Teacher Survey

OMB#: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Spring 2007

Child ID number:
Birth date:

Third Grade Follow-Up

TEACHER SURVEY/TEACHER’S CHILD REPORT

Setting Type:
Setting Name:
Setting ID:
Setting Address:
	Street
	City State Zip
Setting Phone:	( )
Provider/ Respondent Type:
Room Number

Westat

NOTE TO OMB EXAMINER

If a teacher teaches reading and math to a study child, the teacher will complete all items in Sections I and II and items 5, 15-18, and 30 in Section III.

If a teacher teaches only reading to a study child, the teacher will complete all items in Sections I and II.

If a teacher teaches only math to a study child, the teacher will complete all items in Sections I and III.

Dear Teacher,

This survey is an important part of a major longitudinal study of children’s school performance beginning with preschool and continuing through third grade. You have received this survey because one or more of the children in your class are participants in this study.

The Third Grade Follow-Up to the Head Start Impact Study is collecting information from children, parents, teachers, and principals to investigate the impact of Head Start on children’s school performance.

This survey is designed to collect information in the following areas:

1. School Characteristics

2. Teacher Characteristics

3. General Classroom Characteristics

4. Child Characteristics

5. Child’s Class/Group Characteristics

6. Reading Instruction and Activities

7. Math Instruction and Activities

Obviously, only you can provide the teacher information. Although we realize you are very busy, we urge you to complete this survey as accurately as possible. The information you provide is confidential and only will be used for research purposes.

Please write your answers on the survey form by circling the appropriate number or writing your response in the space provided.

Thank you very much for your help.

NOTICE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB Control Number for this information collection is ____________ (expires _____________). The time required to complete this information collection is estimated to average 30 minutes per response, including time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

SECTION I

GENERAL SCHOOL CHARACTERISTICS. PLEASE RESPOND TO FOLLOWING QUESTIONS, BY CIRCLING THE APPROPRIATE NUMBER OR WRITING YOUR RESPONSE IN THE SPACE PROVIDED.

1. Please mark the extent to which you agree or disagree with each of the following statements. (CIRCLE ONE NUMBER ON EACH LINE.)

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. Teachers are involved in making important decisions about this school.	1	2	3	4	5
b. Teachers have a lot of informal opportunities to influence what happens here.	1	2	3	4	5
c. Teachers in this school regularly discuss teaching and learning	1	2	3	4	5
d. Experienced teachers help new teachers.	1	2	3	4	5
e. Teachers share and discuss student work with other teachers.	1	2	3	4	5
f. A conscious effort is made to make new teachers feel welcome here.	1	2	3	4	5
g. Teachers plan together to integrate curriculum across disciplines.	1	2	3	4	5

2. This school year, how often did you work with other faculty on the following? (CIRCLE ONE NUMBER ON EACH LINE.)

	Less than once per month	2-3 times per month	Once or twice a week	Daily
a. Clarifying standards for student learning through analysis of students’ work.	1	2	3	4
b. Integrating instruction across subject areas.	1	2	3	4
c. Examining the scope or sequence of specific subject areas.	1	2	3	4
d. Reviewing the effectiveness of curricular materials	1	2	3	4
e. Modifying instruction to meet student needs.	1	2	3	4
f. Examining student assessments to determine appropriate educational programming.	1	2	3	4

3. How many teachers in this school: (CIRCLE ONE NUMBER ON EACH LINE.)

	None	Some	About half	Most	Nearly all
a. Help maintain discipline in the entire school, not just in their classrooms?	1	2	3	4	5
b. Take responsibility for improving the school?	1	2	3	4	5
c. Set high standards for themselves?	1	2	3	4	5
d. Feel responsible that all students learn?	1	2	3	4	5
e. Feel responsible when students in this school fail?	1	2	3	4	5
f. Are eager to try new ideas?	1	2	3	4	5
g. Are really trying to improve their teaching?	1	2	3	4	5
h. Focus on what’s best for student learning?	1	2	3	4	5
i. Cooperate well with each other?	1	2	3	4	5
j. Have a good grasp of the subject matter they teach?	1	2	3	4	5

4. How satisfied are you with each of the following aspects of teaching at this school? (CIRCLE ONE NUMBER ON EACH LINE.)

	Very dissatisfied	Somewhat dissatisfied	Somewhat satisfied	Very satisfied
a. Recognition and support from the administration	1	2	3	4
b. Recognition and support from parents	1	2	3	4
c. Recognition and support from the community	1	2	3	4
d. Availability of resources and materials/equipment for your classroom	1	2	3	4
e. Your influence over school policies and practices	1	2	3	4
f. Autonomy or control over your own classroom	1	2	3	4
g. Time to prepare lesson/teaching plans	1	2	3	4
h. Student motivation to learn	1	2	3	4
i. Class size	1	2	3	4
j. Student discipline and behavior	1	2	3	4
k. Opportunities for professional development	1	2	3	4
l. The principal’s leadership and vision	1	2	3	4
m. Safety of school environment	1	2	3	4
n. Procedures for teacher performance evaluation	1	2	3	4
o. Professional caliber of colleagues	1	2	3	4
p. Parental involvement in the school	1	2	3	4

5. Please indicate your opinion about each of the following statements: (CIRCLE ONE NUMBER ON EACH LINE.)

	Nothing	Very little	Some	Quite a bit	A great deal
a. How much can you do to control disruptive behavior in your classroom?	1	2	3	4	5
b. How much can you do to motivate students who show no interest in their work?	1	2	3	4	5
c. How much can you do to get students to believe they can do well in school work?	1	2	3	4	5
d. How much can you do to get students to value learning?	1	2	3	4	5
e. How much can you do to get students to follow classroom rules?	1	2	3	4	5
f. How much can you do to help parents support their child’s learning?	1	2	3	4	5

6. The following items are statements that some teachers have made about how children should be taught and managed. Indicate to what extent each statement agrees or disagrees with your personal beliefs about good teaching practice. (CIRCLE ONE NUMBER ON EACH LINE.)

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. Classroom activities should respond to individual differences in development.	1	2	3	4	5
b. Each curriculum area should be taught as a separate subject at separate times.	1	2	3	4	5
c. Children should be allowed to perform their own steps in an experiment, and plan their own creative drama, art, and writing activities	1	2	3	4	5
d. Students should work silently and alone on seatwork.	1	2	3	4	5
e. Children should learn by touching and using objects	1	2	3	4	5
f. Treats, stickers, or stars should be used to encourage appropriate behavior among children	1	2	3	4	5
g. Appropriate behavior among children should be encouraged using punishments or reprimands	1	2	3	4	5
h. Children should be involved in establishing class rules	1	2	3	4	5
i. Teachers know a lot more than students; they shouldn’t let students muddle around when they can just explain the answers directly	1	2	3	4	5
j. Instruction should be built around problems with clear, correct answers and around ideas that most students can grasp quickly	1	2	3	4	5
k. Students are not ready for “meaningful” learning until they have acquired basic reading and math skills	1	2	3	4	5
l. How much students learn depends on how much background knowledge they have – that is why teaching facts is so necessary	1	2	3	4	5
m. It is better when the teacher, not the students, decides what activities are to be done	1	2	3	4	5

7. The principal at this school….(CIRCLE ONE NUMBER ON EACH LINE.)

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. Makes clear to the staff his/her expectations for meeting instructional goals	1	2	3	4	5
b. Communicates a clear vision for this school	1	2	3	4	5
c. Sets high standards for teaching	1	2	3	4	5
d. Understands how children learn	1	2	3	4	5
e. Sets high standards for student learning	1	2	3	4	5
f. Encourages teachers to implement what they learned through professional development	1	2	3	4	5
g. Carefully tracks student academic progress	1	2	3	4	5
h. Is an effective manager who makes the school run effectively	1	2	3	4	5
i. Knows what’s going on in my classroom	1	2	3	4	5
j. Actively monitors the quality of teaching in this school	1	2	3	4	5
k. Communicates effectively with parents	1	2	3	4	5
l. Maintains positive relationships with students	1	2	3	4	5
m. Provides support to teachers regarding parent concerns about students	1	2	3	4	5
n. Treats teachers equitably
o. Treats students equitably

8. How much influence do teachers have over school policy in each of the following areas? (CIRCLE ONE NUMBER ON EACH LINE.)

	None	A little	Some	A great deal
a. Hiring new professional staff	1	2	3	4
b. Planning how discretionary school funds should be used	1	2	3	4
c. Selecting instructional materials	1	2	3	4
d. Establishing the instructional program or curriculum	1	2	3	4
e. Determining the content of in-service training	1	2	3	4
f. Setting standards for student behavior	1	2	3	4

9. To what extent do you agree or disagree with the following statements? (CIRCLE ONE NUMBER ON EACH LINE.)

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. Once we start a new instructional program, we follow up to make sure its working	1	2	3	4	5
b. We have so many instructional programs in this school I can’t keep track of them all	1	2	3	4	5
c. Many special instructional programs come and go at this school	1	2	3	4	5
d. You can see real continuity from one instructional program to another at this school	1	2	3	4	5
e. Curriculum, instruction, and materials are well coordinated across grades	1	2	3	4	5
f. There is instructional consistency among teachers at the same grade	1	2	3	4	5

10. Which of the following is true about how well your school provides you with the instructional materials you need? (CIRCLE ONE NUMBER.)

I get all the resources I need 1

I get most of the resources I need 2

I get some of the resources I need 3

I don’t get the resources I need 4

11. To what extent do you agree or disagree with the following statements? (CIRCLE ONE NUMBER ON EACH LINE.)

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
a. Parents are invited to visit classrooms to observe the instructional program	1	2	3	4	5
b. The principal expects teachers to communicate regularly with parents	1	2	3	4	5
c. We encourage feedback from parents and the community	1	2	3	4	5
d. Teachers really try to understand parents’ concerns	1	2	3	4	5
e. Parents are greeted warmly when they call or visit the school	1	2	3	4	5
f. Teachers work closely with parents to meet students’ needs	1	2	3	4	5
g. This school regularly communicates with parents	1	2	3	4	5
h. Teachers and parents see each others as partners in educating children	1	2	3	4	5
i. Parents have confidence in teacher’s expertise	1	2	3	4	5
j. Staff work hard to build trusting relationships with parents	1	2	3	4	5
k. Parents respect teachers	1	2	3	4	5
l. Parents try to understand educational issues	1	2	3	4	5

12. For the students you teach this year, about how many parents: (CIRCLE ONE NUMBER ON EACH LINE.)

	None	Some	About half	Most	Nearly all
a. Attended parent-teacher conferences when you requested them?	1	2	3	4	5
b. Volunteered to help in the classroom?	1	2	3	4	5
c. Followed through on discipline/behavioral expectations	1	2	3	4	5

13. How much professional development or other training have you received in any of these areas this year? (CIRCLE ONE NUMBER ON EACH LINE.)

	None	A little	Some	A great deal
a. Using student assessments to tailor instruction for students’ individual needs	1	2	3	4
b. Using student assessments to evaluate your teaching effectiveness	1	2	3	4
c. Applying research or theories in child development or student learning	1	2	3	4
d. Adapting instruction based on student culture or background	1	2	3	4
e. Deepening your content knowledge for the subjects you teach	1	2	3	4

14. This school year, how often have you: (CIRCLE ONE NUMBER ON EACH LINE.)

	Never	Once or twice	3-6 times	More than 6 times
a. Participated in a network with teachers outside this school?	1	2	3	4
b. Attended professional development activities within your school?	1	2	3	4
c. Attended professional development activities outside of your school?	1	2	3	4
d. Discussed curriculum or teaching with an outside organization?	1	2	3	4
e. Taken courses at a college or university relative to improving your teaching?	1	2	3	4
f. Been observed teaching by your principal?	1	2	3	4
g. Been observed by another teacher in your school?	1	2	3	4
h. Attended school staff meetings?	1	2	3	4
i. Attended grade-level planning meetings?	1	2	3	4

15. How often do you ask students to use computers for the following activities? (CIRCLE ONE NUMBER ON EACH LINE.)

	Never	Once or twice a semester	Once or twice a month	Once or twice a week	Daily or almost daily
a. Practice drills	1	2	3	4	5
b. Do word processing or typing	1	2	3	4	5
c. Create presentations	1	2	3	4	5
d. Analyze or graph data	1	2	3	4	5
e. Create web pages	1	2	3	4	5
f. Do research using the Internet	1	2	3	4	5
g. Correspond with others via e-mail	1	2	3	4	5

16. Are the following available to your students? (CIRCLE ONE NUMBER ON EACH LINE.)

	YES	NO
a. Computer in the classroom	1	0
b. Computers elsewhere in the school	1	0
c. Internet in the classroom	1	0
d. Internet elsewhere in the school	1	0

17. During a typical school day, what percent of your classroom time do you spend in the following tasks? NOTE: TOTAL SHOULD EQUAL 100 PERCENT. (ENTER THE NUMBER ON EACH LINE.)

Teacher activity	Percent of time
a. Academic instruction	__________
b. Managing classroom behavior	__________
c. Managing classroom tasks (e.g., handing out papers, transitions between activities, etc.)	__________
TOTAL PERCENT	__________

18. To what extent do you agree or disagree with each of the following statements about reading and reading instruction? (CIRCLE ONE NUMBER ON EACH LINE.)

	Strongly disagree				Strongly agree
a. A child needs to be able to verbalize the rules of phonics in order to assure proficiency in processing new words	1	2	3	4	5
b. An increase in reading errors is usually related to a decrease in comprehension	1	2	3	4	5
c. Dividing words into syllables according to rules is a helpful instructional practice for reading new words	1	2	3	4	5
d. Fluency and expression are necessary components of reading that indicate good comprehension	1	2	3	4	5
e. When children do not know a word, they should be instructed to sound out its parts	1	2	3	4	5
f. The use of a glossary or dictionary is necessary in determining the meaning and pronunciation of new words	1	2	3	4	5
g. Reversals (e.g., “saw” for “was”) are significant problems in the teaching of reading	1	2	3	4	5
h. It is a good practice to correct a child as soon as an oral reading mistake is made	1	2	3	4	5
i. It is important for a word to be repeated a number of times after it has been introduced to insure that it will become a part of sight vocabulary	1	2	3	4	5
j. Paying close attention to punctuation marks is necessary to understanding story content	1	2	3	4	5
k. It is a sign of an ineffective reader when words and phrases are repeated	1	2	3	4	5
l. Being able to label words according to grammatical function (nouns, etc.) is useful in proficient reading	1	2	3	4	5
m. When coming to a word that’s unknown, the reader should be encouraged to guess upon meaning and go on	1	2	3	4	5
n. Young readers need to be introduced to the root form of words (run, long) before they are asked to read inflected forms (running, longest)	1	2	3	4	5
o. It is not necessary for a child to know the letters of the alphabet in order to learn to read	1	2	3	4	5
p. Flashcard drills with sight words is an unnecessary form of practice in reading instruction	1	2	3	4	5
q. Ability to use accent patterns in multisyllable words (pho’ to graph, pho to’ gra phy, and pho to gra’ phic) should be developed as part of reading instruction	1	2	3	4	5
r. Controlling text through consistent spelling patterns (The fat cat ran back. The fat cat sat on a hat) is a means by which children can best learn to read	1	2	3	4	5
s. Formal instruction in reading is necessary to insure the adequate development of all the skills used in reading	1	2	3	4	5
t. Phonic analysis is the most important form of analysis used when meeting new words	1	2	3	4	5
u. Children’s initial encounters with print should focus on meaning, not upon exact graphic representation	1	2	3	4	5
v. Word shapes (word configuration) should be taught in reading to aid in word recognition	1	2	3	4	5
w. It is important to teach skills in relation to other skills	1	2	3	4	5
x. If a child says “house” for the written word “home,” the response should be left uncorrected	1	2	3	4	5
y. It is not necessary to introduce new words before they appear in the reading text	1	2	3	4	5
z. Some problems in reading are caused by readers dropping the inflectional endings from words (e.g., jumps, jumped)	1	2	3	4	5

Teacher Characteristics

19. What is the highest degree you have attained? (CIRCLE ONE NUMBER.)

Baccalaureate Degree 1

Graduate Degree 2

20. Are you currently working toward an advanced degree (for example, Master’s or PhD)? (CIRCLE ONE NUMBER.)

Yes 1

No 2

21. What was the major field of study for your bachelor’s degree? (CIRCLE ONE NUMBER ON EACH LINE.)

	YES	NO
a. Early Childhood Education	1	0
b. Elementary Education	1	0
c. Special Education	1	0
d. Other Education-related Major (such as Secondary Education, Educational Psychology, Administration, Music Education, English Education, etc.) (Specify) ________________________________	1	0
e. Non-Education Major (such as History, English, Mathematics, etc.) (Specify) _____________________________________________	1	0

22. What was the major field of study for your graduate degree (including any degree you are currently pursuing)? (CIRCLE ONE NUMBER ON EACH LINE.)

	YES	NO
a. Early Childhood Education	1	0
b. Elementary Education	1	0
c. Special Education	1	0
d. Other Education-related Major (such as Secondary Education, Educational Psychology, Administration, Music Education, English Education, etc.) (Specify) ________________________________	1	0
e. Non-Education Major (such as History, English, Mathematics, etc.) (Specify) _____________________________________________	1	0

23. Which of the following statements most accurately describes the type of teaching certificate/license/ credential that you hold? States vary in the types of certificates they issue. Please select from the list below the statement that BEST describes the certificate/license/credential that you hold. (CIRCLE ONE NUMBER.)

A regular or standard state certificate or advanced professional
certificate 01

An initial certificate that is issued to candidates after satisfying
all requirements except the completion of a probationary period 02

A temporary certificate that is given to persons who need additional
preparatory training, such as coursework and/or student teaching,
in order to satisfy the requirements for full certification 03

An emergency certificate or waiver that is issued for a specified
time period to persons with insufficient teacher preparation 04

Other (Describe) __________________________________________ 05

I am not certified 06

24. Are you currently pursuing a regular OR standard state certificate OR additional advanced, professional certification? (CIRCLE ONE NUMBER.)

Yes 1

No 2

25. From the list below, select the areas in which you are certified, or are seeking certification. (CIRCLE ALL THAT APPLY.)

General elementary 01

Bilingual education 02

A specific subject area (Specify) ______________________________ 03

Special education (Specify) __________________________________ 04

Other (Specify) ____________________________________________ 05

Not certified and not pursuing certification 06

26. Indicate the number of years you’ve worked, including this school year, as any of the following (either part‑time or full-time). (FOR EACH LINE, WRITE THE NUMBER FOR EACH COLUMN. ENTER “0” IF WORKED LESS THAN ONE YEAR.)

	NUMBER OF YEARS
	In this school	In a different school
a. Teacher	__________	__________
b. Teacher aide	__________	__________
c. Long-term substitute teacher	__________	__________
d. Substitute teacher	__________	__________
e. Other school staff (Specify) _______________________________	__________	__________

SECTION II

GENERAL CLASSROOM CHARACTERISTICS. Thinking about the study child identified on the label of this booklet, please respond to the following questions about this child’s reading/language arts class.

1. How many children are in this child’s reading/language arts class? (WRITE THE NUMBER ON THE LINE.) __________CHILDREN

2. Which of the following, if any, characterize this child’s reading/language arts class? (CIRCLE ONE NUMBER ON EACH LINE.)

YES NO

a. Mixed age 1 0

b. Mixed grade 1 0

c. Single gender 1 0

d. Grouped by ability 1 0

e. Inclusion 1 0

3. About how many children in this child’s reading/language arts class: (WRITE THE NUMBER ON EACH LINE. ENTER “0” ON A LINE IF THERE ARE NO CHILDREN IN A CATEGORY.)

a. Have serious reading difficulties? ___________CHILDREN

b. Lack other academic skills and knowledge to learn what you are trying to teach? ___________CHILDREN

c. Are currently enrolled in an English Language Learner (ELL) program? ___________CHILDREN

d. Create serious disruptions in your class? ___________CHILDREN

e. Have a diagnosed physical or psychological disability and need special services? ___________CHILDREN

f. Are classified as Gifted and Talented ___________CHILDREN

g. Are participating in a Gifted and Talented program ___________CHILDREN

h. Are repeating this grade this year ___________CHILDREN

i. Are below grade level in their reading skills ___________CHILDREN

j. Are above grade level in reading ___________CHILDREN

k. Are tardy, on an average day ___________CHILDREN

l. Are absent, on an average day ___________CHILDREN

4. Do you have the following resources available in this child’s reading/language arts classroom? (CIRCLE ONE NUMBER ON EACH LINE.)

YES NO

a. Class library for independent student reading 1 0

b. Reference materials (e.g., dictionaries) 1 0

c. Teacher resources for read aloud 1 0

d. Teacher resources for instruction 1 0

e. Sets of trade books 1 0

f. Sets of chapter books 1 0

g. Computers for children’s use…………….. 1 0

5. On average, how much time is devoted to this child’s reading/language arts class each day? (WRITE THE NUMBER ON THE LINE.) __________MINUTES

6. In this child’s reading/language arts class to what extent do you integrate curriculum areas around common or unifying themes (e.g., using reading and social studies concepts in the same unit of study, etc.)? (CIRCLE ONE NUMBER.)

Never 1

Occasionally 2

Usually 3

All the time 4

7. This year, how often did children in this child’s reading/language arts class work on the following areas in writing? (CIRCLE ONE NUMBER ON EACH LINE.)

Never Rarely Sometimes Often

a. Practice capitalization, punctuation, or spelling using sample sentences or worksheets 1 2 3 4

b. Editing the capitalization, punctuation, or spelling of their own writing 1 2 3 4

c. Editing the word use, grammar, or syntax in their own writing 1 2 3 4

d. Practice grammar or syntax using sample sentences or worksheets 1 2 3 4

e. Revising their own work by elaborating or extending what they wrote 1 2 3 4

f. Revising their own work by reorganizing or refining what they wrote 1 2 3 4

g. Going beyond facts to organize and synthesize information 1 2 3 4

h. Conferencing with you about their writing 1 2 3 4

i. Allowing students to conference in pairs about their writing 1 2 3 4

8. How often were the following comprehension topics a primary focus of your instruction in this child’s reading/language arts class? (CIRCLE ONE NUMBER ON EACH LINE.)

Never Rarely Sometimes Often

a. Activating prior knowledge or making personal connections to text 1 2 3 4

b. Making predictions, previewing, or surveying text 1 2 3 4

c. Students generating their own questions 1 2 3 4

d. Summarizing important or critical details 1 2 3 4

e. Examining literary techniques 1 2 3 4

f. Identifying the author’s purpose 1 2 3 4

g. Using concept maps, story maps, and or graphic organizers 1 2 3 4

h. Answering questions that require inference 1 2 3 4

i. Allowing students to conference in pairs about their writing 1 2 3 4

9. On a typical day, how many times in this child’s reading/language arts classroom is instruction: (CIRCLE ONE NUMBER ON EACH LINE.)

