A-13, July 2010
Adapted from KRESA
Page 1 of 2
Suggested Questions for Parent Input for Re-evaluation
Student’s Name: ___________________________Parent/Guardian Name: ___________________________
Method of Interview (Check one): Personal Interview Telephone Written
Person collected input: ____________________________________________ Date: ________________
1. What are some of your child’s strengths, interests and/or favorite activities?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
2. What goals do you have for your child for this school year? For older students, long range goals/plans?
_______________________________________________________________________________________________
3. Have you seen improvement in your child’s academic performance / behavior / speech and language
during the past 3 years? Yes No Please describe:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
4. Do you have any current concerns about your child’s progress?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
5. Have you seen any recent changes in your child’s behavior or school performance? Yes No
If yes, please explain:
_______________________________________________________________________________________________
6. Medical information:
Vision concerns? _________________________________________________________________________
o Wears glasses? Yes No
Hearing concerns? _______________________________________________________________________
o Wears hearing aid(s)? Yes No
Any other medical/health concerns?
__________________________________________________________________________________________
Medical history: accidents, injuries, surgeries? __________________________________________________
Taking medication (Type, reason, side effects)?
_______________________________________________________________________________________
Any psychological (thinking/emotional) concerns?
_______________________________________________________________________________________
7. Has your child had a psychological or education evaluation from outside of the school in the last 3 years?
Yes No If yes, who did it, when was it done, and what were the results?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
8. Has your child had additional community services in the last 3 years (tutoring, counseling, residential care)?
Yes No If yes, please describe:
_______________________________________________________________________________________________
9. With whom does your child live at home? _____________________________________________________________
