August, 1999

Dear Teacher:

Do you provide Language Arts, Reading or English instruction to the student named on the front cover? (This could include instruction in writing, literature studies, language or communication.)

1	Classroom setting Ô PLEASE CONTINUE WITH QUESTION A2.
2	Individually Ô PLEASE GO TO SECTION B, PAGE 3.

Number
_________	a. General education teachers
_________	b. Special education teachers
_________	c. Teacher aides
_________	d. One-to-one instructional assistants assigned to a specific student
_________	e. Other specialists
_________	f. Adult volunteers
_________	g. General education students
_________	h. Special education students

Percentage of students
_________	Much above average
_________	Somewhat above average
_________	Average
_________	Somewhat below average
_________	Much below average

minutes	Number of minutes per week of language arts, reading, or English instruction
OR
hours	Number of hours per week of language arts, reading, or English instruction

1	General education grade-level curriculum materials are used without modification.	PLEASE GO TO SECTION C, PAGE 6.
2	Some modifications in general education curriculum materials have been made (e.g., modified content expectations, somewhat below grade level curriculum used).
3	Substantial modifications in general education curriculum materials have been made (e.g., very different content expectations, significantly below-grade level curriculum used).	PLEASE ANSWER QUESTION B4.
4	Specialized curriculum or materials are used (e.g., parallel curriculum, individualized curriculum or materials).

1	Reading at grade level
2	Improving general reading skills, but not necessarily to reach grade level
3	Developing functional reading skills, such as word recognition for daily living
4	Building pre-reading skills (i.e., letter recognition, auditory discrimination of sounds, matching words, etc.)
5	No goals regarding reading achievement
6	Don’t know

		Often	Some- times	Rarely/ never	Not applicable	Don’t know
a.	Sight word reading program	1	2	3	4	5
b.	Listening to stories read	1	2	3	4	5
c.	Work with commercially developed curriculum and/or materials designed for special education students	1	2	3	4	5
d.	Work with below-grade-level general education curriculum and/or materials	1	2	3	4	5
e.	Work on phonics/phonological awareness	1	2	3	4	5
f.	Language/communication development, such as ESL, augmentative communication, or sign language	1	2	3	4	5
g.	Braille instruction	1	2	3	4	5
h.	Work on reading fluency and accuracy	1	2	3	4	5
i.	Vocabulary development	1	2	3	4	5

1	The same
2	Somewhat different
3	Very different
4	I do not discipline this student
5	Student does not require or rarely requires disciplining from adults

1	No, this student does not have an IEP or 504 plan. ® ® ® ® ® PLEASE GO TO SECTION E, PAGE 14.
2	Yes, this student has an IEP for special education services. ® ® PLEASE GO TO QUESTION C7.
3	Yes, this student has a 504 plan. ® ® PLEASE GO TO QUESTION C7.
4	Don’t know.

1	Special materials to use with the student
2	In-service training on the needs of this student
3	Special procedures to use with the student
4	Consultation services
5	Teacher aides or instructional assistants
6	Smaller student load or class size
7	Other: ___________________________________________________________
8	None of these
9	No assistance necessary

1	This student’s IEP goals
2	This student’s academic abilities or previous academic performance
3	This student’s social/behavioral needs
4	Instructional modifications or adaptations needed by this student
5	Grading modifications needed by this student
6	Behavioral support plans that apply to this student
7	None of these

	Accommodations/modifications
1	More time in taking tests
2	Test read to student
3	Modified tests
4	Modified grading standards
5	Slower-paced instruction
6	Additional time to complete assignments
7	Shorter assignments
8	Physical adaptations (e.g., preferential seating, special desks)
	Additional personnel
9	Reader or interpreter
10	Teacher aides or instructional assistants
	Additional supports & assistance
11	Student progress monitored by special education teacher or related services provider
12	Tutoring by special education teacher
13	Behavior management program
14	Learning strategies/study skills assistance
	Learning aids
15	Books on tape
16	Communication aids (e.g., Touch Talker, manual printing board)
17	Use of spell checker
18	Computer software designed for students with disabilities
19	Computer hardware adapted for student’s unique needs (e.g., alternative keyboards, switch interface)
20	Other: _________________________________________________________
999	None of these provided

1	Very appropriate
2	Somewhat appropriate
3	Not very appropriate
4	Not at all appropriate
5	Not sure

1	Very adequate
2	Somewhat adequate
3	Not very adequate
4	Not at all adequate
5	Not sure

Number of students
____________	Autism
____________	Deaf-blindness
____________	Developmental delay
____________	Emotional or behavioral impairment
____________	Hearing impairment/deafness
____________	Learning disability
____________	Mental retardation
____________	Orthopedic impairment
____________	Other health impairment
____________	Multiple disabilities
____________	Speech or language impairment
____________	Traumatic brain injury
____________	Visual impairment/blindness
____________	Other: __________________________________________________

		Frequently	Occasionally	Rarely/never
a.	Working with a peer partner	1	2	3
b.	Whole class instruction	1	2	3
c.	Instruction within small groups	1	2	3
d.	Individual instruction from classroom teacher	1	2	3
e.	Individual instruction from another adult	1	2	3

		Frequently	Occasionally	Rarely/never
a.	Computers for Internet use	1	2	3
b.	Computers for writing and other language arts activities	1	2	3
c.	Printed materials to supplement textbooks (e.g., literature selections)	1	2	3
d.	Specialized skill-building curricula (e.g., phonics program, corrective reading programs)	1	2	3
e.	Textbooks	1	2	3
f.	Worksheets or workbooks	1	2	3

