Levin College of Public Affairs and Education

Academic and Degree Programs
Advising and Student Services
College Directory
Site Map

Community Learning Center for Children and Youth

Our History
CLC Staff
Helpful Information
News
Services We Provide

CLC Center-based Tutoring and Registration

CSU Student Intake Form
CLC Faculty Intake Form

Outreach Sites and Forms

Outreach Site-based Tutoring and Registration
Student Intake Questionnaire

Staff Forms

Teacher Reporting Forms
Tutor Hourly Reporting Form
Tutor Reporting Form (General)
Tutor Reporting Forms

CLC Fundraising

Tri-C

Community Learning Center for Children and Youth

Levin College of Public Affairs and Education

Academic and Degree Programs
Advising and Student Services
College Directory
Site Map

Community Learning Center for Children and Youth

Our History
CLC Staff
Helpful Information
News
Services We Provide

CLC Center-based Tutoring and Registration

CSU Student Intake Form
CLC Faculty Intake Form

Outreach Sites and Forms

Outreach Site-based Tutoring and Registration
Student Intake Questionnaire

Staff Forms

Teacher Reporting Forms
Tutor Hourly Reporting Form
Tutor Reporting Form (General)
Tutor Reporting Forms

CLC Fundraising

Tri-C

Mailing Address
Cleveland State University
2121 Euclid Avenue, JH 130
Cleveland, OH 44115

Campus Location
2485 Euclid Avenue
Julka Hall, Room 130
Cleveland, OH 44115

Phone: 216.687.4768
communitylearningctr@csuohio.edu

Campus International Teachers

Student information (Please fill out form for only one student at a time. Complete additional form for each additional.):

Student Name & Grade

1. Student Name

2. Grade

Teacher Information

3. Teacher Name:

4. Phone Number:

5. Email:

Academic Information:

6. Content Areas of Need

Grade Band Content Area Standard Selections (select one)

7. Grade Bands:

Primary (grades pk/K/1)

Elementary (grades 2/3/4/5)

Intermediate (grades 6/7/8)

Secondary (grades 9/10/11/12)

Content Areas: Language Arts, Math, Science, Social Studies -select all that appl

Primary

Primary - Language Arts

Describe characters, settings, and major events in a story

Demonstrate ability to separate sounds within words (for example, “dog” = “/d/-/o/-/g/” sounds)

Demonstrate ability to blend separated sounds into words (for example, “/d/-/o/-/g/” = “dog”)

Isolate and pronounce blends and digraphs within words (for example, /sk/, /cl/, /sh/, /th/)

Letter-sound correspondences (phonemic awareness and phonics)

Know and apply grade-level phonics and word analysis skills in decoding unknown words

Read common high-frequency words by sight

Determine the meaning of words and phrases as they are used in a text

Produce clear and coherent writing (e.g. numbers and letters)

Demonstrate command of the conventions of standard English grammar and usage when writing or speaking

Primary - Math

Count to tell the number of objects

Solve simple addition and subtraction problems

Compare measurable attributes (size, color, etc)

Identify and describe shapes

Work with time, money, measurement (age appropriate)

Primary - Science

Daily and seasonal changes, sun, energy, weather

Properties of objects and everyday materials

Physical and behavioral traits of living things

Motion and materials

Basic needs of living things

Primary - Social Studies

Time

Money

Resources

Models/maps

Diverse cultural practices

Elementary

Elementary - Language Arts

Letter-sound correspondences (phonemic awareness and phonics)

Know and apply grade-level phonics and word analysis skills in decoding unknown words

Read common high-frequency words by sight

Read with sufficient accuracy and fluency to support comprehension

Determine the meaning of words and phrases as they are used in a text

Refer to details, pictures, and examples in a text when explaining what the text says explicitly and when drawing inferences from the text

Determine the meaning of general academic and domain-specific words and phrases in a text

Interpret information presented visually, orally, or quantitatively (e.g., in charts, graphs, diagrams, time lines, animations, or interactive elements on Web pages)

Produce clear and coherent writing in which the development, organization, and style are appropriate to task, purpose, and audience (grade appropriate)

Demonstrate command of the conventions of standard English grammar and usage when writing or speaking

