrases, etc.)

Notes about most concerning Communication/Language Concern:

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Prioritized Concerns
Review the boxes you checked on the previous pages. Identify your top 1-3 concerns (1 = most important). When prioritizing, give
preference to skills/concerns that if improved, would improve the other skills/concerns.

1.

2.

3.

Part G - Previous Instructional/Managerial/Observational Strategies Attempted

Strategy Idea List

Academic Strategy Examples

Parent conferences regarding problems

Use worksheets that require minimal writing
Provide a print outline
Use fill-in questions with space for a brief
response rather than a short essay
Provide instruction at students ability level
Testing accommodation (read aloud, small
group, scheduled breaks, etc.)
Outside agency referral/service
ELD referral

Schedule modification (additional breaks,

different choices, etc.)
Omit assignments that require copying

Daily assignment sheet

Special teaching/materials/program
accommodating teaching style and students
learning style
Mark the correct answers rather than the
incorrect ones
Use both oral and written directions

Have student repeat the directions for a task

Sequence work, with the easiest part first

Check progress and provide feedback often in

the first few minutes of the assignment
Break long-term assignments into small steps
with daily monitoring and frequent grading
Decrease the amount of daily work for students
who perform poorly

Behavioral Strategy Examples

Parent conferences regarding problems

Schedule modification
Documentation/charting behavior
Arrange a check-in time to organize the
day
Daily or weekly behavioral contract/progress
report sent home
Pair the student with a student who is a good
behavior model for class projects
Repeat and /or simplify directions
Modify classroom policies that may
discriminate against the student (e.g. provide
frequent breaks for the student who cannot
pay attention for long periods of time)
Use nonverbal cues to remind the student of
rule violations
Amend consequences for rule violations (e.g.
reward a forgetful student for remembering
to sharpen a pencil in the morning, rather
than punishing the failure to remember)
Reinforce (often) when a student displays
positive behavior
Develop an individualized behavior strategy
plan that is consistent with the students
ability and skills
Arrange for a student to leave the classroom
for designated safe place when highly
stressed
Develop a system or a code word to let a
student know when behavior is not
appropriate
Ignore behaviors that are not seriously
disruptive
Develop strategies for behaviors that are
annoying but not deliberate (e.g. place a
small piece of foam rubber on the desk of a
student who continually taps a pencil on the
desktop)
Sensory breaks
Sensory objects throughout the room that the
student knows how when and how to use
Increase the frequency and immediacy of
reinforcement

Part H1 - Daily Recording of Academic Concern

*Please use this section to collect data. Take 3 weeks of data before submitting referral*

Concern

Date/Subject

Example:

Day 1
Handwriting

9/18/11
Writing

Day 2
9/19/11
Writing

Day 3
9/20/11
Writing

Day 4

9/21/11
Writing

Day 5
9/22/11
Writing

Observation

Strategy

(What did you

see/notice prior?)

(What did you

do/duration?)

Strategy Noticings

-Holding pencil with:

thumb, middle finger,
and pointer, hand
midway on the pencil
-Irregular letter size
-Unfinished words

Gave student a pencil

grip to help with
correct finger and
hand placement

Student was holding pencil in the correct position for 7

minutes out of the 60 minutes during the writing portion of the
day

-Holding pencil with:

thumb, middle finger,
and pointer, hand
midway on the pencil
-Irregular letter size
-Unfinished words
-Holding pencil with:
thumb, middle finger,
and pointer, hand
midway on the pencil
-Irregular letter size
-Unfinished words
-Holding pencil with:
thumb, middle finger,
and pointer, hand
midway on the pencil
-Irregular letter size
-Unfinished words
-Irregular letter size
-Unfinished words

Same as day 1

Same as day 1

Same as day 1

Student was holding pencil in the correct position for 15 of the

60 minutes during writing

Same as day 1 but I

had the student hold
pencil grip in the
correct position
throughout the entire
day for practice.
Same day 4

Student was holding fingers correctly but students finger grip

is starting to move up on pencil and out of the correct writing
position frequently (a noticeable amount of time).

Student was holding pencil firmly and seemly in the correct

position for a portion of the day. Still noticing student is
having trouble not moving fingers up on pencil grip.

