Student Information

	Items denoted with a red asterisk * are required.

1.	Homeroom Teacher*
	First Name   M.   Last Name

2.	Student's Name*
	First Name   M.   Last Name

3.	Student's Grade in 2012-2013*
	3rd Grade    4th Grade    5th Grade

4.	Gender*
	Gender* Male Female

5.	Race *
	Race * White Black Hispanic, Latino, or Spanish Culture in Origin American Indian Asian (including students from India) Pacific Islander

6.	Has this student ever repeated a grade?*
	Has this student ever repeated a grade?* Yes No

7.	If yes, what grade(s)? Please check all that apply.
	Kindergarten    1st Grade    2st Grade    3st Grade    4st Grade    5st Grade

8.	Language Case 21 Projected Scale Score:Administered March 2013 (Located in Assessment Results - 3rd Column)

9.	Math Case 21 Projected Scale Score:Administered March 2013 (Located in Assessment Results-3rd Column)

10.	Multiplication Fact Test Grade*

11.	Does student have an IEP?*
	Does student have an IEP?* Yes No

12.	If yes, what is his/her ruling?

13.	Does this student go to speech?*
	Does this student go to speech?* Yes No

14.	Does this student go to Quest?*
	Does this student go to Quest?* Yes No

15.	Is this student currenlty eligible for limited English services (LEP)?*
	Is this student currenlty eligible for limited English services (LEP)?* Yes No

16.	s this student currently receiving Tier 2 services? *
	s this student currently receiving Tier 2 services? * Yes No

17.	Is this student currently receiving Tier 3 services? *
	Is this student currently receiving Tier 3 services? * Yes No

18.	Behavior Concerns:

19.	Additional Comments: