THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDA

COLLABORATIVE PROBLEM-SOLVING & COMPREHENSIVE EVALUATION: STUDENT RATING FORM

Name: ____________ School: ____________ DOB: ______ Date: _____________

Teacher: _______________ Grade: _____ (Note: Student was retained in grade _____) Subject:
How long have you known this student?: In what capacity?:
ACADEMIC INSTRUCTION
Reading Program/Teacher: ___________________________________ Instructional Reading Level:
IRI Levels - Word Recognition: _____ Reading Comprehension: _____ Listening Comprehension:
Additional reading instruction/practice (reading lab, adult volunteer, etc.) Specify types of practice and hours/week:
______________________________________________________________
Are this student’s reading levels modified or accommodated in other subject areas (e.g. Social Studies, Math)? ____
Explain: __________________________________________________________

Math program/Teacher: ______________________________________ Instructional Math Level:

Additional math instruction/practice (math lab, adult volunteer, etc.) Specify types of practice and hours/week:
__________________________________________________________________
Does this student require accommodations for math instruction (e.g., use of manipulatives, calculator)?
If yes, specify: _____________________________________________________________

Predominant handwriting: Manuscript: _______ Cursive: ________ Level of Legibility? ___________

Estimate level of written expression skills: ___________________

ESOL (Bi-lingual) Language Classification: _____ Date: ________ Is another language used at home?:______
Language involved: Creole____ Spanish_____ Portuguese_____ French: other (specify):
Which ESOL strategies are helpful for this child:
_______________________________________________________________________

Check all services this child is receiving: Speech Therapy (articulation): ___ Language therapy: ___ OT: PT:
Specify other support services (e.g., counseling group, listener):
________________________________________________________________________

Does this child have any of the following in place: 504 Plan: ___ FBA: ___ BIP: ___ PMP: ___ Other:
_________________________________________________________________________

Attach a copy of most recent report card or interim report, and standardized test scores.

Comments: Describe, in objective, observable terms, this student’s major difficulties. Elaborate on any extreme or
unusual behaviors.
_______________________________________________________________________________

Describe student’s strengths in achievement and behavior (e.g., strongest academic area, art, music, etc.):

FORM CONTROL #4375. REVISED 1/07 AND AVAILABLE ON PSYCHOLOGICAL SERVICES AT WWW.BROWARDSCHOOLS.COM
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ACADEMIC SKILLS: Check areas of concern

[ ] 1. Sight vocabulary (word recognition skills)

[ ] 2. Word attack/decoding skills (words in isolation vs. in context)
[ ] 3. Reading comprehension
[ ] 4. Math concepts
[ ] 5. Math calculations (in solving numerical equations)
[ ] 6. Math applications (in solving word and practical problems)
[ ] 7. Spelling
[ ] 8. Proofreading
[ ] 9. Ability to express ideas in writing: sentences/paragraphs/essays
[ ] 10. Speed/fluency of written expression
[ ] 11. Grammar/punctuation/capitalization
[ ] 12. Ability to express ideas and concepts orally
Comments:

ATTENDANCE: Check areas of concern

[ ] 1. Excessive absences
[ ] 2. Excessive tardiness
[ ] 3. Truancy
[ ] 4. Suspension: ___ internal, ___ external, ___ alternative to suspension
[ ] 5. Frequent sign-out/early dismissal
[ ] 6. Frequent class cutting
Comments:
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ADAPTIVE BEHAVIORS
(Please note: The more frequently a behavior in these two sections
is observed, the better the student’s adaptive behavior.)

SOCIAL SKILLS/INTERPERSONAL RELATIONSHIPS

Almost
Rarely Sometimes Often Always
1. Demonstrates self-control [ ] [ ] [ ] [ ]
2. Cooperates and complies with directions from authority figures [ ] [ ] [ ] [ ]
3. Handles redirection or reprimand without overreacting [ ] [ ] [ ] [ ]
4. Makes friends easily [ ] [ ] [ ] [ ]
5. Works cooperatively with peers [ ] [ ] [ ] [ ]
6. Follows rules [ ] [ ] [ ] [ ]
7. Takes responsibility for own actions; does not blame others [ ] [ ] [ ] [ ]
Comments:

