Premeeting Background Form Directions: The referring teacher should complete this form and submit it to the facilitator at least one week before the initial meeting. Team Information Teacher completing form: Date: Service providers (list names and roles): Student Information Student name: Parent/guardian: Parent/guardian contact info: Teacher: Is the Grade: DOB: student part of NCII’s tracking sample? IEP or 504 plan? ________ If the student has an IEP or 504 plan, Is the student an Has the student has the case manager been invited to English had a recent If the student has an IEP or 504 the meeting? ______ language hearing and plan, who is the case manager? learner? vision ______________________________ screening? Results? Has there been consistent communication with the If the referring teacher is not the general parent/guardian? ________ educator, has there been consistent communication with the classroom Will they attend the meeting? ________ teacher/general educator? ________ Will they attend the meeting? _______ Current Supports Content area Describe current supports and tier of intervention/support (if applicable). (check all that apply) Reading Mathematics Behavior/social skills Other
Premeeting Background Form Directions: The referring teacher should complete this form and submit it to the facilitator at least one week before the initial meeting. Team Information Teacher completing form: Date: Service providers (list names and roles): Student Information Student name: Parent/guardian: Parent/guardian contact info: Teacher: Is the student part of NCII’s tracking sample? Grade: DOB: IEP or 504 plan? ________ If the student has an IEP or 504 plan, who is the case manager? ______________________________ If the student has an IEP or 504 plan, has the case manager been invited to the meeting? ______ Is the student an English language learner? Has the student had a recent hearing and vision screening? Results? Has there been consistent communication with the parent/guardian? ________ Will they attend the meeting? ________ If the referring teacher is not the general educator, has there been consistent communication with the classroom teacher/general educator? ________ Will they attend the meeting? _______ Current Supports Content area (check all that apply) Describe current supports and tier of intervention/support (if applicable). Reading Mathematics Behavior/social skills Other
Premeeting_Referral_Form.docx