Strategy Adjustment
(What can you do different?)
Give student a pencil that is smaller than usual with the same grip. The pencil being short may help direct the grip and also may help enhance fine motor skills

Concern

Date/Subject

Observation

(What did you

see/notice prior?)

Strategy

(What did you

do/duration?)

Strategy Noticings

Day 1

Day 2

Day 3

Day 4

10

Day 5

Strategy Adjustment

(What can you do different?)

Concern

Date/Subject

Observation
(What did you
see/notice
prior?)

Strategy

Strategy Noticings

(What did you

do/duration?)

Day 1

Day 2

Day 3

Day 4

Day 5

Strategy Adjustment

(What can you do different?)

Concern

Date/Subject

Observation
(What did you
see/notice prior?)

Strategy

Strategy Noticings

(What did you

do/duration?)

Day 1

Day 2

11

Day 3

Day 4

Day 5

12

Part H2 - Daily Recording of Behavioral Concern

Concern

*Please use this section to collect data. Take 3 weeks of data before submitting referral*
Date/Time
Antecedence
Behavior (What did you see?)
Noticings
(What happened
Consequence (Concern
prior?)
solved, reprimanded, sent out, in
trouble, escape the request of
task, got peer attention)

Example:

Day 1
Physical
aggression
hitting

9/18/11
Math

Day 2
9/19/11
Writing

Day 3

9/20/11
Math

Day 4
9/21/11
Core Knowledge

-Group work
-3 students in group
(K, R, & S)
-K resistant to group
work and didnt
participate

Behavior: K hits Rebecca

-K resistant to group
work and didnt
participate

Behavior: K throws pencil at S and hits desk

with fists

Consequence: Removal of K from the

classroom to calm body down.

When calm K returned to room. K

seemed less red and less tense when
coming back to the classroom. K was
able to continue work with the rest of
the class.

Same as day 1

Consequence: Removal of K from the

classroom to calm body down.
-Group work
-3 students in group
(K, R, & S)
-K resistant to group
work and didnt
participate

Same as day 1

Same as day 1

-K resistant to group
work and didnt
participate

Behavior: K gets frustrated at J and hits

chair with fist on the ground during some
group work time.

When calm K returned to room. K

seemed a bit tense and was very quiet
for the remaining portion of core
knowledge.

Consequence: Removal of K from the

classroom to calm body down.

Day 5

9/22/11
MM

-K resistant to
participate in MM
activity

Behavior: K kicked feet against the ground

and shoved elbow into H who is directly on
Ks right.
Consequence: Removal of K from the
classroom to calm body down.

H didnt seem to be a direct target, just

who was closest. When calm K returned
to room. K seemed a bit tense and was
very quiet for the remaining portion of
core knowledge.

Strategy/Outcome Adjustment
(What can you do different?)
K doesnt get the privilege of any group work activities throughout the day for 1 week. Student must work independently for 1 week without any sort of hitting OR
aggression to earn that privilege back.

Concern

Date/Time

Antecedence
(What happened
prior?)

Behavior (What did you see?)

Consequence (Concern

Noticings

solved, reprimanded, sent out, in

trouble, escape the request of
task, got peer attention)

Day 1

Day 2

13

Day 3

Day 4

Day 5

Strategy/Outcome Adjustment
(What can you do different?)

Concern

Date/Time

Antecedence Behavior (What did you see?)

(What
Consequence (Concern solved,
happened
prior?)

Noticings

reprimanded, sent out, in trouble,

escape the request of task, got
peer attention)

Day 1

Day 2

Day 3

Day 4

Day 5

Strategy/Outcome Adjustment
(What can you do different?)

14

Concern

Date/Time

Antecedence
(What happened
prior?)

Behavior (What did you see?)

Consequence (Concern

Noticings

solved, reprimanded, sent out, in

trouble, escape the request of
task, got peer attention)

Day 1

Day 2

Day 3

Day 4

Day 5

15

Part I - Observations from Other Student Support Providers/Specialists

Partner Teacher:
Comments (concerns/strategies tried):

Date:

Student Support Provider/Specialist:

Comments (concerns/strategies tried):

Date:

Student Support Provider/Specialist:

Comments (concerns/strategies tried):

Date:

Student Support Provider/Specialist:

Comments (concerns/strategies tried):

Date:

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