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Questionnaire for English Teachers

About Students with Learning Disabilities Requesting Testing Modifications

Student’s Name: Erez Shalev Student’s ID Number _____________


Name of Schoo:l Regional Megiddo High Phone Number of School: 04-9598600
Fax Number of School: 04-959811 Semel Mossad:260109
Teacher's Name: Iris Elish Teacher's Phone Number : 04-9836967 Grade:10th
Modules Being Tested: E
All of the above must be completed for your request to be processed.

Please TYPE your answers and give as much information as possible so


the best decision regarding your student can be made.

For level three modifications only (Oral and Mutam)


1. What are your student’s difficulties? (Check as appropriate.)
My student:
cannot decode at the word level.
cannot decode at the sentence level.
when reading, cannot comprehend at the word level
when reading, cannot comprehend at the sentence level.

For ALL levels of modifications


1. What is the level of the student’s English according to the curriculum:
Foundation Intermediate Proficiency
2. What are your student’s difficulties? (Check as appropriate.)
My student:
does not understand a text when read to.
has illegible handwriting.
cannot read own handwriting.
has multiple spelling errors making written work extremely difficult to understand.
has severe difficulty expressing him/herself in writing.
has a clear gap between oral and written skills.
has difficulty communicating orally in English.
has difficulty concentrating during class.
works extremely slowly on tasks.
Other: ___________________________________________________________
3. My student’s reading is not fluent, but s/he can understand what s/he reads. Yes No

4. My student’s reading is not fluent and s/he cannot understand what s/he reads. Yes No

5. Is your student in a special program? Yes No


If yes, which program? Mabar Etgar Ometz Other

6. Has your student received special help with English studies at school? Yes No
What kind of help? ______________________________________________________

7. Has your student received special help with English studies at home? Yes No
Explain. _______________________________________________________________

8. What testing modifications did the moatsa hapedagogit at your school decide on for the
student for English? (Check as appropriate.)
listening to recorded texts
listening to a reader
recording answers onto a tape
oral examination
extra time
ignoring spelling mistakes
using an electronic dictionary

9. Have these modifications been beneficial for your student?


Yes. Explain:________________________________________________________
No. Explain:________________________________________________________
The student has not yet tried these modifications.
10. How have you tested your student during the school year?
in the conventional manner
listening to recorded texts
listening to a reader
recording answers on a tape
dictating answers to a person
giving an oral examination
giving a mutam examination
giving extra time
ignoring spelling mistakes
using an electronic dictionary

11. Have these modifications been beneficial for your student? Yes No
In what way?
________________________________________________________________________________________
____________________________________________________________________

12. Is there anything you would like to add?


___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________

Please attach a composition (original copy) that the student has written in class, with your corrections.

Teacher's Signature ________________________ Date __________________