Multiple Sources of Data Worksheet

Pre-evaluation data review · Patterns of strengths & weaknesses · Assessment planning

Sarah B Holman · 9-2019
For diagnostician / educational use

Student Identification

Student Name

DOB / Age

Campus

Initial / Re-evaluation

Area(s) of Eligibility

LEP / AT Risk / Other

PEIMS Ethnicity

Grade Level

Evaluator

Date

Background, History & Language

Retention

Never retained

Yrs retained

Grade(s) repeated

Attendance

Days Absent

Days Tardy

Health Information

Language

Home Language:

Dominant Language:

Lang. of Instruction:

OLPT English:

OLPT Spanish:

Family & Parent

Family Hx of Similar Difficulties:

Y N

Parent Strengths:

Parent Concerns:

Other Notes:

STAAR Results

Year	READING					MATH
Year	Grade Tested	Did Not Meet / L I	Approaches	Meets / L II	Masters / L III	Grade Tested	Did Not Meet / L I	Approaches	Meets / L II	Masters / L III
Year 1
Year 2
Year 3

Observation / Interview Notes

Page 2 — Grades & Assessment Data

Report Card Grades

Subject	Teacher 1	Teacher 2
Math
Reading
Writing
Science
Social Studies

Curriculum & Other Assessment Data

Curriculum Assessments	Other Assessments	TELPAS
Math (scores):	Writing assessment:	Composite Rating:
Reading (scores):	Science assessment:	Listening:
DRA Level:	Other:	Speaking:
ISIP:	Other:	Reading:
DMA:	Other:	Writing:

Teacher Information

Teacher Concerns

Area Ratings · 1 = Poor 2 = Below Average 3 = Average 4 = Above Average

1) Basic Reading / Decoding

2) Oral Reading / Fluency

3) Reading Comprehension

4) Math Calculation

5) Math Problem Solving

6) Listening Comprehension

7) Oral Expression

8) Written Expression

Page 3 — RTI / MTSS · Review of Records · Eligibility

RTI / MTSS Intervention Data

Intervention #1

Subject / Program:

Frequency:

Duration:

Results / ROI:

Intervention #2

Subject / Program:

Frequency:

Duration:

Results / ROI:

Eligibility Considerations

Failure to Meet Grade-Level Standards

Fails to meet standards?

Area(s):

RTI outcome suggests:

Working Hypothesis

Diagnostician Notes / Summary

Visual, hearing, or motor disability	YN
Limited English proficiency	YN
Intellectual disability	YN
Emotional disturbance	YN
Cultural difference / economic disadvantage	YN
Inadequate or lack of instruction	YN