ADAPTIVE BEHAVIOR: PRODUCTIVITY/EFFICIENCY/ORGANIZATION

Almost
Rarely Sometimes Often Always
1. Is organized [ ] [ ] [ ] [ ]
2. Brings supplies to class [ ] [ ] [ ] [ ]
3. Fills out planner daily (if applicable) [ ] [ ] [ ] [ ]
4. Pays attention to oral directions [ ] [ ] [ ] [ ]
5. Copies accurately from board [ ] [ ] [ ] [ ]
6. Copies accurately from textbook [ ] [ ] [ ] [ ]
7. Remembers instructions/information taught [ ] [ ] [ ] [ ]
8. Transfers what was learned from one situation to another [ ] [ ] [ ] [ ]
9. Turns in homework regularly [ ] [ ] [ ] [ ]
10. Completes classwork on time [ ] [ ] [ ] [ ]
11. Turns in classwork regularly [ ] [ ] [ ] [ ]
12. Asks for help when confused [ ] [ ] [ ] [ ]
13. Demonstrates effort [ ] [ ] [ ] [ ]
Comments:
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BEHAVIORS OF CONCERN
(Please note: The more frequently a behavior in these four sections is
observed, the greater the problem the student’s behavior presents.)

EMOTIONAL ADJUSTMENT
Almost
Never Sometimes Often Always
1. Belittles self or abilities [ ] [ ] [ ] [ ]
2. Needs excessive praise, reassurance, and encouragement [ ] [ ] [ ] [ ]
3. Withdraws (e.g., isolates self) [ ] [ ] [ ] [ ]
4. Avoids verbal communication [ ] [ ] [ ] [ ]
5. Avoids other children [ ] [ ] [ ] [ ]
6. Is ridiculed or ignored by peers [ ] [ ] [ ] [ ]
7. Clings to adults [ ] [ ] [ ] [ ]
8. Appears fearful, timid, anxious [ ] [ ] [ ] [ ]
9. Appears sad [ ] [ ] [ ] [ ]
10. Cries [ ] [ ] [ ] [ ]
11. Claims illness to avoid work or school [ ] [ ] [ ] [ ]
12. Engages in self-injurious behaviors [ ] [ ] [ ] [ ]
13. Talks of harming self [ ] [ ] [ ] [ ]
Comments:

ATTENTION/ACTIVITY LEVEL
Almost
Never Sometimes Often Always
1. Impulsive; e.g. blurts out answers, interrupts others,
answers without thinking [ ] [ ] [ ] [ ]
2. Does not await turn [ ] [ ] [ ] [ ]
3. Does not sit still/squirms/fidgets [ ] [ ] [ ] [ ]
4. Is easily distracted and/or appears inattentive [ ] [ ] [ ] [ ]
5. “On the go,” acts as if driven by a motor [ ] [ ] [ ] [ ]
6. Talks excessively [ ] [ ] [ ] [ ]
7. Loses items necessary for tasks [ ] [ ] [ ] [ ]
Comments:
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CONDUCT PROBLEMS
Almost
Never Sometimes Often Always
1. Argumentative [ ] [ ] [ ] [ ]
2. Defies authority [ ] [ ] [ ] [ ]
3. Verbally aggressive (e.g., teases, ridicules, threatens) [ ] [ ] [ ] [ ]
4. Uses profanity [ ] [ ] [ ] [ ]
5. Physically Aggressive [ ] [ ] [ ] [ ]
6. Lies [ ] [ ] [ ] [ ]
7. Steals [ ] [ ] [ ] [ ]
8. Destroys property [ ] [ ] [ ] [ ]
9. Behaviors require referrals to administration [ ] [ ] [ ] [ ]
Comments:

PHYSICAL/HEALTH
Almost
Never Sometimes Often Always
1. Demonstrates poor hygiene [ ] [ ] [ ] [ ]
2. Appears tired, lethargic [ ] [ ] [ ] [ ]
3. Is congested [ ] [ ] [ ] [ ]
4. Shows poor gross-motor ability; appears clumsy [ ] [ ] [ ] [ ]
5. Shows poor fine-motor ability (e.g., handwriting, fasteners) [ ] [ ] [ ] [ ]
6. Stares blankly [ ] [ ] [ ] [ ]
7. Has toilet accidents: ___wets, ___soils [ ] [ ] [ ] [ ]
8. Has unusual mannerisms (e.g., tics, grimaces) [ ] [ ] [ ] [ ]
9. Presents physical complaints [ ] [ ] [ ] [ ]
10. Is absent due to illness [ ] [ ] [ ] [ ]
11. Has chronic ailments/conditions (e.g., asthma, diabetes) [ ] [ ] [ ] [ ]
Comments:

Psychological Services: 3/15/08