REM Teacher form .pdf

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REM: Teacher Information
Student: ________________________

Meeting Date: ______________

General Education Teachers: _____________________
Most Recent Report Card Grades
Math

______________________

PST Interventions

Reading
Science
Social Studies
Math Work Samples
TYPE OF ASSESSMENT

DATE

GRADE

Accommodations
proximity seating small group instruction
use of manipulatives
DATE

Reading/Writing Work Samples
TYPE OF ASSESSMENT

writing assistance

revisions extended time reduced work
GRADE

assistive technology: _________________
other: ____________________________

Prong I: Documentation of Appropriate Instruction
The student has participated in a research based reading program.
The student has participated in a research based math program.
The student has participated in small group instruction.
The student received standards based instruction by a highly qualified teacher.
The student has participated in a school enrichment program.
The student has participated in a tutorial program.
The student has participated in a private educational program.
The student has received private speech therapy services.
The student’s data has been reviewed & appropriate instructional strategies
have been implemented in the classroom based on the student’s needs.
Other: ____________________________________________________

 Prong II:

Running Record Benchmarks
Level Grade Equivalent
WPM

st

1 9 Weeks
2nd 9 Weeks
3rd 9 Weeks
4th 9 Weeks

 Prong II: Tier 3 Math Data
Skill

Date

% Correct


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