Home Telephone Number Work Telephone Number

Street Address

City State Zip Code

E-mail address

What jurisdiction do you pay taxes in?
Arlington
Alexandria
Fairfax
Other (please specify)

Placement Advisor

Has tutoring ended?
Yes No

If you are not presently tutoring, are you available to tutor? Yes No

A. Total tutoring hours for this quarter

B. Nontutoring volunteer hours
1. Tutor preparation and travel time
2. Trainer (include preparation & travel time)
3. Placement advisor
4. Workshop registration, in-service help
5. Board member
6. Other hours, please specify
Total nontutoring hours (Add 1 through 6, section B)

C. Workshop, in-service and seminar attendance hours

Student Information
First Name Last Name

Home Telephone Number Work Telephone Number

Street Address

City State Zip Code

Jurisdiction
Arlington
Alexandria
Fairfax
Other (please specify)

Total tutoring hours this quarter

Has tutoring ended?
Yes No
If yes, date ended?

Reason tutoring ended

Does the student need another tutor?
Yes No

Current achievement level

Laubach Skill Book
Level Lesson

Challenger Level Lesson

Reading for Today
Level Unit

Other materials used

Please share how tutoring has affected you and/or your student and what skills you and your student are currently working on:

Additional comments (successes, concerns)

Improvement and Achievements (check any that apply)
Self confidence
Got a job
Job performance/advancement
Helped children with homework
Read to children
Registered to vote
Acquired citizenship
Got a library card
Got a driver's license
Read a book
Other (please specify)

Personal Learning Goals Completed This Quarter
Please select any new goals completed this quarter from the Personal Learning Goals List below. Feel free to add other unlisted goals that your student has achieved.
Choose from the goals below 1. Read and write own name, address, and phone number 2. Read and write all letters of the alphabet 3. Read and write number words up to 50 4. Determine correct change in purchasing transactions 5. Understand and use of table of contents 6. Record and write simple telephone message 7. Read and write notes to and from child's school 8. Write short personal note to friend 9. Read a calendar 10. Read labels/directions on medicine bottles 11. Write a shopping list 12. Read a menu 13. Read books to children 14. Write out checks or money orders 15. Alphabetize words with three of the letters the same, in order to use telephone book or dictionary 16. Find name in telephone book 17. Use the dictionary to find out what a word means 18. Fill out a job application or medical form 19. Read the prices of items in ads to determine best buys 20. Read and interpret food labels 21. Read job ads 22. Read and write cursive 23. Write appointments on calendar 24. Use written directions and map to find destination 25. Read and write messages related to work 26. Read and use the "TV Guide" 27. Write short story or poem 28. Use bus/Metro schedule 29. Read newspaper or magazine article 30. Read Bible or other religious material 31. Read and respond to a bill 32. Read and follow a recipe
Choose from the goals below 1. Read and write own name, address, and phone number 2. Read and write all letters of the alphabet 3. Read and write number words up to 50 4. Determine correct change in purchasing transactions 5. Understand and use of table of contents 6. Record and write simple telephone message 7. Read and write notes to and from child's school 8. Write short personal note to friend 9. Read a calendar 10. Read labels/directions on medicine bottles 11. Write a shopping list 12. Read a menu 13. Read books to children 14. Write out checks or money orders 15. Alphabetize words with three of the letters the same, in order to use telephone book or dictionary 16. Find name in telephone book 17. Use the dictionary to find out what a word means 18. Fill out a job application or medical form 19. Read the prices of items in ads to determine best buys 20. Read and interpret food labels 21. Read job ads 22. Read and write cursive 23. Write appointments on calendar 24. Use written directions and map to find destination 25. Read and write messages related to work 26. Read and use the "TV Guide" 27. Write short story or poem 28. Use bus/Metro schedule 29. Read newspaper or magazine article 30. Read Bible or other religious material 31. Read and respond to a bill 32. Read and follow a recipe
Choose from the goals below 1. Read and write own name, address, and phone number 2. Read and write all letters of the alphabet 3. Read and write number words up to 50 4. Determine correct change in purchasing transactions 5. Understand and use of table of contents 6. Record and write simple telephone message 7. Read and write notes to and from child's school 8. Write short personal note to friend 9. Read a calendar 10. Read labels/directions on medicine bottles 11. Write a shopping list 12. Read a menu 13. Read books to children 14. Write out checks or money orders 15. Alphabetize words with three of the letters the same, in order to use telephone book or dictionary 16. Find name in telephone book 17. Use the dictionary to find out what a word means 18. Fill out a job application or medical form 19. Read the prices of items in ads to determine best buys 20. Read and interpret food labels 21. Read job ads 22. Read and write cursive 23. Write appointments on calendar 24. Use written directions and map to find destination 25. Read and write messages related to work 26. Read and use the "TV Guide" 27. Write short story or poem 28. Use bus/Metro schedule 29. Read newspaper or magazine article 30. Read Bible or other religious material 31. Read and respond to a bill 32. Read and follow a recipe
Choose from the goals below 1. Read and write own name, address, and phone number 2. Read and write all letters of the alphabet 3. Read and write number words up to 50 4. Determine correct change in purchasing transactions 5. Understand and use of table of contents 6. Record and write simple telephone message 7. Read and write notes to and from child's school 8. Write short personal note to friend 9. Read a calendar 10. Read labels/directions on medicine bottles 11. Write a shopping list 12. Read a menu 13. Read books to children 14. Write out checks or money orders 15. Alphabetize words with three of the letters the same, in order to use telephone book or dictionary 16. Find name in telephone book 17. Use the dictionary to find out what a word means 18. Fill out a job application or medical form 19. Read the prices of items in ads to determine best buys 20. Read and interpret food labels 21. Read job ads 22. Read and write cursive 23. Write appointments on calendar 24. Use written directions and map to find destination 25. Read and write messages related to work 26. Read and use the "TV Guide" 27. Write short story or poem 28. Use bus/Metro schedule 29. Read newspaper or magazine article 30. Read Bible or other religious material 31. Read and respond to a bill 32. Read and follow a recipe
Other goals achieved:

Reading and Writing Skills Completed this Quarter
Please select from the list below any new reading and writing skills completed this quarter. Please feel free to list any other unlisted skills that you student has completed.
Choose from the skills below 51. Instantly recognizes 50 of the words 52. Instantly recognizes 100 of the words 53. Instantly recognizes 200 of the words 54. Instantly recognizes all 300 of the words 55. Associates the sound for the consonants with the letter 56. Associates the short vowel sound with each vowel 57. Recognizes "r controlled" vowels 58. Recognizes the digraphs ch, sh, th, wh, ng 59. Recognizes beginning and final consonant blends 60. Recognizes five long vowel sounds with regular spellings 61. Recognizes vowel digraphs and diphthongs 62. Recognizes variant sounds for s, ch, c, and g 63. Recognizes variant of known words by adding s 64. Recognizes variant of known words by adding 's 65. Recognizes variants with s, ing, ed 66. Recognizes contractions 67. Recognizes compound words 68. Recognizes prefixes and suffixes 69. Recognizes abbreviations 70. Can write small letters in manuscript writing 71. Can write capital letters in manuscript writing 72. Can copy words or names 73. Can write words from dictation 74. Can understand and use punctuation marks 75. Can write sentences from dictation 76. Can write short answers to questions 77. Can read and write legibly in cursive 78. Can write original sentences 79. Can write short summary of a story 80. Can read to answer literal detail questions (facts) 81. Can read to answer main idea questions 82. Can recall sequence of events of a story 83. Can draw inferences from what is read 84. Can recognize cause and effect 85. Can predict outcomes 86. Can understand the story setting 87. Can recognize the author's purpose 88. Can retell a story in his/her own words
Choose from the skills below 51. Instantly recognizes 50 of the words 52. Instantly recognizes 100 of the words 53. Instantly recognizes 200 of the words 54. Instantly recognizes all 300 of the words 55. Associates the sound for the consonants with the letter 56. Associates the short vowel sound with each vowel 57. Recognizes "r controlled" vowels 58. Recognizes the digraphs ch, sh, th, wh, ng 59. Recognizes beginning and final consonant blends 60. Recognizes five long vowel sounds with regular spellings 61. Recognizes vowel digraphs and diphthongs 62. Recognizes variant sounds for s, ch, c, and g 63. Recognizes variant of known words by adding s 64. Recognizes variant of known words by adding 's 65. Recognizes variants with s, ing, ed 66. Recognizes contractions 67. Recognizes compound words 68. Recognizes prefixes and suffixes 69. Recognizes abbreviations 70. Can write small letters in manuscript writing 71. Can write capital letters in manuscript writing 72. Can copy words or names 73. Can write words from dictation 74. Can understand and use punctuation marks 75. Can write sentences from dictation 76. Can write short answers to questions 77. Can read and write legibly in cursive 78. Can write original sentences 79. Can write short summary of a story 80. Can read to answer literal detail questions (facts) 81. Can read to answer main idea questions 82. Can recall sequence of events of a story 83. Can draw inferences from what is read 84. Can recognize cause and effect 85. Can predict outcomes 86. Can understand the story setting 87. Can recognize the author's purpose 88. Can retell a story in his/her own words
Choose from the skills below 51. Instantly recognizes 50 of the words 52. Instantly recognizes 100 of the words 53. Instantly recognizes 200 of the words 54. Instantly recognizes all 300 of the words 55. Associates the sound for the consonants with the letter 56. Associates the short vowel sound with each vowel 57. Recognizes "r controlled" vowels 58. Recognizes the digraphs ch, sh, th, wh, ng 59. Recognizes beginning and final consonant blends 60. Recognizes five long vowel sounds with regular spellings 61. Recognizes vowel digraphs and diphthongs 62. Recognizes variant sounds for s, ch, c, and g 63. Recognizes variant of known words by adding s 64. Recognizes variant of known words by adding 's 65. Recognizes variants with s, ing, ed 66. Recognizes contractions 67. Recognizes compound words 68. Recognizes prefixes and suffixes 69. Recognizes abbreviations 70. Can write small letters in manuscript writing 71. Can write capital letters in manuscript writing 72. Can copy words or names 73. Can write words from dictation 74. Can understand and use punctuation marks 75. Can write sentences from dictation 76. Can write short answers to questions 77. Can read and write legibly in cursive 78. Can write original sentences 79. Can write short summary of a story 80. Can read to answer literal detail questions (facts) 81. Can read to answer main idea questions 82. Can recall sequence of events of a story 83. Can draw inferences from what is read 84. Can recognize cause and effect 85. Can predict outcomes 86. Can understand the story setting 87. Can recognize the author's purpose 88. Can retell a story in his/her own words
Choose from the skills below 51. Instantly recognizes 50 of the words 52. Instantly recognizes 100 of the words 53. Instantly recognizes 200 of the words 54. Instantly recognizes all 300 of the words 55. Associates the sound for the consonants with the letter 56. Associates the short vowel sound with each vowel 57. Recognizes "r controlled" vowels 58. Recognizes the digraphs ch, sh, th, wh, ng 59. Recognizes beginning and final consonant blends 60. Recognizes five long vowel sounds with regular spellings 61. Recognizes vowel digraphs and diphthongs 62. Recognizes variant sounds for s, ch, c, and g 63. Recognizes variant of known words by adding s 64. Recognizes variant of known words by adding 's 65. Recognizes variants with s, ing, ed 66. Recognizes contractions 67. Recognizes compound words 68. Recognizes prefixes and suffixes 69. Recognizes abbreviations 70. Can write small letters in manuscript writing 71. Can write capital letters in manuscript writing 72. Can copy words or names 73. Can write words from dictation 74. Can understand and use punctuation marks 75. Can write sentences from dictation 76. Can write short answers to questions 77. Can read and write legibly in cursive 78. Can write original sentences 79. Can write short summary of a story 80. Can read to answer literal detail questions (facts) 81. Can read to answer main idea questions 82. Can recall sequence of events of a story 83. Can draw inferences from what is read 84. Can recognize cause and effect 85. Can predict outcomes 86. Can understand the story setting 87. Can recognize the author's purpose 88. Can retell a story in his/her own words
Other skills completed:

Student: What have I learned?

Overall Reading Practices
Tutor, please ask your student, "About how much time do you usually spend reading outside of class time? This includes materials you read at home, at work, in your community and during your leisure time." (Please check only one answer.)
Would you say that you usually read:
Not at all
A few minutes a day
About a half-hour a week
About an hour a week
Two or more hours a week
One hour or more a day