Interviewer / School Year
Date of Registration / Projected Start Date

STUDENT INFORMATION

Student Name
Last / First / Middle
Student ID / Person ID / School / Grade
Current Address / Zip Code
Date of Birth / Age / Certificate # / Gender / M / F
Month/day/year
Country of Birth / Country of Origin

Hispanic/Latino yes no

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Race/Ethnicity Determination: Parent identified Student Identified Observer Determined Unknown

Residency Status / Date of Entry into the United States
“A” Number or Visa Classification

Immigrant Refugee Migrant U.S. Citizen

Language most frequently spoken:

at home / by child at home

Language Spoken:

first by child / by parent to child

List below information on brothers, sisters, and others under 18 years of age living at home

Last Name/First Name / Gender / DOB Mo/Day/Yr / Attending what school?

PARENT GUARDIAN INFORMATION

Name of Father/Guardian
Last / First / Country of Birth
Home Phone / Work Phone / Cell Phone
Name of Mother/Guardian
Last / First / Country of Birth
Home Phone / Work Phone / Cell Phone
Name of Other Contact / Phone
Last / First
Relationship/Agency of Contact
School/Home communication to parent requested in / English / Other Language
Name / Student ID#
Last / First

ACADEMIC HISTORY

Years in (K-12) / First Entry K-12 US School
Retained in grade (s)
Currently repeating grade / JCPS K-12 Entry
Last grade completed
Limited or No Formal Education / Yes No
School Attended / City, State / Country / School Year / Grade / Age / Language of Instruction

Has student received or been referred for special education? Yes No

Are there any concerns about your child’s health or has your child had personal experiences that might have an impact on school performance? Yes No

Remarks:

Transcripts/grades from previous schools

Transcripts/grades not available

Revised 08/24/10

Name / Test Date
Last / First / Month /Day/Year
Student ID #

W-APT FOR ENGLISH LANGUAGE LEARNER (ELL) PLACEMENT

Speaking and Listening Domains: Grade K through Grade 1, 1st Semester

Student’s Listening and Speaking Score / Listening and Speaking Raw Score Range / Oral Proficiency Category
0 – 10 / Limited English Proficient – Low
11 – 18 / Limited English Proficient – Mid
19 – 28 / Limited English Proficient – High
29 – 30 / Orally English Proficient

Reading and Writing Domains: Grade K, 2nd semester through 1, 1st Semester

Student’s Reading Score / Reading Raw Score Range / Diagnostic Skills Description / Student’s Writing Score / Writing Raw Score Range / Diagnostic Skills Description
0 - 2 / No demonstrable skills / 0 -3 / No demonstrable skills
3 – 5 / Can match simple pictures / 4 – 7 / Can copy letters
6 – 10 / Can recognize letters / 8 – 11 / Can complete simple words w/initial letter
11 – 12 / Can recognize words / 12 -14 / Can write simple words
13 / Can read simple phrases / 15 – 16 / Can write simple phrases
14 -15 / Can read simple sentences / 17 - 18 / Can write simple sentences

Listening, Speaking, Reading, Writing Domains: Grade 1, 2nd Semester through Grade 12

Domains / Student’s Raw Score / Proficiency level 1.0-6.0
Listening
Speaking
Reading
Writing / Not Applicable

W-APT Composite Proficiency Category: Grade 1, 2nd Semester through Grade 12

Student’s Composite Proficiency Level / Composite Proficiency Levels / Proficiency Category
1.0 -1.9 / Limited English Proficient
2.0 – 2.9 / Limited English Proficient
3.0 – 3.9 / Limited English Proficient
4.0 – 4.9 / Limited English Proficient
5.0 – 6.0 / Fully English Proficient

Revised 08/24/10

Name / Student ID #
Last / First

Bilingual/ESL Type

Mark student’s current program model(s)

Parent/Guardian refusal of services1

The student participates full time in mainstream classroom without the support of specially designed

English language development instruction.

Content area tutoring

One-on-one or small group tutoring/assistance to ELLs during school hours in the content areas, including

English/language arts, mathematics, science, and social studies. Tutoring is generally provided by teachers

other than bilingual or ESL teachers and may be provided by an aide under the direction of a teacher.

Content-based ESL

Programs in which English is taught through the content areas of mathematics, English/language arts,

science, and social studies.

Pull-out ESL/Resource

Programs remove ELLs from general education classes to pre-teach, teach, or re-teach English language skills

and/or academic content covered by the general education classroom teacher.

Sheltered English Instruction 2 (Formerly Type 3)

Instruction is in English and adapted to the student’s English proficiency levels and provides modified, curriculum-based content.

Structured English Immersion (push-in)

Programs in which ESL teachers or bilingual instructional aides provide linguistic and academic support to ELLs in the general education classrooms.

Two-way Immersion (Hawthorne Elementary only)

Programs are bilingual programs that serve English proficient speakers and ELLs in the same classroom. Both English and the primary language of the ELL students are used in content and language arts instruction.

1Participation in an ESL program is voluntary. Parents/Guardians have the right to waive ESL services at any time.

2For ESL program students who have not achieved a Composite proficiency level of 5.0 or higher and a Literacy proficiency level of 4.0 or higher on Tier B or C of ACCESS for ELLs, but who have demonstrated academic success and language proficiency in other ways, it may be appropriate to create a schedule without direct ESL support. For a Sheltered English Instruction student, indicate the criteria used in making that determination and provide a brief description (test results, numeric GPA, etc.) in the spaces below.

ACCESS
GPA/Academic Progress
District Assessment
Teacher Recommendations
KCCT
Other

Revised 08/24/10

Name / Student ID #
Last / First

Instructional Accommodations

To support the student’s progress in attaining English language proficiency and meeting academic content standards, the checked instructional accommodations, listed below, will be provided on a routine basis:

Original PSP (Current Year) / Amended PSP
Month/Day/Year
Read Text In English / Oral Native Language Support / Bilingual or English glossary
Scribe Responses / Read Text in Primary Language / Simplified Language
Bilingual or English Dictionary / Extended Time / Assistive Technology
Prompting/Cueing / Small Group/Single Test form Admin. / Adapt Pace of Instruction
Provide Visuals/Organizers / Provide Adapted Materials/Technology / Use Computer/Software
Use Spellcheck / Link Instruction to Prior Learning / Provide Language Objectives
Provide Content Objectives / Build Background Knowledge / Model Language/Task Completion
Engage in Academic Conversations / Scaffold Responses (oral/written) / Provide Interaction Opportunities
Teach and Model Meta-Cognitive

Assessment Accommodations

Reader in English / Reader in Primary Language / Scribe Responses
Simplified Language / Oral Native Language Support / Bilingual or English Glossary
Bilingual or English Dictionary / Extended Time / Prompting/Cueing
Small Group/Single Test Form Admin. / Assistive Technology

EXPECTED RATE OF TRANSITION

With regular school attendance and parental support, it is anticipated that the student will transition to full participation in classrooms that are not tailored for students with limited English proficiency in years

Signatures of Program Services Plan Committee Members

Date
Principal (required)
Date
Date
Date

Revised 08/24/10

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