RECORD COPY-SBT folderPBSD 1548 (Rev 3/11/2015) Page 1 of 2

THE SCHOOL DISTRICT OF PALM BEACH COUNTYSAFE SCHOOLS

School Based Team (SBT) Student Information Checklist for Elementary

Student ID # First Name Middle Name Last Name

This checklist is to be completed by a classroom teacher or referring staff member. Check any areas of observable/documented difficulty. Additional narrative information should be included in PBSD 2106 Problem Solving/School Based Team Referral.

Grade Gender Date of Birth Current DateSchool/Dept Name

SBT Leader First Name Phone Number/PX

First Name of Person Completing This Form

SBT Leader Last Name

Last Name of Person Completing This Form Job Title

Primary Language/Communication Mode of Parent/Legal Guardian:

Interventions Attempted:

Student Strengths:

BEHAVIORDisorganized/loses materials and papers

Unmotivated

Daydreams/unable to concentrate

Talks constantly, interrupts others

Consistently off task

Makes excuses for poor work habits

Chronic fatigue

Seeks negative attention by acting inappropriately

Easily distracted

Angry/volatile behavior towards peers/teachers

Teases others

Withdrawn

Does not complete classwork/homework

Untruthful

Tardy for school

Chronic absenteeism

BEHAVIOR continued

Does not request assistance

Constant movement/unable to sit still

Does not work well independently/groups

Takes items that belong to others

Uses inappropriate language

Hits/Kicks

Bullied by others/bullies other students

Other:

Work is messy

Rushes to get done

ATYPICAL BEHAVIORChanges in friends/peer groups

Known home problems-runaway/suicide/divorce

Rapid mood changes

Similar symptoms evident in sibling(s)

Talks freely about death/loss

Time disorientation

Refuses/avoids contact with adults

Witnessed/suspected possession of drugs/alcohol

Wears drug and/or gang affliated symbols

Unusual/violent drawings

Other:

RECORD COPY-SBT folderPBSD 1548 (Rev 3/11/2015) Page 2 of 2

MATH

Difficulty adding/subtracting single digit numbers

Has difficulty solving word problems

Has difficulty adding/subtracting with regrouping

Unable to tell time on the hour, half hour, quarter hour

Unable to recall multiplication facts

Difficulty with division

Difficulty with decimals/fractions

Difficulty with measurement

Other:

Bruises/physical injuries

Coordination difficulties/tremors

Poor eye contact

Glassy/bloodshot eyes/wearing sunglasses

Stuttering

Uncontrollable crying

Sleeping in class

Rapid weight loss/gain

Change in appearance

Other:

Chronically soiled clothes/body odor/sweating

PHYSICAL SYMPTOMS

Thumb sucking (at an inappropriate age)

READING

Cannot decode words phonetically

Cannot say entire alphabet

Unable to identify most/some letters

Cannot identify beginning letter of words

Has not mastered letter/sound associations

Poor oral reading abilities/omits/adds words

Poor reading comprehension skills

Other:

Limited sight vocabulary

Cannot count orally

Cannot match numbers

Cannot identify numbers

Cannot object count

Needs manipulatives to add/subtract

WRITTEN LANGUAGECannot write name

Cannot write alphabet

Has poor letter/number formation

Has difficulty spelling

Does not write on lines

Transposes letters within words

Poor noun-verb agreement

Sentences are basic/few details

Cannot write a paragraph

Reversals and/or rotations

Does not write on lines/spaces

Other:

ORAL LANGUAGEDoes not speak at all

Nonsensical/illogical language

Repeats what is heard

Does not use complete statements

Has limited speaking vocabulary

Unable to ask questions

Fails to use correct verb tense

Misuse of subject/verb agreement

Other:

INDEPENDENT FUNCTIONINGCannot eat independently

Requires toilet assistance

Cannot access campus independently

Cannot recite personal information (name, address, phone #)

Does not follow directions

Other:

GROSS and/or FINE MOTOR DEVELOPMENT

Falls often

Stumbles and bumps into objects

Poor handwriting

Poor hand/eye coordination

Cannot jump/skip

Weaknesses in cutting, pasting, coloring, drawing, or copying

Other: