Read 180

School name

Name of person completing this request

Name of administrator who supervises READ 180 in the school

Name of READ 180 teacher to work with the consultant

Is the teacher aware of this request?
Yes No

Times this teacher’s READ 180 classes meet

Did the school meet AYP in reading last year?
Yes No Don't know

Do the READ 180 classes meet for 90 minutes daily?
Yes No

Has the READ 180 teacher attended professional development?
Yes No I Don't Know

Please note any dates that will conflict with school activities such as assemblies, planned fire drills, and testing.

Please describe your reasons for requesting a consultation.

Please describe the desired format of the consultation (e.g., classroom observation and feedback, planning session).

You will receive an email confirming receipt of your request within two school days.