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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