		Frequently	Occasionally	Rarely/never
a.	Responds orally to questions	1	2	3
b.	Takes quizzes or tests	1	2	3
c.	Participates in class discussion	1	2	3
d.	Completes a reading assignment	1	2	3
e.	Works on a project or presentation	1	2	3
f.	Completes a writing assignment	1	2	3
g.	Receives skill-building instruction	1	2	3
h.	Reads silently	1	2	3

999	Progress is not evaluated, or grades are not determined for this student.	Not important in determining grades	Somewhat important in determining grades	Very important in determining grades
a.	Attitude/behavior	1	2	3
b.	Class participation	1	2	3
c.	Homework	1	2	3
d.	Items in student portfolios	1	2	3
e.	Performance on daily class work	1	2	3
f.	Performance on special projects	1	2	3
g.	Performance relative to a set standard	1	2	3
h.	Performance relative to the rest of the class	1	2	3
i.	Results of tests	1	2	3

	Accommodations/modifications
1	More time in taking tests
2	Test read to student
3	Modified tests
4	Modified grading standards
5	Slower-paced instruction
6	Additional time to complete assignments
7	Shorter assignments
8	Physical adaptations (e.g., preferential seating, special desks)
	Additional supports & assistance
9	Reader or interpreter
10	Teacher aides or instructional assistants
11	Student progress monitored by special education teacher or related services provider
12	Tutoring by special education teacher
13	Behavior management program
14	Learning strategies/study skills assistance
	Learning aids
15	Books on tape
16	Communication aids (e.g., Touch Talker, manual printing board)
17	Use of spell checker
18	Computer software designed for children with disabilities
19	Computer hardware adapted for child’s unique needs (e.g. alternative keyboards, switch interface)
20	Other: ___________________________________________________________
21	None of these provided

0	Preschool/Kindergarten level	7	7th grade level
1	1st grade level	8	8th grade level
2	2nd grade level	9	9th grade level
3	3rd grade level	10	10th grade level
4	4th grade level	11	11th grade level
5	5th grade level	12	12th grade or higher
6	6th grade level

999	Student does not receive grades, progress notes, or report cards.
Circle ONE		OR	Circle ONE
1	Mostly A’s		10	Mostly "excellent"
2	Mostly A’s & B’s
3	Mostly B’s		11	Mostly "good"
4	Mostly B’s & C’s
5	Mostly C’s		12	Mostly "fair"
6	Mostly C’s & D’s
7	Mostly D’s		13	Mostly "needs improvement"
8	Mostly D’s & F’s
9	Mostly F’s

1	Native English-speaker ® ® ® PLEASE GO TO QUESTION E4.
2	Bilingual (proficient or developing proficiency in both first language and English)
3	Limited-English-proficient PLEASE GO TO QUESTION E3b.
4	Non-English speaker

1	Yes
2	No

0	Never
1	Once
2	A few times over the school year
3	Once every other month
4	Once a month
5	Once a week or several times a month
6	Every day or several times a week

1	Yes
2	No
3	Not applicable. We do not have parent conferences or "back-to-school night."
4	Don't know

1	Not at all involved
2	Not very involved
3	Fairly involved
4	Very involved
5	Don’t know

1	Full-time general education teacher
2	Full-time special education teacher
3	Part-time general education teacher
4	Part-time special education teacher
5	Itinerant teacher (i.e., you provide instruction at more than one school)
6	Long-term substitute (i.e., will fill the role of a regular teacher on a long-term basis, but are still considered a substitute)
7	Related services provider (e.g., speech therapist) PLEASE GO TO QUESTION F5.
8	Paraeducator
9	Other: ___________________________________________________________

1	Yes
2	No

_________

Years in teaching

_________

Years in teaching special education students

1	High school diploma
2	Associate’s degree
3	Bachelor’s degree
4	At least 1 year of course work beyond a bachelor’s but not a graduate degree
5	Master’s degree
6	Education specialist or professional diploma with at least 1 year of course work past a master’s degree
7	Doctorate degree
8	Other: _____________________________________________________________

1	Regular or standard or advanced certificate
2	Probationary certificate
3	Provisional (or other type given to persons who are still participating in an "alternative certification program")
4	Temporary certificate (requires some additional coursework and/or student teaching)
5	Emergency certificate or waiver
6	Other: _____________________________________________________________
7	None of the above

1	General education credential
2	Disability-specific credential or endorsement
3	Special education credential or endorsement (for more than one disability category)
4	Speech/language certification
5	Physical therapy license
6	Occupational therapy license
7	Other: ___________________________________________________________
8	None of these

1	Teach language arts, reading, English, or writing
2	Work with students who are considered to be "at risk"
3	Work with students with disabilities
4	Classroom management
5	None of these

		Needs Fully improvement competent
a.	Motivate students to participate in academic tasks	1 2 3 4 5
b.	Use technology in instruction	1 2 3 4 5
c.	Adapt instruction and/or materials to address varying needs and achievements of individual students	1 2 3 4 5
d.	Teach reading skills	1 2 3 4 5
e.	Teach English at this student’s grade level	1 2 3 4 5
f.	Monitor students’ progress	1 2 3 4 5
g.	Adjust instruction based on student progress	1 2 3 4 5
h.	Manage behavior	1 2 3 4 5

		Strongly agree	Agree	Disagree	Strongly disagree
a.	I am given the support I need to teach students with special needs.	1	2	3	4
b.	I have adequate training for teaching students with disabilities.	1	2	3	4
c.	The school leadership has high expectations and standards for students and teachers.	1	2	3	4
d.	The principal promotes instructional improvement among school staff.	1	2	3	4
e.	This school is a safe place for students.	1	2	3	4

SEELS DESIGN DOCUMENTS