		Never	Once	Twice	3-4 times	More than 4 times
a.	Disrupted by student misbehavior	1	2	3	4	5
b.	Interrupted by announcements, messages, etc.	1	2	3	4	5
c.	Disrupted by students coming in late, or noise in the hallway	1	2	3	4	5

10. Do you have an assistant teacher or teacher’s aide in this child’s reading/language arts class? (CIRCLE ONE NUMBER.)

YES 1

NO 2 (SKIP TO QUESTION 13)

11. How many assistant teachers or teacher’s aides are assigned to this child’s reading/language arts class? (CIRCLE ONE NUMBER.)

One assistant teacher or teacher’s aide 1

Two assistant teachers or teacher’s aides 2

More than two teacher assistants or teacher’s aides 3

12. Does this person(s) provide direct instruction to children including one-on-one or with small groups? (CIRCLE ONE NUMBER.)

YES 1

NO 2

13. How many nights per week do children in this child’s reading/language arts class typically have homework? (CIRCLE ONE NUMBER.)

Zero nights per week 1

One night per week 2

Two nights per week 3

Three nights per week 4

Four nights per week 5

Five nights per week 6

14. Is this a school policy? (CIRCLE ONE NUMBER.)

YES 1

NO 2

15. Estimate the amount of time, in minutes, an average student in this child’s reading/language arts class is expected to spend doing reading/language arts homework on each weeknight it is assigned. (WRITE THE NUMBER ON THE LINE.)

__________MINUTES

16. When you are involved in reading/language arts instruction, how much time during a typical school day do students in this child’s reading/language arts class spend in the following activities? (CIRCLE ONE NUMBER ON EACH LINE.)

		No	Little Time	Some Time	Most of the time
a.	Teacher-directed whole class activities	1	2	3	4
b.	Teacher-directed small group activities	1	2	3	4
c.	Working one-on-one with teacher (student-teacher conferencing)………….	1	2	3	4
d.	Children working independently in pairs/teams/small groups	1	2	3	4
e.	Children working individually on class assignments	1	2	3	4
f.	Children-selected individual activities	1	2	3	4
g.	Discussing or debating ideas with students responding to each other……..	1	2	3	4
h.	Reading or presenting their writing/work to the class or groups of students.	1	2	3	4

17. How often do you or someone else do children in this child’s reading/language arts class engage in the following? (CIRCLE ONE NUMBER ON EACH LINE.)

		Never	Once a month or less	Two or three times a month	Once or twice a week	Three or four times a week	Every day
a.	Discuss new or difficult vocabulary	1	2	3	4	5	6
b.	Work on phonics	1	2	3	4	5	6
c.	Listen to you read stories	1	2	3	4	5	6
d.	Retell stories	1	2	3	4	5	6
e.	Read aloud.	1	2	3	4	5	6
f.	Read silently	1	2	3	4	5	6
g.	Talk with each other about what they have read	1	2	3	4	5	6
h.	Work in a reading workbook or on a worksheet	1	2	3	4	5	6
i.	Write words from dictation, to improve spelling	1	2	3	4	5	6
j.	Write with encouragement to use invented spellings, if needed	1	2	3	4	5	6
k.	Write about something they have read	1	2	3	4	5	6
l.	Read books they have chosen themselves	1	2	3	4	5	6
m.	Read text with controlled vocabulary	1	2	3	4	5	6
n.	Read text with strong phonetic patterns	1	2	3	4	5	6
o.	Read text with patterned or predictable text	1	2	3	4	5	6
p.	Read thematic or literature based text	1	2	3	4	5	6
q.	Compose and write stories or reports	1	2	3	4	5	6
r.	Do a group activity or project about what they have read	1	2	3	4	5	6
s.	Discuss different interpretations of what they have read	1	2	3	4	5	6
t.	Explain or support their understanding of what they have read	1	2	3	4	5	6
u.	Publish their own writing	1	2	3	4	5	6
v.	Perform plays and skits	1	2	3	4	5	6
w.	Write stores in a journal	1	2	3	4	5	6
x.	See/hear stories from story tellers or other artists	1	2	3	4	5	6
y.	Work in mixed-achievement groups on language arts activities	1	2	3	4	5	6
z.	Take quizzes or tests	1	2	3	4	5	6
aa.	Watch movies, videos, filmstrips, television, or listen to tapes, compact discs, or records	1	2	3	4	5	6

18. What type of materials form the core of your reading program for this child’s reading/language arts class? (CIRCLE ONE NUMBER ON EACH LINE.)

		YES	NO
a.	Primarily basal	1	0
b.	Primarily trade books	1	0
c.	Both basal and trade books	1	0
d.	Other materials (Specify)_________ _______________________________	1	0

19. To what extent do you agree or disagree with each of the following statements about reading and reading instruction? (CIRCLE ONE NUMBER ON EACH LINE.)

		Strongly disagree				Strongly agree
a.	A child needs to be able to verbalize the rules of phonics in order to assure proficiency in processing new words	1	2	3	4	5
b.	An increase in reading errors is usually related to a decrease in comprehension	1	2	3	4	5
c.	Dividing words into syllables according to rules is a helpful instructional practice for reading new words	1	2	3	4	5
d.	Fluency and expression are necessary components of reading that indicate good comprehension	1	2	3	4	5
e.	When children do not know a word, they should be instructed to sound out its parts	1	2	3	4	5
f.	The use of a glossary or dictionary is necessary in determining the meaning and pronunciation of new words	1	2	3	4	5
g.	Reversals (e.g., “saw” for “was”) are significant problems in the teaching of reading	1	2	3	4	5
h.	It is a good practice to correct a child as soon as an oral reading mistake is made	1	2	3	4	5
i.	It is important for a word to be repeated a number of times after it has been introduced to insure that it will become a part of sight vocabulary	1	2	3	4	5
j.	Paying close attention to punctuation marks is necessary to understanding story content	1	2	3	4	5
k.	It is a sign of an ineffective reader when words and phrases are repeated	1	2	3	4	5
l.	Being able to label words according to grammatical function (nouns, etc.) is useful in proficient reading	1	2	3	4	5
m.	When coming to a word that’s unknown, the reader should be encouraged to guess upon meaning and go on	1	2	3	4	5
n.	Young readers need to be introduced to the root form of words (run, long) before they are asked to read inflected forms (running, longest)	1	2	3	4	5
o.	It is not necessary for a child to know the letters of the alphabet in order to learn to read.	1	2	3	4	5
p.	Flashcard drills with sight words is an unnecessary form of practice in reading instruction	1	2	3	4	5
q.	Ability to use accent patterns in multisyllable words (pho’ to graph, pho to’ gra phy, and pho to gra’ phic) should be developed as part of reading instruction	1	2	3	4	5
r.	Controlling text through consistent spelling patterns (The fat cat ran back. The fat cat sat on a hat) is a means by which children can best learn to read	1	2	3	4	5
s.	Formal instruction in reading is necessary to insure the adequate development of all the skills used in reading	1	2	3	4	5
t.	Phonic analysis is the most important form of analysis used when meeting new words	1	2	3	4	5
u.	Children’s initial encounters with print should focus on meaning, not upon exact graphic representation	1	2	3	4	5
v.	Word shapes (word configuration) should be taught in reading to aid in word recognition	1	2	3	4	5
w.	It is important to teach skills in relation to other skills	1	2	3	4	5
x	If a child says “house” for the written word “home,” the response should be left uncorrected	1	2	3	4	5
y.	It is not necessary to introduce new words before they appear in the reading text	1	2	3	4	5
z.	Some problems in reading are caused by readers dropping the inflectional endings from words (e.g., jumps, jumped)	1	2	3	4	5

CHILD CHARACTERISTICS. Thinking about the study child identified on the label of this booklet, please respond to the following questions about this child.

20. Overall, how would you rate this child’s academic skills in reading/language arts, compared to other children of the same grade level? (CIRCLE ONE NUMBER.)

Far below average 1

Below average 2

Average… 3

Above average 4

Far above average 5

21. Since the beginning of the school year, has this child been: (CIRCLE ONE NUMBER ON EACH LINE.)

YES NO

a. In the same school? 1 2

b. In the same class? 1 2

22. Was this child given a developmental or readiness assessment prior to starting third grade or in the early months of the school year? (CIRCLE ONE NUMBER.)

