KindergartenTransitionTeacherInput-IntermediateUnit1.docVIP

Kindergarten Transition Teacher Input for Case Managers/Contributors Child’s Name: Birthdate: Age: Gender: Male Female Parent’s Name: Phone Number: Address: Preschool Location: Day/Time Attending: Teacher/Therapist: School District: Home School: District Liaison: Transition Meeting Date: Persons Attending: The child receives the following services: Special Instruction Speech Therapy Occupational Therapy Physical Therapy Hearing Support Vision Support Other: (specify) Information from the following is attached: Special Instruction Speech Therapy Occupational Therapy Physical Therapy Hearing Support Vision Support Other: (specify) Complete each question. Physical condition, social, or cultural background and adaptive behavior relevant to the student’s disability and need for special education: Does the child have a medical or educational diagnosis? Yes No If yes, explain: Does the child have any health problems/physical limitations? Yes No If yes, explain: Are there any Hearing and Vision difficulties relevant to the student’s disability? Yes No If yes, explain: Is the child verbal/nonverbal? Verbal Nonverbal explain: Does the child have speech difficulties? Yes No If yes, explain: Does the child have good attendance? Yes No Is the child potty trained? Yes No Will the school district need to consider any special needs for the child? (Example - does the child have any special restrictions - food allergies; physical limitations – wheelchair, braces, blind; deaf/hard of hearing; etc?) Yes No If yes, explain: Evaluations and information provided by the parent (or documentation of LEA’s attempts to obtain parental input): Is there any parent input? If so, summarize Yes No Is there any parent concern? If so, summarize Yes No Did the parent complete any recent checklists? If so, summarize Yes No Copy P