------------------------------------- For GE folder---------------School Year_________________________

Student Name _________________________________________Grade______ Tchr______________

Referred by: Parent____ Educator____ Self ____ Other (specify)_____
Parent Permission for evaluation:

Date Received ______________

Teacher rating scale (present): Date received ___________ total ____

Teacher rating scale (past): Date received ___________ total ____
Teacher narrative date received: __________
Average of 2 tchr rating scales_____
Student/ 3DUHQW

%_____

narrative date received: __________

Parent rating scale: Date sent ____________

Date received ___________ total ____ %____

Student rating scale: Date sent ___________

Date received ___________ total ____ %____

D. Martinez
Assessment Conducted by __________________________
Date ___________________
Name of Assessment ______________________ Perentile Results _________________________
Name of Assessment ______________________ Percentile Results _________________________
7HUUD1RYDYR________7RWDOBBBBB5GJBBBBBB/$BBBBBB0DWKBBBBBB6FLBBBBBB66BBBBBBB
Terra Nova YR _______ Total_____ Rdg______LA______Math______Sci______SS_______
Terra Nova YR _______ Total_____ Rdg______LA______Math______Sci______SS_______
Other forms of assessment (i.e. CogAT, etc.)

SAGES date of assessment____________ level _____ M/Sci ______ LA/SS_______ R_______

65,'DWH BBBBBBBBBBBBBBBBBB/H[LOHBBBBBBBBBBBB3HUFHQWLOHBBBBBBBBBBB
SRI Date __________________ Lexile ____________ Percentile___________
SRI Date __________________ Lexile ____________ Percentile___________
SRI Date __________________ Lexile ____________ Percentile___________
SRI Date __________________ Lexile ____________ Percentile___________
SRI Date __________________ Lexile ____________ Percentile___________
SRI Date __________________ Lexile ____________ Percentile____________
SRI Date __________________ Lexile ____________ Percentile____________

Review committee meeting date: ____________

In attendance/input given:________________________________________________________________
______________________________________________________________________________________
Committee review rating scale (1-4) Obs____ Int ____ Perf____ Acc____ Acad ____ Port ____
Student Status E _____ M______ I _______
Services (minimum of two):
______A: Additional Opportunities
______D: Grade Acceleration in Content Area
______E: Grade Acceleration
______F: Individualized Services
______H: Resource Class (Pull-out program)
______I: Regular Class with Cluster Group
______J: Regular Class with Content Acceleration
______K: Regular Class With Differentiation
Parents/Guardians Notified by letter or e-mail sent on: _________________
Parent permission for services date received ______________________
Comments:_______________________________________________________________