Placement Sheet for Future 2020
First
Second
Third
Fourth
Name
Teacher
Gender
BOY
GIRL
Reading:
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Small Group Phonics Skill or 2nd and 3rd grade fill in DRA Level (approximate)
Highest PAST Assessment Level-Accurate and Automatic:
Has the student reached all benchmark levels in DIBELS as of last PM
YES
NO
If not, which ones:
Did this student receive reading intervention at any point in the school year?
YES
NO
Math:
Addition
Below Grade Level
On Grade Level
Above Grade Level
Subtraction
Below Grade Level
On Grade Level
Above Grade Level
Place Value
Below Grade Level
On Grade Level
Above Grade Level
Measurement/ Data
Below Grade Level
On Grade Level
Above Grade Level
Solving Word Problems
Below Grade Level
On Grade Level
Above Grade Level
Additional Area of Concern/ Strength for Math
Health Problems:
Does the child take medication?
Yes
No
If they do take medication, for what?
Diagnosed as having ADHD?
Yes
No
Do they take Medication for ADHD?
Yes
No
Receiving special services
SPED
Speech
GT
ESL
OT
PT
OGC
Referral in process:
SPED
Speech
GT
Previous referral for:
SPED
Speech
GT
Separate From:
Student Strengths:
Student Struggles:
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