School Observation Form

Name:
Date of Birth:
Date:	(mm/dd/yyyy)
Person/Title completing this form:
School:
Grade:
Phone:
Current classroom placement:
Describe the use of amplification (hearing aid and/or FM).:
List auditory skills you observe in the classroom. Indicate the types of amplification benefit you feel the child receives.:
Describe the speech and language skills and mode of communication used.:
Describe the cognitive and learning style of the child.:
Describe how the family supports the learning of the child. How does the family communicate with school personnel?:
What are the expectations for cochlear implantation?:
What benefit do you feel the child will receive from cochlear implantation?:
What current support services does the child receive? What additional support services would be available following implantation?: