Adopted: October 2006
Revised:
Download 602.5.2P - Report of Educational Assessment for Consideration of Retention
Student's name ____________________________________ Birthdate _____________________________________________________ C.A.________________
(please print) first last yr/mth
Grade _____________ School ___________________
Names of parent(s)/guardian(s) ___________________________________________________________________________
Address ____________________________________________ Phone ( )_____________________________________________________
DIRECTIONS: Summarize the findings of the evaluation. List areas of assessment and test instruments or sources of data used in each area of assessment, e.g. "Woodcock," "Interview," "Psychological,” “Observation” and/or “Light’s Retention Scale.”
Name of test:
Results:
Assessment completed by:__________________________________ Date:____________________________________________________________
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Name of test:
Results:
Assessment completed by:__________________________________ Date:____________________________________________________________
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Procedure 602.5.2P
Page 2
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Name of test:
Results:
Assessment completed by:__________________________________ Date:____________________________________________________________
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Observation report by classroom teacher:
Teacher:____________________________________________________ Date:____________________________________________________________
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Observation report by classroom teacher:
Teacher:____________________________________________________ Date:____________________________________________________________
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Psychological assessment summary:
Assessment completed by:__________________________________ Date:____________________________________________________________