C. ELEMENTARY SCHOOL Enrollment Academics Attendance & Social/Emotional Special Education & Other Services School Year: Grade: School: District: School Type: Enter Date: Exit Date: Grades Subject: T1/T2/T2 CST Testing ELA: Math: CMA Testing: ELA: Math: CAASPP Testing: ELA: Math: CELDT Overall Level: Noted Academic Concerns/ Interventions: Attendance Mental Health/Attention/Behavior/Discipline SST Date: Concerns: Intervention Plan: 504 Plan Date: Disability: Intervention Plan: ERH Consent? Assessment Date: CA: CG: Summary of Results: Recommendation(s): IEP Date: Eligibility: Relevant Placement & Services: ERH Consent? Sample (Grade 2 only) School Year: 05-06 Grade: 2 School: Moss Elementary District Hills Unified SD School Type: Comprehensive School Enter Date: Beg. of Year Exit Date: 3/12/06 Grades Subject: T1/T2/T3 Reading: 2/3/_ Writing: 2/2/_ Math: 3/2/_ Listening: 2/2/_ Speaking: 3/3/_ Social Science: 2/3/_ Science: 4/4/_ CST Testing ELA: Basic Math: Proficient CELDT Overall Level: Intermediate Noted Academic Concerns/ Interventions: Teacher Note on T1 report card: Practice decoding. Attendance Days Absent: 4 Tardies: 2 Attendance Band: >95% Mental Health/Attention/Behavior/Discipline 2/3/06: Children’s Bureau Diagnosis of ADHD None School: Wise Elementary District: XYZ Unified SD School Type: Comprehensive School Enter Date: 3/15/06 Exit Date: End of Year Grades Subject: S1/S2 Scale: O=Outstanding, S=Satisfactory, NI=Needs Improvement Reading Decoding: _/NI Reading Comprehension: _/NI Writing: _/ S Math Fluency: _/ S CELDT: None (ELL status gone) Noted Academic Concerns/ Interventions: Report Card notes referral for retention due to reading skills. Attendance Days Absent: 0 Tardies: 3 Attendance Band: >95% None Elementary School Specific Notes & Instructions:
III. Needed Interventions And Outcome-Tracking For YY/YY Current Status Needed Interventions Outcomes Education Rights Holder Unable to identify ERH No contact information for current ERH Attempts to contact ERH unsuccessful (specify and methods of contact): ERH not available to meaningfully participate in student’s education (specify): ERH no longer has relationship with student (specify): Other (specify): No Concern Contact the youth’s social worker and/or legal representative to obtain up-to-date ERH contact information. Send ERH Appointment Request Letter to CSW. Contact the court directly to express concern about ERH appropriateness. Current ERH identified and contacted (provide name/phone number): New ERH appointed, court documentation received, and ERH contacted (provide name/phone number): ERH not appointed, district surrogate appointed (provide name and phone number): Other (specify): School of Origin Enrolled in current school within last 15 months because of a home placement change Home placement change imminent No concern Discuss youth’s school of origin rights with ERH and current caregiver Identify school of origin options, including transportation funding availability Discuss pros and cons of options Identify ERH decision Remained in/returned to school of origin Transferred to new school per ERH decision Academics Earning poor grades Scored below average on state or district testing Other signs of academic delays (specify): No concern Refer for after county office of education tutoring Refer for school based tutoring Refer for SST for Special Education Assessment. Conduct 30-day IEP meeting. Refer for on campus after school “Bridge to Tomorrow” tutoring provided by local agency. Grades improved Test scores improved Other (specify): Attendance