Form Ats-102 - Review Committee Documentation Form
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1
2Warren County Schools
Review Committee Documentation Form
Grades 3, 5, and 8
School______________________________ Student____________________________ Grade________
Principal______________________________ Teacher_______________________________________
Special Area (Complete if applicable)
Limited English Proficient
Previous Promotional Waiver
English Proficiency Level –
Approved(date)_________________
Listening_________ Speaking_________
Reading__________ Writing__________
Exceptional Children(Specify Exceptionality)
Academically Intellectually Gifted
Level of Services:
Area:
Language Arts____
Math____ Written Lang_____
Regular______ Resource______ Self-Contained____
Other:______________________________________
___________________________________________
504: Yes____ No____
Number of Previous Retentions:
None____ One____ Two____ Three ____
_____________________________________________
Grades:___________________________
Reason for
Review__________________________________________________________________________
Subject
EOG Scores
EOG Scores
EOG Scores
EOG Scores
Gr___
Gr___
Gr___
Gr___
Regular
Retest
Regular
Retest
Regular
Retest
Regular
Retest
Math Scale Score
/Achievement Level
Reading Scale Score
/Achievement Level
Science Scale Score
/Achievement Level
Subject
Benchmark 1
Benchmark II
Benchmark III
Benchmark IV
Math Percentage
Reading Percentage
Science
Performance Criteria: Final Grade Averages: Language Arts/Reading__________ Math__________
Additional Assessment Data Reviews: (Examples: Accelerated Reader, Star Reader and Math, K-2 Assessment, ClassScape,
Dibbles, teacher-made assessments)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
WCS Testing Department
Review Committee Documentation
ATS-102, page 1
08/27/10
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