Start Time
End Time

School Personnel Involved

Site Visit Review Items for the Month

Site Visit Review Items

Comments and Documentation

Other Items Discussed

Stakeholder Data to be Collected

Stakeholder Interview(s)

Technical Assistance and Guidance Provided

Areas of strength for this month

Areas for Improvement Identified this Month

Area for Improvment

Action Steps Required

Timeframe for Completion

Follow-Up on Previously Identified Areas for Improvement

Area for Improvement

Progress of Action Steps Required

Timeframe for Completion

Improvement Progress

Summary of Findings

General Student File Review

Student Files
Student File Checklist

Sign- In Sheet Included?

Biographical Information

Student Initials

Student ID Number

Grade Level

Birth Certificate with Proper Name/Spelling


Proof of Residency


Health Information

Signed Emergency Medical Release


Immunization Chart

Immunizations Current


Vision Screening

Vision Current? (K,1, 3, 5, 7, 9, New Student)


Hearing Screening

Hearing Current? (K, 1, 3, 5, 9, 11, New Student)


Academic Information

Most recent school grade report


State Test Results


Did the student transfer from a different school?

Records Release?


Transcript from previous school

Number of Requests Documented

Date of most recent request
Overall Assessment

General Comments or Concerns

Student File - up Needed?

Follow up will take place

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.