Weekly report

Fill out and send to Carl Peterson


Can our learning program
help you in spite of hearing
difficulties? Yes _____ No _____

How much can our free program
help with hearing and speaking?

Will you try it
and report your results?

USER TRACKING LOG_____________________________________________
STUDENT'S NAME___________________________Age in months_____

DATE ___|____TO DATE______
Student goals, tracking and results|___TEACHER___________________

Parents Name__________________________________________________

Address_______________________________________________________

Phones________________________________________________________

E-mail addresses________________________________________________

GOAL IS TWO HOURS PER DAY - Follow example below.
Day   Done  Start   End    By     Total  Rate Time         Goal

                                                                   on Task

                                                                   1 to 10    
_____|_____|_____|_____|_____|_____|_____|_____|___Score 1 to 10
_____|_____|_____|_____|_____|_____|_____|_____|___listening
_____|_____|_____|_____|_____|_____|_____|_____|___outcomes
_____|_____|_____|_____|_____|_____|_____|_____|___reading
_____|_____|_____|_____|_____|_____|_____|_____|___speaking
_____|_____|_____|_____|_____|_____|_____|_____|___writing

_____|_____|_____|_____|_____|_____|_____|_____|___handwriting
_____|_____|_____|_____|_____|_____|_____|_____|___meaning
_____|_____|_____|_____|_____|_____|_____|_____|___memory
_____|_____|_____|_____|_____|_____|_____|_____|___other benefits
_____|_____|_____|_____|_____|_____|_____|_____|___time on task
_____|_____|_____|_____|_____|_____|_____|_____|___more successes
_____|_____|_____|_____|_____|_____|_____|_____|___fewer failures

_____|_____|_____|_____|_____|_____|_____|_____|___self confidence
_____|_____|_____|_____|_____|_____|_____|_____|___memory loss
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________

_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________

_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________
_____|_____|_____|_____|_____|_____|_____|_____|_________________

Print out and send this finished form to Carl Peterson

2160 S. Cook Street

Denver, CO 80210

Phone: 1-800-SCHOOL3

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