PRIMARY TALENT POOL TEACHER REFERRAL FORM

Student: Grade:

Referral Date: ______School: ______

Referring Teacher:______

Dear Primary Talent Pool Committee,

Please consider this student for the Primary Talent Pool. Service area(s) for consideration are checked below. A written statement with supporting valid documentation and three pieces of informal assessment (copies) are attached for each area checked, (i.e., portfolio entries, test scores, work samples, anecdotal records and other diagnostic formal and informal data.) Please check off all supporting documentation attached to this referral.

General Intellectual(GI) (Check and attach at least 3).

  • __ Jot Down for GI and date
  • __ MAP score and date
  • __ DIBELS and date
  • __ STAR and date
  • __ Teacher made test(s) and date(s)
  • __ Parent Questionnaire Form and date

PRIMARY TALENT POOL TEACHER REFERRAL FORM

Student: Grade:

Referral Date: ______School: ______

Referring Teacher:______

Dear Primary Talent Pool Committee,

Please consider this student for the Primary Talent Pool. Service area(s) for consideration are checked below. A written statement with supporting valid documentation and three pieces of informal assessment (copies) are attached for each area checked, (i.e., portfolio entries, test scores, work samples, anecdotal records and other diagnostic formal and informal data.) Please check off all supporting documentation attached to this referral.

Creative Thinking (Check and attach at least 3).

  • __ Jot Down for Creativity and date
  • __ Student Work and date
  • __ Parent Questionnaire Form and date
  • __ Peer Referral

PRIMARY TALENT POOL TEACHER REFERRAL FORM

Student: Grade:

Referral Date: ______School: ______

Referring Teacher:______

Dear Primary Talent Pool Committee,

Please consider this student for the Primary Talent Pool. Service area(s) for consideration are checked below. A written statement with supporting valid documentation and three pieces of informal assessment (copies) are attached for each area checked, (i.e., portfolio entries, test scores, work samples, anecdotal records and other diagnostic formal and informal data.) Please check off all supporting documentation attached to this referral.

Leadership (Check and attach at least 3).

  • __ Jot Down for Leadership and date
  • __ Peer Referral
  • __ Self Referral
  • __ Parent Questionnaire Form and date
  • __ Student Portfolio

PRIMARY TALENT POOL TEACHER REFERRAL FORM

Student: Grade:

Referral Date: ______School: ______

Referring Teacher:______

Dear Primary Talent Pool Committee,

Please consider this student for the Primary Talent Pool. Service area(s) for consideration are checked below. A written statement with supporting valid documentation and three pieces of informal assessment (copies) are attached for each area checked, (i.e., portfolio entries, test scores, work samples, anecdotal records and other diagnostic formal and informal data.) Please check off all supporting documentation attached to this referral.

Specific Academic Area(s)

Language Arts(Check and attach at least 3).

  • __ Jot Down for Language Arts and date
  • __ MAP score and date
  • __ STAR score and date
  • __ DIBELS and date
  • __ Teacher made test(s) and date(s)
  • __ Student writing sample(s) and date(s)
  • __ Parent Questionnaire Form and date

Social Studies(Check and attach at least 3).

  • __ Jot Down for Social Studies and date
  • __ Teacher made test(s) and date(s)
  • __ ParentQuestionnaire Form and date

Math (Check and attach at least 3).

  • __ Jot Down for Math and date
  • __ Teacher made test(s) and date(s)
  • __ GMade score and date
  • __ Orchard Math score and date
  • __ ThinkLink Math score(s) and date(s)
  • __ ParentQuestionnaire Form and date

Science(Check and attach at least 3).

  • __ Jot Down for Science and date
  • __ Teacher made test(s) and date(s)
  • __ Science Fair evidence and date(s)
  • __ ParentQuestionnaire Form and date

Visual/Performing Arts

Art(Check and attach at least 3).

  • __ Jot Down for Art and date
  • __ Teacher made test(s) and date(s)
  • __ Student work samples and date(s)
  • __ ParentQuestionnaire Form and date
  • __ Art contest(s) results and date(s)

Music(Check and attach at least 3).

  • __ Jot Down for Music and date
  • __ Teacher made test(s) and date(s)
  • __ ParentQuestionnaire Form and date
  • __ Student musical performance(s) / contest(s) (vocal or instrumental) and date(s)

Dance(Check and attach at least 3).

  • __ Jot Down for Dance and date
  • __ Teacher made test(s) and date(s)
  • __ ParentQuestionnaire Form and date
  • __ Student dance performance(s)/ contest(s) and date(s)

Drama(Check and attach at least 3).

  • __ Jot Down for Drama and date
  • __ Teacher made test(s) and date(s)
  • __ ParentQuestionnaire Form and date
  • __ Student drama performance(s) / Drama/acting contest(s) and/or talent show(s) and date(s)

Please return to Gifted and Talented Box in the teacher workroom as soon as possible.

Date submitted: