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EWS Teacher Form
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Teacher Last Name
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Student Last Name
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Student First Name
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Grade
6-1
6-2
6-3
7-1
7-2
7-3
8-1
8-2
8-3
Special Area Teacher
8:1:2
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Subjects of Concern
Math
English
Social Studies
Science
World Languages
Electives/Specials
Other:
Area of Concern - Check all that apply
Attendance -5 or more full day absences
Not completing the attendance requirement for virtual learning day
Missing 3 or more classroom assignments
Failing 2 or more tests/quizzes
Disrupting the learning environment
Interventions - Check all that apply
Spoke to parent on the phone
Communicated with parent through email
L/M or did not get through to parent on more than 1 occasion
Conferenced with student
Team meeting with other teachers about student
Team meeting with guidance
Team meeting with parent
Spoke to PPS/admin about student
Referral to the dean's office
Supported student in extra help
Recommended extra help for student
Other:
Dates of Previous Outreach:
Your answer
Additional Pertinent Information:
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