Evergreen Park Elementary School District 124

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9400 South Sawyer * Evergreen Park Illinois 60805 * 708-423-0950 * Fax 708-423-5020 * Website www.d124.org

Parent Input for Domain Meeting

1. Health Concerns: (Allergies, illnesses, seizures, ear infections, hospitalizations, major accidents, medications, medical diagnosis etc)

c Yes

c No

If yes, please describe:

1. Vision/Hearing Concerns:

c Yes

c No

If yes, please describe:

2. Social/Emotional Concerns: (Divorce, Financial, Death, Moving etc)

Social Skills Behavior Self Help Emotional Family Stressors

□ Yes □ Yes □ Yes □ Yes □ Yes

□ No □ No □ No □ No □ No

If yes, please describe:

3. Academic Concerns:

Reading Writing Math

□ Yes □ Yes □ Yes

□ No □ No □ No

If yes, please describe:

4. Cognitive Concerns

c Yes

c No

If yes, please describe:

5. Communication Concerns (Understanding language, use of language, clarity of speech etc)

c Yes

c No

If yes, please describe:

6. Motor Concerns

c Yes

c No

If yes, please describe: