Simply replace the unfilled areas such as "__" and "_[date]_" with your information.
Dear [teacher name],
From [her/his] grades and from the notes we have received home from you, it does not appear that _[name of student]_ is completed all of the required homework for your class. I would like to be able to assist in resolving this issue, and am now going to be monitoring his homework on a daily basis in order to insure that it is all completed on time.
In order to best facilitate this, I would like to request that you send a completed homework list home each day or each week, which ever is most convenient to you. I will work with [name of student] to make sure all the assignments listed are completed in a prompt and correct manner.
Thank you for your help with this issue.