Student Information

Student Name: Grade: Current Placement: Date:

Section 1: Current Educational Environment Analysis

Academic Participation

Rate current level of participation in general education for each core subject (1-5, with 5 being full participation):

• Math:
• Reading:
• Writing:
• Science:
• Social Studies:

Current Supports in Place

Check all that are currently provided and note effectiveness:

Instructional Supports

• [ ] Modified assignments
• Effectiveness: □ Very Effective □ Somewhat Effective □ Not Effective
• Notes:
• [ ] Alternative materials
• Effectiveness: □ Very Effective □ Somewhat Effective □ Not Effective
• Notes:
• [ ] Specialized technology