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Form 210-20Tier III Program PlanRoadways to ReadingBox 700, Rosetown, Sask., S0L 2V0Phone: (306) 882-2677 Fax: (306) 882-3366Toll Free: 1(866) 375-2677, sunwestsd.caReferenceAP 210 Services for Students with Diverse NeedsRevisedOctober 16, 2017LevelDivisionSubmit toStudent Support Services ConsultantWhenAs RequiredSchool YearStudent NameBirth Date(mm/dd/yyyy)School NameAttendance in Program (days attended/days offered)TeacherEntrance Date (mm/dd/yyyy)Exit Date (mm/dd/yyyy)Psychological AssessmentYesNoSpeech-Language AssessmentYesNoOccupational Therapist AssessmentYesNoDiagnosed Condition(If yes, please specify in space provided below)YesNoAssessmentSCORESEntranceOct/MarchNov/AprilDec/MayExitDRA (Independent Level/ Running Record)Dolch Sight Words/220/220/220/220/220/518/518/518/518/518Words Their WayTotal FP/Total FP/Total FP/Total FP/Total FP/Total Words Correct/Total Words Correct/Total Words Correct/Total Words Correct/Total Words Correct/Kindergarten Screener (PA)/30/30/30/30/30Phonological Awareness Screening Test (PAST) Correct/52Correct/52Correct/52Correct/52Correct/52Automatic/52Automatic/52Automatic/52Automatic/52Automatic/52Quick Phonics Screener/242/242/242/242/242Phonics Q /75/75/75/75/75Jerry Johns (Instructional Level)Read Live (Instructional Level)Student Support Teacher’s SignatureDate ................
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