5/9/2007PreReferral Procedures - Documentation

(§300.309(a)(1)(b)(1)(2)(c) of final regulations)

Child / Grade / K123456789101112 / Subject / MathEnglish
Last / First
Teacher / “Highly Qualified” Credentials / Passed ContentHOUSSETeacher/Degree/NBCMulti-Subject HOUSSENo
Area of Specific Concern / Reading Comprehension / Fluency / Word Reading
(Check all that apply) / Vocabulary / Listening Skills
Math Applications and Reasoning / Math Calculations
Other, specify
Previous interventions / Title I Reading / Title I Math / Retention
(Check all that apply) / Enrichment Reading / Enrichment Math / Summer School
Extended Day Services / Other, specify
Examples of researched-based instruction/curriculum being used with the student include:
Am Choice LiteracyAm Choice MathCMP MathLiteracy Lab (Smart Step)Step up to WritingGlencoeThe Little SchoolhouseWord JourneysThe Fluent ReaderReading FirstReading NextWriting NextELLABring Words to LifeWords Words WordsBuilding Academic Vocab / Am Choice LiteracyAm Choice MathCMP MathLiteracy Lab (Smart Step)Step up to WritingGlencoeThe Little SchoolhouseWord JourneysThe Fluent ReaderReading FirstReading NextWriting NextELLABring Words to LifeWords Words WordsBuilding Academic Vocab / Am Choice LiteracyAm Choice MathCMP MathLiteracy Lab (Smart Step)Step up to WritingGlencoeThe Little SchoolhouseWord JourneysThe Fluent ReaderReading FirstReading NextWriting NextELLABring Words to LifeWords Words WordsBuilding Academic Vocab / Am Choice LiteracyAm Choice MathCMP MathLiteracy Lab (Smart Step)Step up to WritingGlencoeThe Little SchoolhouseWord JourneysThe Fluent ReaderReading FirstReading NextWriting NextELLABring Words to LifeWords Words WordsBuilding Academic Vocab
Am Choice LiteracyAm Choice MathCMP MathLiteracy Lab (Smart Step)Step up to WritingGlencoeThe Little SchoolhouseWord JourneysThe Fluent ReaderReading FirstReading NextWriting NextELLABring Words to LifeWords Words WordsBuilding Academic Vocab / Am Choice LiteracyAm Choice MathCMP MathLiteracy Lab (Smart Step)Step up to WritingGlencoeThe Little SchoolhouseWord JourneysThe Fluent ReaderReading FirstReading NextWriting NextELLABring Words to LifeWords Words WordsBuilding Academic Vocab / Am Choice LiteracyAm Choice MathCMP MathLiteracy Lab (Smart Step)Step up to WritingGlencoeThe Little SchoolhouseWord JourneysThe Fluent ReaderReading FirstReading NextWriting NextELLABring Words to LifeWords Words WordsBuilding Academic Vocab / Am Choice LiteracyAm Choice MathCMP MathLiteracy Lab (Smart Step)Step up to WritingGlencoeThe Little SchoolhouseWord JourneysThe Fluent ReaderReading FirstReading NextWriting NextELLABring Words to LifeWords Words WordsBuilding Academic Vocab
Am Choice LiteracyAm Choice MathCMP MathLiteracy Lab (Smart Step)Step up to WritingGlencoeThe Little SchoolhouseWord JourneysThe Fluent ReaderReading FirstReading NextWriting NextELLABring Words to LifeWords Words WordsBuilding Academic Vocab / Am Choice LiteracyAm Choice MathCMP MathLiteracy Lab (Smart Step)Step up to WritingGlencoeThe Little SchoolhouseWord JourneysThe Fluent ReaderReading FirstReading NextWriting NextELLABring Words to LifeWords Words WordsBuilding Academic Vocab

Give examples of appropriate, high quality, instructional strategies and accommodations. Include general strategies, motivational strategies, environmental strategies, organizational strategies, and presentation strategies.

Instructional Strategies / Effectiveness( +, -, NA) / Implementation Date / Frequency
(based on assessment results listed below) / Begin / End / (Daily, Weekly, Test)
Individual HelpModified TestsReduced AssignmentsRepeated DirectionsStudy GuidePreferential Seating / +-NA / DailyWeeklyTest
Individual HelpModified TestsReduced AssignmentsRepeated DirectionsStudy GuidePreferential Seating / +-NA / DailyWeeklyTest
Individual HelpModified TestsReduced AssignmentsRepeated DirectionsStudy GuidePreferential Seating / +-NA / DailyWeeklyTest
Individual HelpModified TestsReduced AssignmentsRepeated DirectionsStudy GuidePreferential Seating / +-NA / DailyWeeklyTest
Individual HelpModified TestsReduced AssignmentsRepeated DirectionsStudy GuidePreferential Seating / +-NA / DailyWeeklyTest
+-NA / DailyWeeklyTest
+-NA / DailyWeeklyTest

Give assessment data of above described interventions which were appropriate for the child’s age:

Name of Assessment / Specific Skill Assessed / Date of Assessment / Result of Assessment / Date of Parental Notification of Results
Benchmark and ITBS / Math and Literacy / 05 and 06 / See TRIAND / Sept 05 and Sept 06
See grade reports / Listed on grade report / On report / On attached report

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