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(CS-2)
Newport News Public Schools
To be completed by
REFERRAL TO CHILD STUDY COMMITTEE – GRADES 6-12
referring source
Student
DOB
Student ID#
School
Grade
Referred by
Relationship to student
Reason for referral (To be completed by referral source):
GRADES: circle: MP1 MP2 MP3 MP4 F
SOL SCORES:
Most recent
Subject
Grade
Subject
Grade
Area Assessed
Score
Area Assessed
Score
Does the student have a 504 Plan?
Has the student ever received Special Ed Services?
If checked, enter date and disability:
AREAS OF STRENGTH: (Check all that apply)
Academic performance: Reading
DORA Scores:
Academic performance: Math
Academic performance: Written Expression
IReady Scores:
Academic performance: Other
Social Skills
Verbal Expression
Voyager Scores:
Work/Study Skills
Positive Attitude
Attention/Concentration
Attendance
DOMA Scores:
Following Directions
Leadership Skills
Other: (describe)
Other:
OTHER ASSESSMENT SCORES: (Indicate date and scores)
AREAS OF CONCERN: (Check areas of most concern)
ACADEMIC PERFORMANCE
BEHAVIOR (if checked, attach discipline record)
Reading
Attention/Distractibility
Work/Study skills
Math
Activity Level
Non-compliance
Written Expression
Impulsivity
Disruptive
Other:
Other:
Description of Weakness:
Description of Weakness:
EMOTIONAL/SOCIAL
OTHER
Relationship with teachers
Relationship with peers
Attendance if checked:
(#Absences) as of
(date)
Easily frustrated
Withdrawn
Speech/Communication
Atypicality
Emotional self-control
Health
Home/Family
Other:
Other:
Description of Weakness:
Description of Weakness:
Dates of parent conference (Attach parent contact log/conference forms)
Dates:
Student Intervention Plan (CS-1) (Check that it is attached
)
Discipline Record (must be attached if Behavior is an area of concern
)
Signature of Referring Source
Date
NNPS Revised 8/2013
24
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