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Student Placement Form

Summarizes a student's reading level, math progress, and individual needs to guide the right classroom or grade placement.

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Placement Sheet for Next School Year

Kindergarten 1st Grade 2nd Grade 3rd Grade

Name

Teacher

Gender

Male Female

Reading Assessment

Small Group Phonics Skill or 2nd and 3rd Grade Approximate DRA Level

Highest Past Assessment Level - Accurate and Automatic

Has the student reached all benchmark levels in DIBELS as of the last progress check?

Yes No

If not, which ones?

Did this student receive reading intervention at any point in the school year?

Yes No

Addition

Strength Adequate Needs Improvement

Subtraction

Strength Adequate Needs Improvement

Place Value

Strength Adequate Needs Improvement

Measurement/Data

Strength Adequate Needs Improvement

Solving Word Problems

Strength Adequate Needs Improvement

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

Yes, receiving special services

Referral in Process

Yes, a referral is in process

Previous Referral

Yes, there was a previous referral

Separate From

Student Strengths

Student Struggles

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