Review Committee Documentation Form for Grades 3, 5, and 8 - Warren County Schools

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Warren County Schools
Review Committee Documentation Form
Grades 3, 5, and 8
School______________________________ Student____________________________ Grade________
Principal______________________________ Teacher_______________________________________
Special Area (Complete if applicable)
Limited English Proficient
Previous Promotional Waiver
English Proficiency Level –
Approved(date)_________________
Listening_________ Speaking_________
Reading__________ Writing__________
Exceptional Children(Specify Exceptionality)
Academically Intellectually Gifted
Level of Services:
Area:
Language Arts____
Math____ Written Lang_____
Regular______ Resource______ Self-Contained____
Other:______________________________________
___________________________________________
504: Yes____ No____
Number of Previous Retentions:
None____ One____ Two____ Three ____
_____________________________________________
Grades:___________________________
Reason for
Review__________________________________________________________________________
Subject
EOG Scores
EOG Scores
EOG Scores
EOG Scores
Gr___
Gr___
Gr___
Gr___
Regular
Retest
Regular
Retest
Regular
Retest
Regular
Retest
Math Scale Score
/Achievement Level
Reading Scale Score
/Achievement Level
Science Scale Score
/Achievement Level
Subject
Benchmark 1
Benchmark II
Benchmark III
Benchmark IV
Math Percentage
Reading Percentage
Science
Performance Criteria: Final Grade Averages: Language Arts/Reading__________ Math__________
Additional Assessment Data Reviews: (Examples: Accelerated Reader, Star Reader and Math, K-2 Assessment, ClassScape,
Dibbles, teacher-made assessments)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
WCS Testing Department
Review Committee Documentation
ATS-102, page 1
08/27/10
Warren County Schools
Review Committee Documentation Form
Grades 3, 5, and 8
School______________________________ Student____________________________ Grade________
Principal______________________________ Teacher_______________________________________
Special Area (Complete if applicable)
Limited English Proficient
Previous Promotional Waiver
English Proficiency Level –
Approved(date)_________________
Listening_________ Speaking_________
Reading__________ Writing__________
Exceptional Children(Specify Exceptionality)
Academically Intellectually Gifted
Level of Services:
Area:
Language Arts____
Math____ Written Lang_____
Regular______ Resource______ Self-Contained____
Other:______________________________________
___________________________________________
504: Yes____ No____
Number of Previous Retentions:
None____ One____ Two____ Three ____
_____________________________________________
Grades:___________________________
Reason for
Review__________________________________________________________________________
Subject
EOG Scores
EOG Scores
EOG Scores
EOG Scores
Gr___
Gr___
Gr___
Gr___
Regular
Retest
Regular
Retest
Regular
Retest
Regular
Retest
Math Scale Score
/Achievement Level
Reading Scale Score
/Achievement Level
Science Scale Score
/Achievement Level
Subject
Benchmark 1
Benchmark II
Benchmark III
Benchmark IV
Math Percentage
Reading Percentage
Science
Performance Criteria: Final Grade Averages: Language Arts/Reading__________ Math__________
Additional Assessment Data Reviews: (Examples: Accelerated Reader, Star Reader and Math, K-2 Assessment, ClassScape,
Dibbles, teacher-made assessments)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
WCS Testing Department
Review Committee Documentation
ATS-102, page 1
08/27/10
Classroom Participation: A written teacher summary of student performance in the classroom, which
should include cooperative learning participation, projects, extra effort, remediation efforts, homework,
and growth made during the school year should be included.
Items to be included in Student Portfolio:
Reading
Mathematics
Writing samples (represent 2 of the following modes: narrative
Writing samples depicting problem solving strategies (2)
(personal or imaginative), argumentative, clarification, persuasive,
Responses from 2 teacher made tests depicting different math
point-of-view)
strands
Responses from 2 teacher made tests depicting usage of reading
Responses from 2 commercially-made tests (Benchmark Tests, etc.)
strategies, reading selection tests, etc.
Responses from 2 commercial-made tests (Benchmark Tests, etc.)
Exceptional Children
Limited English Proficiency
Written statements from the exceptional children’s and regular
Written statements from the ESL teacher and classroom teachers
education teachers that address student’s current progress
that address the progress the student has made during the academic
year
Student’s current IEP & EC placement folder information
Work samples demonstrating progress in all academic areas
Recommendations on waiver from the IEP committee
Any additional measures demonstrating student achievement
All Students
Students Report Card – copy should be included in the cumulative
folder
Include any other information which would document student
performance and support granting the wavier.
Attendance:
__________________________________
__________________________________
__________________________________
Teacher’s Signature/Date
Parent’s Signature/Date
Principal’s Signature/Date
Committee Member’s Recommendation:
Date:___________________________________________________
To Promote_________ to grade__________
To Retain__________ in grade__________
Committee Signatures:
Principal:____________________________________________________________________________
Teacher of Current GradeLevel:__________________________________________________________
Teacher of Receiving Grade Level:_______________________________________________________
Central Office Representative:___________________________________________________________
EC Representative:____________________________________________________________________
LEP
Representative:_______________________________________________________________________
Parent:______________________________________________________________________________
WCS Testing Department
Review Committee Documentation
ATS-102, page 2
08/27/10

Download Review Committee Documentation Form for Grades 3, 5, and 8 - Warren County Schools

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