Confidential and Privileged Student Information for Professional Use Only

CONFIDENTIAL AND PRIVILEGED STUDENT INFORMATION FOR PROFESSIONAL USE ONLY

Supporting Documentation for Application of an Extraordinary Exemption from Assessment
School: / Student:
Student Number: / Grade:
Date of Birth: / Name of Parent/Guardian:
Student Address: / Student Phone Number:
Case manager: / Statewide Assessment for which exemption request is being made:

All documentation must be submitted no later than sixty (60) calendar days before the first day of the administration of the statewide standardized assessment for which the request is made. In accordance with Senate Bill 1108 the following supporting documentation has been collected. Please state the specific piece of evidence you will be including as documentation for each section below. Both written and attached supporting documentation is required. One piece of evidence may support multiple requirements below. Highlight corresponding information that supports each area.

1. A written description of the student’s disabilities, including a specific description of the student’s impaired sensory, manual or speaking skills. (i.e. present level information from the IEP)
Attached supporting documentation: (e.g. Medical report, IEP, evaluations, IEP meeting notes)
2. Written documentation of the most recent evaluation data.
Attached supporting documentation: (e.g. Speech/Language, Psychological, Occupational/Physical Therapy, Assistive Technology Evaluations, Functional Vision/Learning Media Assessment)
3. Written documentation if available of the most recent administration of statewide standardized assessments. (e.g. FSAA, FSA, FCAT scores)
Attached supporting documentation: (e.g. FSAA, FCAT, FSA report)
4. A written description of the circumstance’s or condition’s effect on the student’s participation in statewide standardized assessments, as defined in subsection (1) of this rule.

“Circumstance” means a situation in which accommodations allowable for use on the statewide standardized assessment are not offered to a student during the current year’s assessment administration due to technological limitations in the testing administration program. This would lead to results that reflect the student’s impaired sensory, manual, or speaking skills rather than the student’s achievement of the benchmarks.
“Condition” means an impairment, whether recently acquired or longstanding, which affects a student’s ability to communicate in modes deemed acceptable for statewide assessments, even if appropriate accommodations are provided.

This would create a situation in which the results would reflect the student’s impaired sensory, manual, or speaking skills rather than the student’s achievement of the benchmarks.
5. Written evidence that the student has had the opportunity to learn the skills being tested. (e.g. current schedule, attendance, grades)
Attached supporting documentation:
6. Written evidence that the student has been provided appropriate instructional accommodations.
Attached supporting documentation: (e.g. lesson plans with accommodations documented, accommodation logs, accommodation page from IEP)
7. Written evidence as to whether the student has had the opportunity to be assessed using the instructional accommodations on the student’s IEP which are allowable in the administration of a statewide standardized assessment. (e.g. assessment accommodations page from IEP when the student was assessed)
Attached supporting documentation:
8. Written evidence of the circumstance or condition as defined in subsection (1) of this rule. (e.g. Speech/Language, Psychological, Occupational/Physical Therapy, Assistive Technology Evaluations, Functional Vision/Learning Media Assessment, Medical Report)

Application submitted to the state for approval on:

Approved:

______Yes
______No
Reason denied:______
______
______
Reviewer:______

*If approved, the extraordinary exemption is valid for the current school year.

Revised 7/2015