Teachers who wish to refer students to the appropriate Grade Level Action Team may download the form here:GLAT Referral Form This is how the form is designed: CONFIDENTIAL Teacher's name:  Date:   Grade Level Action Plan Referral Name of student: Grade: Subject/Content area: Current average in class: Primary concern: 1. Strategies used in reteaching/remediation: Date and Time: Student received extra help. Addressed motivational issues. Left missing assignments with study hall monitor. Academic detention was given. Quiz/test was retaken; assignment was rewritten. Provided alternate assessment. Utilized peer tutor. Provided organizational tools or assistance. Scheduled make-up work. Encouraged use of learning aids (calculator, computer, etc.). Teacher conferred with other school personnel, (ie: Guidance Counselor, Chapter 1 Specialist, student's prior teacher(s), other.) Assignments sent home during absences. Other:   2. Parent/Guardian contact: Date: Telephone contact E-mail contact Parent conference Progress Report Report Card 3. Reasons for Referral: Poor attendance Failure to complete assignments Poor quiz grades Poor test grades Does not complete makeup work Does not seek additional help Refuses additional help Disruptive in class Poor organizational skills Does not participate in class Inattentive in class Other: Revised 6/26/2006