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Student *
Date Referred
Grade Level
School
Staff Submitting Form
How many months have you known this child?
Student has unusually advanced vocabulary for age or grade level. Verbal behavior is characterized by richness of expression, elaboration, and fluency.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
5 N/A Not Applicable
Student possesses a large storehouse of information about a variety of topics or knows a great amount of in-depth information about one subject area
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student has quick mastery and can recall factual information.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student has a ready grasp of underlying principles and can quickly make valid generalizations about events, people, or things.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student is a keen and alert observer; usually sees more and gets more out of a story, film, etc. than others.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student reads a great deal on own; usually prefers older/adult level books, may show a preference for biographies, autobiographies, encyclopedias, and atlases.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Please give specific examples/supporting statements for the above questions. *
Student tries to understand complex material by separating it into its respective parts, reasoning things out.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student becomes absorbed and truly involved in certain topics or problems.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student easily loses interest in repetitive tasks; often bored with routine tasks and computations.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student needs little external motivation to follow through with self selected tasks.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student is self-critical; is not easily satisfied with own speed or products.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student prefers to work independently.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student is interested in world problems or issues (politics, hunger, homelessness), and/ or is interested in statistics and data related to problems or issues.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Please give specific examples/supporting statements for the above questions. *
Student often is assertive (sometimes even aggressive); persistent in beliefs.
1 seldom or never o observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student is able to organize and bring structure to things, people, and situations; is able to disregard irrelevant data.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistenly observed
N/A not applicable
Student is quite concerned with right and wrong, good and bad; often evaluates and passes judgment on events, people, and things.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student approaches matters critically and is unwilling to accept authoritarian pronouncements without critical examination.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student displays a great deal of curiosity about many things constantly asking questions about anything and everything.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student generates a large number of ideas or solutions to problems and questions; often offers unusual ("way out"), unique, or clever responses.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student is uninhibited in expressions of opinion; is sometimes radical and spirited in disagreement; is tenacious.
1 seldom or never observed
2 occasionally observed
3 freqently observed
4 consistently observed
N/A not applicable
Please give specific examples/supporting statements for the above questions. *
Student is a high risk taker; is adventurous and speculative.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student displays a good deal of intellectual playfulness: fantasizes, imagines ("I wonder what would happen if?"), manipulates ideas.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student displays a keen sense of humor and sees humor in situations that may not appear to be humorous to others.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student shows emotional sensitivity to situations.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistenly observed
N/A not applicable
Student shows an appreciation of beauty and patterns in nature, art, music, mathematics, etc.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student is nonconforming; can accept disorder; does not fear being different or solving problems in own way.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Student displays flexibility in thought and/or with materials.
1 seldom or never observed
2 occasionally observed
3 frequently observed
4 consistently observed
N/A not applicable
Please give specific examples/supporting statements for the above questions. *
Please describe the child’s outstanding ability(ies) and special interests. *
In what area(s) does the child need additional challenges or support (this includes affective as well as academic help)? *
If this child seems to possess high potential but does not produce in the classroom, please explain: *
Please answer the following text questions with a 1-4 or N/A
1 Characteristic is seldom or never observed
2 Characteristic is occasionally observed
3 Characteristic is frequently observed
4 Characteristic is consistently observed
N/A Not applicable
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