Yes 1

No 2 (Skip to Question 24)

23. How were the results of the assessment used? (CIRCLE ONE NUMBER ON EACH LINE.)

	YES	NO
a. Child was placed in a regular third grade reading/language arts class	1	0
b. Child was identified as needing special education services	1	0
c. Teacher adjusted teaching techniques for this child based on assessment	1	0
d. Child was given advanced instruction	1	0
e. Child was referred for further diagnostic testing	1	0
f. Other (specify) _______________________________________________	1	0

24. Will this child be promoted to fourth grade? (CIRCLE ONE NUMBER.)

(If a promotion decision has not yet been made, please indicate your best estimate of what will happen, based on what you know at this time.)

Yes, will be promoted to regular fourth grade class 1

Will repeat third grade 2

Other (specify) ________________________________________________ 3

25. Have one or both of this child’s parents (or guardians) attended open house meetings, back-to-school nights, or class events, such as a class play or recital, this school year? (CIRCLE ONE NUMBER.)

Yes 1

No 2

26. Have one or both of this child’s parents (or guardians) acted as volunteers or helped out with class activities or class trips this year? (CIRCLE ONE NUMBER.)

Yes 1

No 2

27. How often have this child’s parents (or guardians) initiated contact with you to find out how things were going with the child or to offer help with class activities? (CIRCLE ONE NUMBER.)

Not at all 1

Once or twice during the school year 2

Three to five times during the school year 3

About once a month or more often 4

28. How often have you contacted or tried to contact this child’s parent(s) (or guardians) about behavior or schoolwork problems with this child? (CIRCLE ONE NUMBER.)

Not at all 1

Once or twice during the school year 2

Three to five times during the school year 3

About once a month or more often 4

29. Has any professional such as a doctor or other health or education professional mentioned this child having a developmental problem or delay, for example, any special need or disability, such as physical, emotional, language, hearing difficulty or other special need? (CIRCLE ONE NUMBER.)

Yes 1

No 2 (SKIP TO SCHOOL ACCOMPLISHMENTS SECTION)

Don’t Know 8 (SKIP TO SCHOOL ACCOMPLISHMENTS SECTION)

30. How did the doctor or other health or education professional describe this child’s needs or disability? (CIRCLE ALL THAT APPLY.)

Vision Impairment 01

Blindness 02

Hearing Impairment/Hard of Hearing 03

Deafness 04

Motor Impairment 05

Speech Impairment/Difficulty Communicating 06

Mental Retardation 07

Development Delay 08

Autism 09

Behavior Problems/Hyperactivity/Attention Deficit 10

Other (specify) ______________________________________ 11

Don’t Know 98

31. What has been done so far to address the child’s condition or the concerns about the child’s health and development? (CIRCLE ALL THAT APPLY.)

(The definition of IFSP/IEP is as follows: “a written plan that describes goals for this child and the services [he/she] should receive.”)

Discussions/plans are in progress 1

A specialist has been contacted 2

The child has been observed or evaluated 3

A meeting with the parents and the special needs team has been made 4

An individualized education plan (IEP) or an Individual Family Service
Plan (IFSP) has been developed 5

Modifications or accommodations to the classroom or class activities
have been made 6

Don’t Know 8

School Accomplishments. The following section asks you to rate the child’s skills, knowledge, and behaviors. Your ratings should be based on your experiences with this child, using a five-point scale (described below). Each question includes examples that are meant to help you think of the range of situations in which the child may demonstrate similar skills and behaviors. The examples do not exhaust all the ways that a child may demonstrate what he/she knows or can do. The examples do, however, indicate the level of proficiency a child should have reached in order to receive the highest rating. Some of these examples describe a very high level of performance (beyond typical standards) in order to be able to evaluate achievement levels of even the high performing students. The following five-point scale is used for each of the questions. It reflects the degree to which a child has acquired and/or chooses to demonstrate the targeted skills, knowledge and behaviors.
Score		Label	Definition
1	=	Not Yet	Child has not yet demonstrated skill, knowledge, or behavior.
2	=	Beginning	Child is just beginning to demonstrate skill, knowledge or behavior but does so very inconsistently.
3	=	In progress	Child demonstrates skill, knowledge or behavior with some regularity but varies in level of competence.
4	=	Intermediate	Child demonstrates skills, knowledge or behavior with increasing regularity and average competence, but is not completely proficient.
5	=	Proficient	Child demonstrates skill, knowledge or behavior competently and consistently.
6	=	Not Applicable	Skill, knowledge or behavior has not been introduced in classroom setting.
Rate only the child’s current achievement. Please use the full range of ratings. If the skill, knowledge, or behavior has been introduced in the classroom, please rate the child using the numbers 1-5. Circle “6” only if the skill, knowledge, or behavior has not been introduced in your classroom setting. Children with Limited English Proficiency: Please answer the questions based on your knowledge of this child’s skills. If the child does not yet demonstrate his/her skills in English but does demonstrate them in his/her native language, please answer the questions with the child’s native language in mind. Children with Special Needs: It may be necessary to consider adaptations for some questions to make them more inclusive for this child’s skills and/or use of adaptive equipment. Some children may utilize alternative forms of verbal communication (e.g., sign language, communication boards) or written communication (e.g., word processors, Braille, dictation). Please answer the questions with these adaptations in mind.

32. This child…(CIRCLE ONE NUMBER ON EACH LINE.)	Not Yet	Beginning	In Progress	Inter-mediate	Proficient	Not Applicable
a. Conveys ideas clearly when speaking—for example, presents a well-organized oral report or uses precise language to express opinions, feelings, and ideas, or provides relevant answers to questions that summarize classmate’s concerns	1	2	3	4	5	6
b. Uses various strategies to gain information—for example, uses the index or table of contents to locate information, or uses encyclopedias or other reference books/media to learn about a topic	1	2	3	4	5	6
c. Reads fluently—for example, easily reads words as part of meaningful phrases rather than word by word including words with three or more syllables, such as rambunctious, residential, genuinely, and pneumonia.	1	2	3	4	5	6
d. Reads third grade books (fiction) independently with comprehension—for example, relates why something happened in a story, or identifies emotions of characters in a story, or identifies a turning point in the story	1	2	3	4	5	6
e. Reads and comprehends expository text—for example, after reading about how early colonists lived, creates a chart comparing life today with colonial life, or after reading a children’s news story about pollution, identifies cause and effect relationships, or summarizes main ideas and the supporting details in a science or social studies selection.	1	2	3	4	5	6
f. Composes multi-paragraph stories/reports—for example, writes a report by developing and following an outline, or writes stories with a clear plot and distinct characters	1	2	3	4	5	6
g. Rereads and reflects on writing, making changes to clarify or elaborate—for example, adds more adjectives and description, or includes additional details to increase clarity, or combines choppy sentences	1	2	3	4	5	6
h. Makes mechanical corrections when reviewing a rough draft—for example, rereads a story and adds omitted words, or correct spelling and capitalization errors, or adds end punctuation when necessary	1	2	3	4	5	6
i. Uses the computer for a variety of purposes—for example, to write reports or stories formatting them correctly, or to use a database to retrieve information	1	2	3	4	5	6

CHILD SOCIAL-EMOTIONAL CHARACTERISTICS

33. Below is a series of statements about your relationship with this child. For each statement, please circle the number of the category that most applies to your relationship with him/her. (CIRCLE ONE NUMBER ON EACH LINE.)

