Re-Evaluation Referral For Teacher (K-6) Page 3
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4Referral for Re-Evaluation (K-6)
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RETURN TO PSYCHOLOGIST BY
_______________________
CLASSROOM TEACHER COMPLETES THIS SECTION
Student’s Name: ______________________________
School: __________________________________
CLASSROOM TEACHER REPORT
Name of teacher(s) providing information ________________________ Subject area ___________________
How long have you had this student in your class?_________________________________________________
Attendance Information
good attendance
punctual
frequently tardy (# of days_____)
frequently absent (# of days _______)
Number of out of school suspension days this year __________ Reasons _______________________________
Number of APPLE Room/ISS referrals
Reasons _______________________________
READING
Attach Latest Quarterly Assessment Results
NWEA Reading Results (date administered) _________ Score/Cut Score _______/________
ISTEP Reading Results (date administered)
Score/Cut Score_______/_________
Current Reading level based on benchmarks: ________________________________
Current Comprehension score based on benchmarks: ___________________________
Current Fluency score based on benchmarks: _________________________________
Current grades in Reading: _______________________________________________
Is a modified grading scale used? Yes ___ No ___
SPELLING/WRITTEN LANGUAGE
Attach Latest Quarterly Assessment Results
NWEA Writing Results (date administered)________) Score/Cut Score _______/_________
ISTEP Writing Results (date administered _________) Score/Cut Score_______/_________
Latest Writing Prompt Scores: __________________________________________________
Current grades in Spelling/English _______________
Is a modified grading scale used? ________________
MATHEMATICS
Attach Latest Quarterly Assessment Results
NWEA Math Results (date administered)________) Score/Cut Score _______/_________
ISTEP Math Results (date administered _________) Score/Cut Score_______/_________
Current math level ______________________
Current grades in Math __________________
Is a modified grading scale used? __________
Summarize current special education services, including related services:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe any other interventions the student has received in school: ___________________________________
__________________________________________________________________________________________
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