
 
 
 
Students, please return to your counselor once form is completed.  Form can be downloaded from www.dematha.org. 
 
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       Student Name: _____________________   Evaluation Period: _________________ 
       Grade:          9         10        11         12       Requested by: _____________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
Subject / Teacher Name: _____________________________/____________________________________ 
What is the student’s approximate grade at this point?  A   B   C   D   F (additional comments on back of sheet) 
If C or below, please check all that apply:   ___Homework incomplete  ___Behavioral problem 
Teacher Initials:  ______        ___ Poor test / quiz grades  ___ Attendance  
Date:  ___ /___ /___          Recent academic and/or behavioral progress noted?  Yes  or   No 
         
Subject / Teacher Name: _____________________________/____________________________________ 
What is the student’s approximate grade at this point?  A   B   C   D   F (additional comments on back of sheet) 
If C or below, please check all that apply:    ___Homework incomplete  ___Behavioral problem 
Teacher Initials:  ______        ___ Poor test / quiz grades  ___ Attendance  
Date:  ___ /___ /___          Recent academic and/or behavioral progress noted?  Yes  or   No 
 
 
 
 
            ___ Other / Comments (please note on back of this sheet)   
     
Subject / Teacher Name: _____________________________/____________________________________ 
What is the student’s approximate grade at this point?  A   B   C   D   F (additional comments on back of sheet) 
If C or below, please check all that apply:    ___Homework incomplete  ___Behavioral problem 
Teacher Initials:  ______        ___ Poor test / quiz grades  ___ Attendance  
Date:  ___ /___ /___          Recent academic and/or behavioral progress noted?  Yes  or   No
       
Subject / Teacher Name: _____________________________/____________________________________ 
What is the student’s approximate grade at this point?  A   B   C   D   F (additional comments on back of sheet) 
If C or below, please check all that apply:    ___Homework incomplete  ___Behavioral problem 
Teacher Initials:  ______        ___ Poor test / quiz grades  ___ Attendance  
Date:  ___ /___ /___          Recent academic and/or behavioral progress noted?  Yes  or   No
         
 
    
___ Other / Comments (please note on back of this sheet)         
Subject / Teacher Name: _____________________________/____________________________________ 
What is the student’s approximate grade at this point?  A   B   C   D   F (additional comments on back of sheet) 
If C or below, please check all that apply:    ___Homework incomplete  ___Behavioral problem 
Teacher Initials:  ______        ___ Poor test / quiz grades  ___ Attendance  
Date:  ___ /___ /___          Recent academic and/or behavioral progress noted?  Yes  or   No