Student: ____________________________________ Date of Birth________________

Classroom Teacher: _________________ Grade____ Title I Teacher: ______________

Parent/Guardian: ___________________________ Phone: _______________________

Address: ________________________________________________________________

FOR OFFICE USE ONLY

Student Eligibility and Selection (Points/Referral) :______________________________

Parent/Guardian Consent (Date): ___________________

Assessment Data

DRA

Spring Date: __________ Stage ________ Level _______ Accuracy______

Notes:__________________________________________________________________

DIBELS

Fall Date: ________ LNF_______ PSF _______ NWF ________ ORF _________

Notes: __________________________________________________________________

Winter Date: _______ LNF_______ PSF _______ NWF ________ ORF _________

Notes: __________________________________________________________________

Spring Date: ________ LNF_______ PSF _______ NWF ______ ORF _________

Notes: __________________________________________________________________

DOLCH WORD ASSESSMENT

Fall Date: _________ Gr. 1 Total # of Words ____/36 Total % _______

Gr. 2 Total # of Words ____/220 Total % _______

Spring Date: _________ Gr. 1 Total # of Words ____/220 Total % _______

Gr. 2 Total # of Words ____/220 Total % _______

Title I Parent Advisory Meeting (Date): _________ Attended by Parent/Guardian Y/N

Progress Reports: January ________ June ________

Parent Conference Dates : _____________________________

_____________________________