	Definitely Does Not Apply	Not Really	Neutral, Not Sure	Applies Sometimes	Definitely Applies
a. I share an affectionate, warm relationship with this child	1	2	3	4	5
b. This child and I always seem to be struggling with each other	1	2	3	4	5
c. If upset, this child will seek comfort from me	1	2	3	4	5
d. This child is uncomfortable with physical affection or touch from me	1	2	3	4	5
e. This child values his/her relationship with me	1	2	3	4	5
f. When I praise this child, he/she beams with pride	1	2	3	4	5
g. This child spontaneously shares information about himself/herself	1	2	3	4	5
h. This child easily becomes angry at me	1	2	3	4	5
i. It is easy to be in tune with what this child is feeling	1	2	3	4	5
j. This child remains angry or is resistant after being disciplined	1	2	3	4	5
k. Dealing with this child drains my energy	1	2	3	4	5
l. When this child is in a bad mood, I know we’re in for a long and difficult day	1	2	3	4	5
m. This child’s feelings toward me can be unpredictable or can change suddenly	1	2	3	4	5
n. This child is sneaky or manipulative with me	1	2	3	4	5
o. This child openly shares his/her feelings and experiences with me	1	2	3	4	5

34. Please rate each of the listed behaviors according to how well each describes this child. (CIRCLE ONE NUMBER ON EACH LINE.)

Not at all A little Moderately well Well Very well

a. Expresses needs and feelings appropriately. 1 2 3 4 5

b. Thinks before acting. 1 2 3 4 5

c. Resolves peer problems on his/her own. 1 2 3 4 5

d. Can calm down when excited or all wound up. 1 2 3 4 5

e. Very good at understanding other people’s feelings. 1 2 3 4 5

f. Controls temper when there is a disagreement. 1 2 3 4 5

g. Is helpful to others. 1 2 3 4 5

h. Can give suggestions and opinions without being bossy. 1 2 3 4 5

i. Acts friendly towards others. 1 2 3 4 5

35. Please rate each of the listed behaviors according to how well each describes this child over the last six months or this school year. (CIRCLE ONE NUMBER ON EACH LINE.)

Not True Somewhat True Certainly True

a. Considerate of other people’s feelings. 1 2 3

b. Restless, overactive, cannot stay still for long. 1 2 3

c. Often complains of headaches, stomach-aches or sickness. 1 2 3

d. Shares readily with other children, for example toys, treats, pencils. 1 2 3

e. Often loses temper. 1 2 3

f. Rather solitary, prefers to play alone. 1 2 3

g. Generally well behaved, usually does what adults request. 1 2 3

h. Many worries or often seems worried. 1 2 3

i. Helpful if someone is hurt, upset or feeling ill. 1 2 3

Not True Somewhat True Certainly True

j. Constantly fidgeting or squirming. 1 2 3

k. Has at least one good friend. 1 2 3

l. Often fights with other children or bullies them. 1 2 3

m. Often unhappy, depressed or tearful 1 2 3

n. Generally liked by other children. 1 2 3

o. Easily distracted, concentration wanders 1 2 3

p. Nervous or clingy in new situations, easily loses confidence. 1 2 3

q. Kind to younger children. 1 2 3

r. Often lies or cheats. 1 2 3

s. Picked on or bullied by other children. 1 2 3

t. Often offers to help others (parents, teachers other children). 1 2 3

u. Thinks things out before acting. 1 2 3

v. Steals from home, school or elsewhere. 1 2 3

w. Gets along better with adults than with other children. 1 2 3

x. Many fears, easily scared. 1 2 3

y. Good attention span, sees work through to the end……………………………. 1 2 3

SECTION III

GENERAL CLASSROOM CHARACTERISTICS. Thinking about the study child identified on the label of this booklet, please respond to the following questions about this child’s math class.

1. How many children are in this child’s math class? (WRITE THE NUMBER ON THE LINE.) __________ CHILDREN

2. Which of the following, if any, characterize this child’s math class? (CIRCLE ONE NUMBER ON EACH LINE.)

YES NO

a. Mixed age 1 0

b. Mixed grade 1 0

c. Single gender 1 0

d. Grouped by ability 1 0

e. Inclusion 1 0

3. About how many children in this child’s math class: (WRITE THE NUMBER ON EACH LINE. ENTER “0” ON A LINE IF THERE ARE NO CHILDREN IN A CATEGORY.)

a. Have serious reading difficulties? __________CHILDREN

b. Lack other academic skills and knowledge to learn what you are trying to teach? __________CHILDREN

c. Are currently enrolled in an English Language Learner (ELL) program? __________CHILDREN

d. Create serious disruptions in your class? __________CHILDREN

e. Have a diagnosed physical or psychological disability and need special services? __________CHILDREN

f. Are classified as Gifted and Talented __________CHILDREN

g. Are participating in a Gifted and Talented program __________CHILDREN

h. Are repeating this grade this year __________CHILDREN

i. Are below grade level in their math skills __________CHILDREN

j. Are above grade level in math __________CHILDREN

k. Are tardy, on an average day __________CHILDREN

l. Are absent, on an average day __________CHILDREN

4. On average, how much time is devoted to this child’s math class each day? (WRITE THE NUMBER ON THE LINE.) __________MINUTES

5. Consider the lessons you taught this year in this child’s math class. About how often would the following statements be true? (CIRCLE ONE NUMBER ON EACH LINE.)

		None	A few	About half	Most
a.	The lessons were focused on studying a topic in depth, rather than covering the basic facts or concepts	1	2	3	4
b.	The lessons required students to organize, interpret, evaluate, and use information to produce an original piece of work	1	2	3	4
c.	The lessons required students to connect to prior work	1	2	3	4
d.	The lessons required students to build models or charts	1	2	3	4
e.	The lessons required students to collect data by counting, observing, or conducting surveys	1	2	3	4
f.	The lessons provided opportunity for hands-on materials	1	2	3	4

6. In this child’s math class to what extent do you integrate curriculum areas around common or unifying themes? (e.g., using math and science concepts in the same unit of study, etc.) (CIRCLE ONE NUMBER.)

a. Never 1

b. Occasionally 2

c. Usually 3

d. All the time 4

7. On a typical day, how many times in this child’s math classroom is instruction: (CIRCLE ONE NUMBER ON EACH LINE.)

		Never	Once	Twice	3-4 times	More than 4 times
a.	Disrupted by student misbehavior	1	2	3	4	5
b.	Interrupted by announcements, messages, etc.	1	2	3	4	5
c.	Disrupted by students coming in late, or noise in the hallway	1	2	3	4	5

8. Do you have an assistant teacher or teacher’s aide in this child’s math class? (CIRCLE ONE NUMBER.)

YES 1

NO 2 (SKIP TO QUESTION 11)

9. How many assistant teachers or teacher’s aides are assigned to this child’s math class? (CIRCLE ONE NUMBER.)

One assistant teacher or teacher’s aide 1

Two assistant teachers or teacher’s aides 2

More than two teacher assistants or teacher’s aides 3

10. Does this person(s) provide direct instruction to children including one-on-one or with small groups? (CIRCLE ONE NUMBER.)

YES 1

NO 2

11. How many nights per week do children in this child’s math class typically have homework? (CIRCLE ONE NUMBER.)

Zero nights per week 1

One night per week 2

Two nights per week 3

Three nights per week 4

Four nights per week 5

Five nights per week 6

12. Is this a school policy? (CIRCLE ONE NUMBER.)

YES 1

NO 2

13. Estimate the amount of time, in minutes, an average student in this child’s math class is expected to spend doing math homework on each weeknight it is assigned. (WRITE A NUMBER ON THE LINE.)

__________ MINUTES

14. When you are involved in math instruction, how much time during a typical school day do students in this child’s math class spend in the following activities? (CIRCLE ONE NUMBER ON EACH LINE.)

		No	Little Time	Some Time	Most of the time
a.	Teacher-directed whole class activities	1	2	3	4
b.	Teacher-directed small group activities	1	2	3	4
c.	Working one-on-one with teacher (student-teacher conferencing)………….	1	2	3	4
d.	Children working independently in pairs/teams/small groups	1	2	3	4
e.	Children working individually on class assignments	1	2	3	4
f.	Children-selected individual activities	1	2	3	4
g.	Discussing or debating ideas with students responding to each other……..	1	2	3	4
h.	Reading or presenting their writing/work to the class or groups of students.	1	2	3	4

15. How often do children in this child’s math class engage in the following? (CIRCLE ONE NUMBER ON EACH LINE.)

		Never	Once a month or less	Two or three times a month	Once or twice a week	Three or four times a week	Every day
a.	Work with manipulatives (e.g., geometric shapes, etc.)	1	2	3	4	5	6
b.	Work with counting manipulatives to learn basic operations	1	2	3	4	5	6
c.	Play math-related games	1	2	3	4	5	6
d.	Use a calculator	1	2	3	4	5	6
e.	Use music to understand math concepts.	1	2	3	4	5	6
f.	Use creative movement or creative drama to understand math concepts	1	2	3	4	5	6
g.	Work with measuring instruments (e.g., rulers, etc.)	1	2	3	4	5	6
h.	Explain how a math problem is solved	1	2	3	4	5	6
i.	Engage in calendar-related activities	1	2	3	4	5	6
j.	Solve mathematics problems on worksheets	1	2	3	4	5	6
k.	Solve math problems from their textbooks	1	2	3	4	5	6
l.	Complete math problems on the chalkboard	1	2	3	4	5	6
m.	Solve math problems in small groups or with a partner	1	2	3	4	5	6
n.	Work and discuss math problems that reflect real-life situations	1	2	3	4	5	6
o.	Work on problems for which there are several appropriate methods or solutions	1	2	3	4	5	6
p.	Do worksheet or workbook page emphasizing routine practice or drill	1	2	3	4	5	6
q.	Write a few sentences about how to solve a math problem	1	2	3	4	5	6
r.	Talk to the class about their mathematics work	1	2	3	4	5	6
s.	Write reports or do mathematics projects	1	2	3	4	5	6
t.	Discuss solutions to mathematics problems with other children	1	2	3	4	5	6
u.	Use a computer for math	1	2	3	4	5	6
v.	Work in mixed-achievement groups on math activities	1	2	3	4	5	6
w.	Take mathematics tests	1	2	3	4	5	6

16. In planning lessons for this child’s math class, how much do you rely on: (CIRCLE ONE NUMBER ON EACH LINE.)

		Not at all	A little	Some	A great deal
a.	Teacher’s Guides?.....................................................................................	1	2	3	4
b.	Teacher edition of textbook?......................................................................	1	2	3	4
c.	A written plan compiled by teachers in this school?...................................	1	2	3	4
d.	Advice from other teachers or specialists in your school?..........................	1	2	3	4
e.	Feedback from student assessment? ………………………………………..	1	2	3	4
f.	Multiple supplemental teacher resources? …………………………………..	1	2	3	4
g.	Internet resources? ……………………………………………………………..	1	2	3	4

17. How much emphasis do you give to the following goals in your mathematics instruction for this child’s math class? (CIRCLE ONE NUMBER ON EACH LINE.)

	None	Little	Moderate	Major
a. Understanding the concepts behind mathematics	1	2	3	4
b. Knowing how to do a problem	1	2	3	4
c. Thinking about what a problem means and ways it might be solved	1	2	3	4
d. Understanding that there may be more than one way to solve a problem	1	2	3	4
e. Performing computations with speed and accuracy	1	2	3	4
f. Having students prepare creative projects related to math topics they have studied	1	2	3	4
g. Using concrete objects like rulers, counting blocks, or geometric shapes	1	2	3	4
h. Memorizing facts, rules, and steps	1	2	3	4
i. Understanding why and when a rule is needed	1	2	3	4
j. Getting the right answer	1	2	3	4
k. Developing students’ confidence in their ability to do mathematics	1	2	3	4
l. Developing students’ awareness of the practical application of math skills to everyday life	1	2	3	4

CHILD CHARACTERISTICS. Thinking about the study child identified on the label of this booklet, please respond to the following questions about this child.

18. Overall, how would you rate this child’s academic skills in math, compared to other children of the same grade level? (CIRCLE ONE NUMBER.)

Far below average 1

Below average 2

Average… 3

Above average 4

Far above average 5

19. Since the beginning of the school year, has this child been: (CIRCLE ONE NUMBER.)

YES NO

a. In the same school? 1 2

b. In the same class? 1 2

20. Was this child given a developmental or readiness assessment prior to starting third grade or in the early months of the school year? (CIRCLE ONE NUMBER.)

Yes 1

No 2 (Skip to Question 22)

21. How were the results of the assessment used? (CIRCLE ONE NUMBER ON EACH LINE.)

	YES	NO
a. Child was placed in a regular third grade math class	1	0
b. Child was identified as needing special education services	1	0
c. Teacher adjusted teaching techniques for this child based on assessment	1	0
d. Child was given advanced instruction	1	0
e. Child was referred for further diagnostic testing	1	0
f. Other (specify) _______________________________________________	1	0

22. Will this child be promoted to fourth grade? (CIRCLE ONE NUMBER.)

(If a promotion decision has not yet been made, please indicate your best estimate of what will happen, based on what you know at this time.)

Yes, will be promoted to regular fourth grade class 1

Will repeat third grade 2

Other (specify) ________________________________________________ 3

23. Have one or both of this child’s parents (or guardians) attended open house meetings, back-to-school nights, or class events, such as a class play or recital, this school year? (CIRCLE ONE NUMBER.)

Yes 1

No 2

24. Have one or both of this child’s parents (or guardians) acted as volunteers or helped out with class activities or class trips this year? (CIRCLE ONE NUMBER.)

Yes 1

No 2

25. How often have this child’s parents (or guardians) initiated contact with you to find out how things were going with the child or to offer help with class activities? (CIRCLE ONE NUMBER.)

Not at all 1

Once or twice during the school year 2

Three to five times during the school year 3

About once a month or more often 4

26. How often have you contacted or tried to contact this child’s parent(s) (or guardians) about behavior or schoolwork problems with this child? (CIRCLE ONE NUMBER.)

Not at all 1

Once or twice during the school year 2

Three to five times during the school year 3

About once a month or more often 4

27. Has any professional such as a doctor or other health or education professional mentioned this child having a developmental problem or delay, for example, any special need or disability, such as physical, emotional, language, hearing difficulty or other special need? (CIRCLE ONE NUMBER.)

Yes 1

No 2 (Skip to SCHOOL ACCOMPLISHMENTS SECTION)

Don’t Know 8 (Skip to SCHOOL ACCOMPLISHMENTS SECTION)

28. How did the doctor or other health or education professional describe this child’s needs or disability? (CIRCLE ALL THAT APPLY.)

Vision Impairment 01

Blindness 02

Hearing Impairment/Hard of Hearing 03

Deafness 04

Motor Impairment 05

Speech Impairment/Difficulty Communicating 06

Mental Retardation 07

Development Delay 08

Autism 09

Behavior Problems/Hyperactivity/Attention Deficit 10

Other (specify) ______________________________________ 11

Don’t Know 98

29. What has been done so far to address the child’s condition or the concerns about the child’s health and development? (CIRCLE ALL THAT APPLY.)

(The definition of IFSP/IEP is as follows: “a written plan that describes goals for this child and the services [he/she] should receive.”)

