Placement Questionnaire for the Mathematics Teacher

We ask your help in completing the following questionnaire, in order that we may place the student in an appropriate level of mathematics at Loomis Chaffee. This questionnaire will be used for placement purposes only, as the student has already been accepted to our school. This is a confidential statement.

Please submit all questionnaires by May 22. Thank you for your help!

Name of Studentrequired

Name of Schoolrequired

School City and Staterequired

Name of Teacherrequired

Phone number during summer, if possible

If other, please explain:

This student is currently enrolled in

Official description of the course (if available):

What section is the student in?

Honors Advanced Regular Other

If other, please explain:

If this student is currently taking Algebra I:

Check all that apply.

A full year of the course has been covered. Only part of the course has been covered. Student would benefit from taking this course again.

Within all sections at this level, this student ranked in the:

top 10% top third middle third bottom third

Would you recommend this student for an honors level section at Loomis Chaffee?*

Yes No

Comments:required

Title and author of textbook used:

What course or subject topics would this student study at your school next year if he or she were to continue?

On a scale of 1–5, with 5 being highest, please rank this student on the following topics:

What will this student's probable grade be at the end of the year?

Please list the student's grades on the last three major assessments.

What are the student's strengths?

What are the student's weaknesses?

Is there anything else you would like us to know?

SYLLABUS:

Please check off all the topics covered by your course this past year.

If a student is coming from a school outside of the United States and submitting a syllabus is easier, feel free to email one in English, if possible, to academic_office@loomis.org.

You agree that by typing your name below, you are electronically signing this form and declaring that the information you have provided is true and accurate.

Teacher Full Namerequired

Daterequired (mm/dd/yyyy)