Elementary - Math

Simple addition and subtraction

Multidigit addition and subtraction

Solve simple problems involving money, measurement, and time

Simple multiplication and division

Solve simple word problems

Elementary - Science

Atmosphere

Changes in motion

Interactions within habitats

Earth’s resources, surface, and living history

Matter and forms of energy

Behavior, growth, and changes

Electricity, heat, light, and sound

Solar system

Ecosystems, rocks, minerals, and soil

Cellular to multicellular

Elementary - Social Studies

Biographies and timelines

Physical/political maps

Systems of government

Cultural diversity

Globes/geographic tools/longitude/latitude

Intermediate

Intermediate - Language Arts

Write arguments to support claims with clear reasons and relevant evidence

Cite specific textual evidence to support analysis of primary and secondary sources

Demonstrate understanding of figurative language, word relationships, and nuances in word meanings

Read with sufficient accuracy and fluency to support comprehension

Determine the meaning of words and phrases as they are used in a text

Determine the meaning of general academic and domain-specific words and phrases in a text

Interpret information presented visually, orally, or quantitatively (e.g., in charts, graphs, diagrams, time lines, animations, or interactive elements on Web pages)

Read and comprehend informational texts, including history/social studies, science, and technical texts

Produce clear and coherent writing in which the development, organization, and style are appropriate to task, purpose, and audience (grade appropriate)

Demonstrate command of the conventions of standard English grammar and usage when writing or speaking

Intermediate - Math

Simple arithmetic

Multidigit arithmatic

Represent and interpret data graphically

Solve problems involving money, measurement, and estimation of intervals of time, liquid volumes, and masses of objects

Solve two-step word problems using the four operations

Fraction equivalence, rate, ratio, common multiples

Solving problems involving area, surface area, and volume

Convert like measurement units and decimals

Basic geometry (e.g. identify lines and angles)

Pre-algebra/algebra (solving problems where letters stand for numbers)

Intermediate - Science

Earth and space science

Life science

Physical science

Intermediate - Social Studies

Early civilizations (India, Egypt, China and Mesopotamia)

Empires in Africa (Ghana, Mali and Songhay) and Asia (Byzantine, Ottoman, Mughal and China)

Greece and Roman empires

Major world religions

Monarchies, theocracies, dictatorships or democracies

The renaissance and reformation

Markets, supply and demand, basic banking

Cultural biases

U.S. Constitution

Industrial revolution

Secondary

Secondary - Language Arts

Cite strong and thorough textual evidence to support analysis of what the text says explicitly as well as inferences drawn from the text

Determine the meaning of words and phrases as they are used in the text, including figurative and connotative meanings

Integrate and evaluate multiple sources of information presented in different media or formats (e.g., visually, quantitatively) as well as in words in order to address a question or solve a problem

Translate quantitative or technical information expressed in words in a text into visual form (e.g., a table or chart) and translate information expressed visually or mathematically (e.g., in an equation) into words

Read and comprehend informational texts, including history/social studies, science, and technical texts

Produce clear and coherent writing in which the development, organization, and style are appropriate to task, purpose, and audience (grade appropriate

Demonstrate command of the conventions of standard English grammar and usage when writing or speaking

Use appropriate resources to find information/solutions (e.g., driving maps, google, email/phone directories)

Complete applications related to secondary and post-secondary needs (e.g. job, college, housing, financial applications)

Life skills (e.g. driving, budgeting, shopping, health and safety needs, intra/interpersonal relationships)

Secondary - Math

Basic arithmatic/calculations

Solve problems involving money, measurement, and estimation of intervals of time, liquid volumes, and masses of objects

Measurement

Fractions/ratios

Work with radicals and integer exponents

Pythagorean Theorem

Perform operations with numbers expressed in scientific notation

Statistics and probability

Geometry

Precalculus/calculus

Secondary - Science

Environmental science/geology

Biology

Chemistry

Physics

Secondary - Social Studies

American history

American government

Modern world history

Economics and financial literacy

Contemporary world social issues

World geography

Social/Emotional/Behavioral Areas of Need

8. Social/Emotional/Behavioral Areas of Need

Needs Domain Indicator (select all that apply):

9. Social:

Peer relationships

Conflict resolution

Bullying

Social isolation

Not applicable

10. Emotional:

Self-regulation

Empathy

Anxiety

Depression

Not applicable

11. Behavioral:

Off-task, task persistence

Noncompliance

Verbal/physical aggression

Avoidance/escape

Not applicable

12. Provide Examples of Needs in more Detail