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Student Name:____________________________ Grade:_______________

Teacher:_________________________ Class:__________  Period:_______

Special Education Teacher:______________________________________

CLASSROOM MODIFICATIONS

1. Daily assignment will be shortened.   Yes:_____  No: _____ 
2. Extra time given for completion of assignment . Yes:____  No:_____ 
3. Alternative assignments given.   Yes:____  No:____ 
4. Material on lower reading level.  Yes:____  No:____ 
5. Student needs to tape lecture.  Yes:____ No:_____ 
6. Special Seating Arrangements.  Yes:____ No:_____ 
7. Behavior Intervention made.  Yes:____ No:_____ 
8. Teacher and /or peer class notes given.  Yes:____ No:_____
   

TESTING PROCEDURES

1. Use of notes during test in classroom.  Yes:__ No:___      
   1. In resource room.  Yes:___  No:___ 
2. Open book tests in classroom.  Yes:____ No:_____      
   1. In resource room. Yes: _____ No: _____
3. Reading test to student in classroom.  Yes:____ No:_____      
   1. In resource room.  Yes:____  No:____ 
4. Test finished in resource room (if student asks).  Yes:____ No:_____ 
5. Takes regular test in regular classroom.  Yes:____ No:_____ 
6. Takes modified test in classroom.  Yes:____ No:_____       
   1. In resource room.  Yes:____ No:_____ 
7. Modification of test questions:
       _____Word banks
       _____Fewer choices on multiple choice
       _____Color coding on matching 
8. Can review with test before test time in resource room.  Yes:____ No:____
   

STUDY HELPS 

1. Individual Assistance before________, during_______, or after school________. 
2. Peer tutoring available.  Yes:_____  No:______
   

GRADING 

1. Student is on same grading system as other students.  Yes:____ No:____ 
2. Individualized grading system.  Yes:____ No:____ 
3. Student is on s/u grading system.  Yes:____ No:____ 
4. Student should be graded more on daily work, notebook checks and less on tests.                    Yes:____  No:_____ 
5. Student grade is given by classroom teacher.  Yes:____ No:____ 
         resource room teacher.  Yes:____ No:_____ 
6. Grade checks with resource room teacher.  Yes:____ No:____
   

CLASSROOM TEACHER______________________ DATE________________
STUDENT__________________________________ DATE________________
RESOURCE ROOM TEACHER__________________ DATE________________