Series 602.5.2P - Report of Educational Assessment for Consideration of Retention
Adopted: October 2006
Revised:
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