Form M 5_2013_Final_2 - Texas Education Agency



4686300-279400Required Form (Sample)00Required Form (Sample)Student Success InitiativeGrade Placement Committee Meeting Minutes FORMTEXT [State of Texas Assessments of Academic Readiness (STAAR)/State of Texas Assessments of Academic Readiness (STAAR) Spanish]Second Administration of the FORMTEXT [Grade 5/Grade 8] Mathematics Assessment FORMTEXT [Insert name of school district/campus]Student: FORMTEXT [Insert name]Date of Notice: FORMTEXT [Insert date of notice]Parent/Guardian: FORMTEXT [Insert name]Date of Meeting: FORMTEXT [Insert date of meeting]Address: FORMTEXT [Insert address]Location: FORMTEXT [Insert location]Phone: FORMTEXT [Insert phone #]MembershipMemberName FORMCHECKBOX Principal (or designee) FORMTEXT ????? FORMCHECKBOX Mathematics Teacher FORMTEXT ????? FORMCHECKBOX Parent/Guardian FORMTEXT ????? FORMCHECKBOX Parent/Guardian FORMTEXT ????? FORMCHECKBOX LPAC Representative (if applicable) FORMTEXT ????? FORMCHECKBOX District Designee acting on behalf of student because no parent/guardian could be located FORMTEXT ????? FORMCHECKBOX Other FORMTEXT ?????Purpose/RoleReview assessment and accelerated instruction historyPrescribe required accelerated instructionI. Review Assessment Reports (STAAR Report Card, which includes results for each reporting category and for the assessment overall) FORMTEXT [STAAR/STAAR Spanish] Score Code(scored, absent, other)Significant improvement from the1st administration2nd administration FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoII. Accelerated Instruction Plan (See attached documentation.) FORMTEXT [Insert local options] FORMCHECKBOX Tutorials FORMCHECKBOX Extended School Year (Summer School) FORMCHECKBOX Other FORMTEXT ?????_______________Notes FORMTEXT ?????SignaturesMemberNamePrincipal (or designee)Mathematics TeacherParent/Guardian (circle one)*Parent/Guardian (circle one)*LPAC Representative (if applicable)Other* I acknowledge that if my child changes residence after this meeting, it is my obligation to notify the new school that my child must receive accelerated instruction before the third administration of the FORMTEXT [STAAR/STAAR Spanish] mathematics assessment on FORMTEXT [Insert date]. ................
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