Discussions/plans are in progress 1

A specialist has been contacted 2

The child has been observed or evaluated 3

A meeting with the parents and the special needs team has been made 4

An individualized education plan (IEP) or an Individual Family Service
Plan (IFSP) has been developed 5

Modifications or accommodations to the classroom or class activities
have been made 6

Don’t Know 8

School Accomplishments. The following section asks you to rate the child’s skills, knowledge, and behaviors. Your ratings should be based on your experiences with this child, using a five-point scale (described below). Each question includes examples that are meant to help you think of the range of situations in which the child may demonstrate similar skills and behaviors. The examples do not exhaust all the ways that a child may demonstrate what he/she knows or can do. The examples do, however, indicate the level of proficiency a child should have reached in order to receive the highest rating. Some of these examples describe a very high level of performance (beyond typical standards) in order to be able to evaluate achievement levels of even the high performing students. The following five-point scale is used for each of the questions. It reflects the degree to which a child has acquired and/or chooses to demonstrate the targeted skills, knowledge and behaviors.
Score		Label	Definition
1	=	Not Yet	Child has not yet demonstrated skill, knowledge, or behavior.
2	=	Beginning	Child is just beginning to demonstrate skill, knowledge or behavior but does so very inconsistently.
3	=	In progress	Child demonstrates skill, knowledge or behavior with some regularity but varies in level of competence.
4	=	Intermediate	Child demonstrates skills, knowledge or behavior with increasing regularity and average competence, but is not completely proficient.
5	=	Proficient	Child demonstrates skill, knowledge or behavior competently and consistently.
6	=	Not Applicable	Skill, knowledge or behavior has not been introduced in classroom setting.
Rate only the child’s current achievement. Please use the full range of ratings. If the skill, knowledge, or behavior has been introduced in the classroom, please rate the child using the numbers 1-5. Circle “6” only if the skill, knowledge, or behavior has not been introduced in your classroom setting. Children with Limited English Proficiency: Please answer the questions based on your knowledge of this child’s skills. If the child does not yet demonstrate his/her skills in English but does demonstrate them in his/her native language, please answer the questions with the child’s native language in mind. Children with Special Needs: It may be necessary to consider adaptations for some questions to make them more inclusive for this child’s skills and/or use of adaptive equipment. Some children may utilize alternative forms of verbal communication (e.g., sign language, communication boards) or written communication (e.g., word processors, Braille, dictation). Please answer the questions with these adaptations in mind.

30. This child…(CIRCLE ONE NUMBER ON EACH LINE.)	Not Yet	Beginning	In Progress	Inter-mediate	Proficient	Not Applicable
a. Creates and extends patterns – for example, extends an alternating pattern involving addition and subtraction (+3, -1, +3, -1, +3…or +5, -3, +5, -3…) or creates a complex visual pattern (aabc…)	1	2	3	4	5	6
b. Uses a variety of strategies to solve math problems – for example, adds 100 and then subtracts 4 when doing the mental math problem 467 + 96, or writes the algorithms or equations needed to solve a word problem, or orders steps sequentially in a multi-step problem	1	2	3	4	5	6
c. Recognizes properties of shapes and relationships among shapes – for example, recognizes that rectangles are composed of two right triangles, or demonstrates congruence by copying the exact size and shape of a pentagon onto a geoboard	1	2	3	4	5	6
d. Uses measuring tools accurately – for example, measures with rulers to the quarter-inch, or measures liquids to the nearest milliliter	1	2	3	4	5	6
e. Shows understanding of place value with whole numbers – for example, correctly orders the numbers 19,321, 14,999, 9,900, and 20,101 from least to greatest, or correctly regroups when adding and subtracting	1	2	3	4	5	6
f. Makes reasonable estimates of quantities and checks answers – for example, estimates the cost of a list of 8 different items and compares to actual cost, or estimates the perimeter of a bulletin board and then checks with a yardstick	1	2	3	4	5	6
g. Surveys, collects, and organizes data into simple graphs – for example, charts temperature changes over time, or makes a bar or line graph comparing the population in different cities of their state, or interprets a pictograph in which each symbol represents 5 people.	1	2	3	4	5	6
h. Models, reads, writes, and compares fractions – for example, shows that ½ of the candy bar is ¼ + ¼, or shows that ¼ of a set of 12 is 3	1	2	3	4	5	6
i. Divides a 3 digit number by a 1 digit number – for example, 348 ÷ 4 or 228 ÷ 6	1	2	3	4	5	6

CHILD SOCIAL-EMOTIONAL CHARACTERISTICS

31. Below is a series of statements about your relationship with this child. For each statement, please circle the number of the category that most applies to your relationship with him/her. (CIRCLE ONE NUMBER ON EACH LINE.)

	Definitely Does Not Apply	Not Really	Neutral, Not Sure	Applies Sometimes	Definitely Applies
a. I share an affectionate, warm relationship with this child	1	2	3	4	5
b. This child and I always seem to be struggling with each other	1	2	3	4	5
c. If upset, this child will seek comfort from me	1	2	3	4	5
d. This child is uncomfortable with physical affection or touch from me	1	2	3	4	5
e. This child values his/her relationship with me	1	2	3	4	5
f. When I praise this child, he/she beams with pride	1	2	3	4	5
g. This child spontaneously shares information about himself/herself	1	2	3	4	5
h. This child easily becomes angry at me	1	2	3	4	5
i. It is easy to be in tune with what this child is feeling	1	2	3	4	5
j. This child remains angry or is resistant after being disciplined	1	2	3	4	5
k. Dealing with this child drains my energy	1	2	3	4	5
l. When this child is in a bad mood, I know we’re in for a long and difficult day	1	2	3	4	5
m. This child’s feelings toward me can be unpredictable or can change suddenly	1	2	3	4	5
n. This child is sneaky or manipulative with me	1	2	3	4	5
o. This child openly shares his/her feelings and experiences with me	1	2	3	4	5

32. Please rate each of the listed behaviors according to how well each describes this child. (CIRCLE ONE NUMBER ON EACH LINE.)

Not at all A little Moderately well Well Very well

a. Expresses needs and feelings appropriately. 1 2 3 4 5

b. Thinks before acting. 1 2 3 4 5

c. Resolves peer problems on his/her own. 1 2 3 4 5

d. Can calm down when excited or all wound up. 1 2 3 4 5

e. Very good at understanding other people’s feelings. 1 2 3 4 5

f. Controls temper when there is a disagreement. 1 2 3 4 5

g. Is helpful to others. 1 2 3 4 5

h. Can give suggestions and opinions without being bossy. 1 2 3 4 5

i. Acts friendly towards others. 1 2 3 4 5

33. Please rate each of the listed behaviors according to how well each describes this child over the last six months or this school year. (CIRCLE ONE NUMBER ON EACH LINE.)

Not True Somewhat True Certainly True

a. Considerate of other people’s feelings. 1 2 3

b. Restless, overactive, cannot stay still for long. 1 2 3

c. Often complains of headaches, stomach-aches or sickness. 1 2 3

d. Shares readily with other children, for example toys, treats, pencils. 1 2 3

e. Often loses temper. 1 2 3

f. Rather solitary, prefers to play alone. 1 2 3

g. Generally well behaved, usually does what adults request. 1 2 3

h. Many worries or often seems worried. 1 2 3

i. Helpful if someone is hurt, upset or feeling ill. 1 2 3

j. Constantly fidgeting or squirming. 1 2 3

Not True Somewhat True Certainly True

k. Has at least one good friend. 1 2 3

l. Often fights with other children or bullies them. 1 2 3

m. Often unhappy, depressed or tearful 1 2 3

n. Generally liked by other children. 1 2 3

o. Easily distracted, concentration wanders 1 2 3

p. Nervous or clingy in new situations, easily loses confidence. 1 2 3

q. Kind to younger children. 1 2 3

r. Often lies or cheats. 1 2 3

s. Picked on or bullied by other children. 1 2 3

t. Often offers to help others (parents, teachers other children). 1 2 3

u. Thinks things out before acting. 1 2 3

v. Steals from home, school or elsewhere. 1 2 3

w. Gets along better with adults than with other children. 1 2 3

x. Many fears, easily scared. 1 2 3

y. Good attention span, sees work through to the end 1 2 3

34. Please feel free to use this space for any additional comments you may have on this child.

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If found, return to:

Westat

1650 Research Boulevard

Room RB3111 – XXXX.XX

Rockville, MD 20850