Grades 3-5 Teacher Questionnaire Form - Chicago Friends School

Chicago Friends School cherishes the individuality and uniqueness of each of its students and considers the whole child during the admission process. All the information you provide is confidential. Thank you for your thoughtful evaluation.

Student's Name *

First

Last

Current Grade Level

Third Grade
Fourth Grade
Fifth Grade

Parent/Guardian Name *

First

Last

Relationship

Mother
Dad
Other

If other is chosen, please explain below.

Further explanation of relationship

Student's Address *

Address Line 1

Address Line 2

City

State

Zip Code

How long have you known the child?

In what capacity?

What is the number of students in your classroom?

Selected Value: 0

What are the first three words that come to mind to describe this child? *

SOCIAL-EMOTIONAL DEVELOPMENT SECTION

We recognize that children develop at different paces along a developmental continuum. If the child demonstrates concern in an area of development, please comment including whether this is a possible area of concern or if the child has been formally evaluated and receives special services.

Sensitivity Towards Other's Feelings/Respect for Individual Differences. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Form Friendships. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Appropriately Initiates and Responds to Peer Interaction. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Respects Personal Boundaries and Property of Others. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Seek Positive Relationships with Adults. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Demonstrate Self-Control and Makes Appropriate Emotional Reactions. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Makes Transitions Appropriately. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Express Feelings and Needs Appropriately. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Willingly Observes Rules and Accepts School Protocols. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

If there is additional information or concerns please share.

ACADEMIC DEVELOPMENT

Stays On and Completes Tasks, Persists when Difficult. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Demonstrates Creativity and Imagination. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Engages In Thoughtful Problem Solving. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Participates, Contributes, and Listens Appropriately in Group Setting. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Monitors Own Learning, Seeks Help When Appropriate. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Able to Work Independently. *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Oral Comprehension *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Reading Skills *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Writing Skills *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Expressive Speaking Skills *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

Math Skills and Quantitative Thinking *

Exceeding
Age-Appropriate
Progressing
Areas of Concern

Please choice one

If there is additional information or concerns, please share with us.

Does this student have a learning or behavioral difference that impacts their learning experience in the classroom? If yes, please describe.

Can this student's needs be met in a general education class setting?

Do you have any comments or concerns about this student's physical development or physical skills?

Does this student have any particular affinities or interests you would like to share?

Is there any additional information that would be helpful to us in our evaluation of this applicant?

Parents/Gaurdian are an important part of our relationship with the student. Please share with us any thoughts you have regarding this applicant's family, including their involvement in your school. *

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May we contact you if we have additional questions? *

Yes
No

Teacher's Name *

First

Last

Cell Phone *

School's Name *

School's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Work Email *

School's Phone

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Thank you! Your perspective is important to us.