Student Evaluation

Student Name*

First Last

Current Grade Level*

Current School*

Contact Information

Name of Evaluator*

First Last

Position/Title*

Place of Employment*

Contact Number*

Email Address*

Date*

Personal Work Habits

Persistence

Collaboration

Ability to Follow Directions

Completion of Assignments

Disciplined Work Habits

Attendance

Excused Absences This School Year

Excused Absences Last School Year (if applicable)

Unexcused Absences This School Year

Unexcused Absences Last School Year (if applicable)

Times Tardy This School Year

Times Tardy Last School Year (if applicable)

If student did not attend your school last year, please list which school(s) he did attend.

Optional notes:

General

Does the student have any significant health problems or physical disabilities?

Yes
No

If yes, please describe.

Does the student have a diagnosed learning disability?

Yes
No

Does the student have an IEP?

Yes
No

Are any type of educational accommodations made for this student?

Yes
No

If yes, please describe.

Has the student ever been placed on probation, suspended, or expelled in or out of school?

Yes
No

If yes, briefly describe.

Are there specific concerns (disciplinary, academic, or otherwise) about this student that you would like to discuss by phone?

Yes
No

Overall Evaluation

As a Young Person

As a Student