Series 602.5.1P - Request for Consideration of Retention

To be completed by preassessment team:

Student's name _____________________________________  Birthdate ________________

(please print)      first                               last

Grade ___________  School ____________________________________________________

Names of parent(s)/guardian(s) _________________________________________________

Address ________________________________________ Phone (       )__________________

1.  Reason(s) why retention is being considered: 

 

 

 

 

 

2.  What alternatives/interventions have been tried to meet the student's needs?

 

 

 

 

 

3.  Standardized test data:

 

 

 

 

4.  Other test data or pertinent information (Light’s Retention Scale):

 

 

 

 

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Signatures of Preassessment Team Members                          Title

Please check one:

   ❏ Refer to Child Study

   ❏ Complete 602.5.1.2P, Summary of Decision not to Proceed with Retention Assessment

   ❏ Complete 602.5.1.3P, Permission for Retention Assessment

                                                                                                                            

Date of pre-referral meeting       Signature of Principal

Procedures/602.5.1P/10-16-06