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  2. 2015
  3. December
  4. R
  5. RTI Survey By Student
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Exit Survey
 
 
Hello--

In order to better serve our students, please fill out this survey for each student about whom you have concerns. This is for RTI intervention, so please put in any student who currently has a service plan, IEP or 504 plan, plus any other student whom you feel may need extra help.

This report is confidential to Karen Ball and Myself, and to the administration.

Thank you for your cooperation.

Wendy Strauss
 
 
 
Your Name:
   
 
 
 
Student's name and class period for your class/classes:
   
 
 
Organization/Generalizations/Memory
Always Usually Often Sometimes Never N/A
Is disorganized
Has difficulty understanding abstract concepts
Needs verbal questions and directions frequently repeated
Has difficulty concentrating
Fails to generalize knowledge from one situation to another
Fails to remember sequence
 
 
Classroom Performance
Always Usually Sometimes Rarely Never N/A
Does not perform or complete classroom assignments during class time
Fails to complete homework assignments and return them to school
Performs classroom tests, quizzes or tasks at failing level
Does not prepare for assigned activities or daily routines
Does not remain on task for the required length of time
Does not perform academically at his/her ability level
Does not read or follow written directions
Rushes through activities and assignments with little or no regard to accuracy, quality or neatness
Fails to make appropriate use of study time
Does not begin assignments after receiving directions, instructions, etc.
Does not complete assignments after receiving directions, instructions, etc.
 
 
Reading, Writing and Spelling
Always Usually Sometimes Rarely Never N/A
Does not comprehend what he/she reads
Fails to finish assignments because of reading difficulties
Fails to demonstrate word attack skills
Fails to recognize words on grade level/vocabulary
Does not read independently
Has difficulty identifying the topic sentence and main idea when reading
Has difficulty finding supporting details when reading
Performs assignments so carelessly as to be illegible
Fails to write when given space
Does not compose complete sentences or express complete thoughts when writing
Fails to correctly organize writing activities
Fails to use spelling rules
Omits, substitutes, adds or rearranges letters or sound units when spelling words
 
 
Math Calculations:
Always Usually Sometimes Rarely Never N/A
Has difficulty solving math word problems
Does not understand abstract math concepts without concrete examples
Fails to correctly solve math problems involving fractions or decimals
Cannot tell time
Does not remember math facts
 
 
Interpersonal Relationships
Always Usually Sometimes Rarely Never N/A
Makes inappropriate comments or unnecessary noises in the classroom
Has little or no interaction with teachers and peers
Bothers others when they are trying to work, listen, etc.
Does not make appropriate use of free time
Fails to work appropriately with peers in a tutoring or small group project situation
Interrupts the teacher and other students
Does not participate in class discussions
 
 
Motivation and Listening Skills:
Always Usually Sometimes Rarely Never N/A
Blames other persons or materials to avoid taking responsibility for his/her mistakes and failures
Does not participate or demonstrate an interest in classroom activities or special events that are interesting to other students
Blames self for situations beyond his/her control
Is not motivated by rewards
Demonstrates self-destructive behavior
Cheats
Is tired, listless, apathetic, unmotivated and/or not interested in school
Indicates that he/she is not concerned about performance, grades, report cards, graduation, etc.
Does not care for personal appearance
Does not listen to or follow verbal directions
Is unsuccessful in activities requiring listening
Does not listen to what other students are saying
 
 
Rules and Expectations
Always Usually Sometimes Rarely Never N/A
Lies, denies, exaggerates/distorts the truth
Student does not bring necessary materials to class
Engages in nervous habits
Demonstrates inappropriate behavior in a small group setting
Has difficulty working effectively in a group situation
Uses obscene, profane or inappropriate language
Does not follow directions from teacher or other school personnel
Does not follow school or classroom rules