CHARLES COUNTY BOARD OF EDUCATION



CHARLES COUNTY BOARD OF EDUCATION

EDUCATIONAL HISTORY

Date of Initial Screening Meeting:

Student: Grade: Referring Teacher: ___________________

I. Previous Schools Attended and Attendance History

Attendance

School Year Grade School Name Days Absent / Days Present

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II. Performance Data Summary:

A. Grades in which retained (if any):___________________________________________________________

B. MSA Scores: _____________ ______________

Reading Math

HSA Scores: ______________ ______________ _____________

English Algebra Biology

Quarterlies: Q1______________ Q2:_________________ Q3:_______________ Q4:______________

Performance Series: _______________ ______________

Reading Math

C. High School credits earned: __________________________________________________________________

SE13-3 (1/12)

D. List significant grades or trends (Is there evidence that a problem has existed over a period of time? Note behavioral patterns as well as academic.)

|YR |GR |R |LA |

| | | | |

| |Special Education | | |

| |Speech/Language | | |

| |OT | | |

| |PT | | |

| |Hearing | | |

| |Vision | | |

| |504 Plan | | |

SE12-3 (1/12)

IV. Other Information:

A. Social/Behavioral

1. Is there a discipline file on the student?

Yes No

If yes, explain the nature of these referrals:________________________________________________________

2. Is the student receiving counseling?

Yes No

B. Has the student been referred to the PPW?

Yes No

Explain the nature of these referrals:

C. Is there a psychological evaluation on file at the school?

Yes No

D. Are there any additional reports or evaluations by an individual or agency?

Yes No

Does the school have copies of this information?

Yes No

If yes, what is the nature of the report?

______________________

Name of person completing report Date

SE13-3 (1/12)

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