Teacher/Staff Interview Summary (Evaluation)

Student: [Student full name]; [DOB or Student ID]; [Grade]; [School]

Interview Date: [Date and time]; [in-person / phone / video / questionnaire review]

Interviewer: [Interviewer name], [Role/credentials]

Informant: [Informant name], [Role]; [Subjects/settings served]

Interpreter: [Language] (Only include if interpreter was used)

Authorization: [Basis for information exchange, date, and scope] (If unclear or pending, explicitly state this and note any content limitations)

Referral Question(s): [Referral source; primary concerns; target domains; timeframe of concern]

Records Reviewed: [Documents reviewed for this interview] (If none, state "None reviewed for this interview")

Informant Context

[Narrative describing informant's relationship with student, instructional exposure, settings observed, and comparison frame used] (Include: duration of relationship, subjects taught, minutes/days of contact, group size, settings observed such as classroom/specials/lunch/transitions. Note any limitations on perspective such as limited contact time, recent teacher change, frequent student absences, or reliance on secondhand information. Use explicit attribution throughout.)

Strengths and Protective Factors

• Academic/Learning: [Specific strengths with concrete examples]
• Behavioral/Social: [Specific strengths with concrete examples]
• Environmental/Supports: [Strategies or contexts that reliably help]

Primary Concerns

[Summary of informant's main concerns and functional/educational impact] (Begin with attributed narrative: "Per [informant role] report..." Include a short direct quote only if it clarifies urgency or captures a distinctive concern.)

Concern Details by Domain

(Include only domains relevant to the referral. For each, use narrative format with embedded details. Maintain clear attribution.)

Academic: [Nature of difficulty, distinguishing skill vs. performance deficits; accuracy vs. fluency vs. comprehension; contextual factors; functional impact on classwork and assessments] (Include only if academic concerns are present)

Behavioral/Self-Regulation: [Observable patterns for attention, hyperactivity/impulsivity, emotional regulation, or task avoidance; antecedents/triggers; consequences and hypothesized function; effective strategies] (Describe behaviors, not diagnostic labels. Include only if behavioral concerns are present)

Social: [Pragmatic communication issues; peer interaction patterns; social inclusion/exclusion contexts] (Include only if social concerns are present)

Adaptive/Executive Functioning: [Organization, time management, multi-step directions, transitions, flexibility] (Include only if adaptive/executive concerns are present)

Cross-Setting Patterns: [Whether concerns appear across settings/subjects or are isolated to specific contexts, times, or task types]

Intervention History and Supports

(Document current and past interventions. For each, include: name/description, start date and duration, frequency/intensity, group size and implementer, fidelity if known, and student response with data when available. If no interventions exist, state "No formal interventions reported.")

• [Intervention name]: [Start date; duration; frequency; group size; implementer; student response/outcome]
• [Additional intervention]: [Details] (Repeat as needed)

Progress Monitoring Data

(Summarize objective data with time windows and units. If data conflict with informant narrative, document both and flag for follow-up.)

Academic: [CBM scores, progress monitoring trends, grades with context, work completion rates] (Include only if data available)

Behavioral: [ODRs, frequency/duration counts, point sheets, time out of instruction] (Include only if data available)

(If no formal data were provided, state: "No formal progress monitoring data provided at time of interview.")

Safety Concerns

[Summary of safety-relevant information; actions taken; current status] (Include this section only if informant reported self-harm statements, suicidal ideation, aggression with injury risk, threats, weapon concerns, or abuse/neglect disclosures. Use neutral language. Document who was notified, when, and disposition. Omit section entirely if no safety concerns reported.)

Informant Recommendations

[What informant believes would help; what they hope the evaluation will clarify] (Label clearly as informant opinion. May include suggested accommodations, instructional strategies, behavioral supports, or specific diagnostic questions.)

Summary and Limitations

• [Key finding 1]
• [Key finding 2]
• [Key finding 3]

(Synthesize 3–6 key points including strengths and needs; reference objective data or note its absence; maintain attribution such as "Per teacher report...")

Limitations: [Constraints on interpretation such as single informant, no data shared, limited observation time, indirect report, language/cultural factors]

Next Steps

• [Additional interviews planned]
• [Classroom observation target]
• [Rating scales to send/collect]
• [Additional data requests]
• [Team meeting date] (If known)

[Author name], [Role/credentials] — [Date]

(Include co-signature line if supervised trainee)

Attachments: [List of attachments] (If none, state "None")