Series 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:_________________

Name of test:

Results:

 

  

 

 

Assessment completed by:______________________________ Date:_________________

Name of test:

Results:

 

  

 

 

Assessment completed by:______________________________ Date:_________________

Observation report by classroom teacher:

Teacher:______________________________________________ Date:_________________

Observation report by classroom teacher:

Teacher:______________________________________________ Date:_________________

Psychological assessment summary:

 

 

 

Assessment completed by:______________________________ Date:_________________

Procedures /602.5.2P/10-16-06