STUDENT/PARENT/TEACHER - alexandria.k12.mn.us
Grade 5 Title/At Risk Qualification Form
(Teachers, use this form to gather parent permission/signature required for Title/At Risk Services)
School: School Year: ID #
Student: Grade: 5
Parent/Guardian:
Classroom Teacher: Title I/At Risk Teacher:
Current School Year – Grade 5
|Math (qualify w/2 or more no’s) |Reading (qualify w/1 or more no’s) |
|Yes |No |Skill |Yes |No |Skill |
| | |AVMR FNWS Level 5: | | |F & P Text Level (below target) |
| | |Can produce the forward number word sequence from 1 to 100 | | | |
| | |Can produce the number words just after a given number word in the range of 1 to 100 without | | | |
| | |dropping back | | | |
| | |AVMR BNWS Level 5: | | |Reading STAR below 40th percentile|
| | |Can produce the backward number word sequence from 100 to 1 | | | |
| | |Can produce the number words just before a given number word in the range of 100 to 1 without | | | |
| | |dropping back | | | |
| | |AVMR NID Level 4: | | |Reading MCA (does not meet or |
| | |Can identify six digit numerals | | |partially meets standard) |
| | |AVMR Structuring No. Level 5: | | |Reading OLPA (below cut score) |
| | |Can combine and partition numbers in the range of 1 to 20 without counting | | | |
| | |AVMR Add/Sub Construct Level 5: | | | |
| | |Use a range of non-count-by-one strategies to add and subtract | | | |
| | |AVMR Mult/Div Construct 4: | | | |
| | |Uses multiplicative counting to count composite units in repeated addition and subtraction | | | |
| | |Can use the composite unit a specified number of times without visible markers for the groups or| | | |
| | |the individual items | | | |
| | |AVMR Place Value Construct 4: | | | |
| | |Treats tens and ones as conceptual structures that are available in the absence of materials | | | |
| | |Can choose from a range of mental strategies to efficiently solve two-digit addition and | | | |
| | |subtraction tasks | | | |
| | |Math MCA (does not meet or partially meets standard) | | | |
| | |Math OLPA (below cut score) | | | |
Based on the checklist above, your child qualifies for Title/At Risk assistance in: Reading Math
Please sign and return this form if you agree to assistance for your child.
__________________________ __________ _________________________ __________
Parent Signature Date Classroom Teacher Signature Date
(place in student cum folder once signed)
To Qualify for Next School Year – Grade 6 Complete form below
|Math (qualify w/2 or more no’s) |Reading (qualify w/1 or more no’s) |
|Yes |No |Skill |Yes |No |Skill |
| | |AVMR FNWS Level 5 | | |Reading MCA (D or P) |
| | |AVMR BNWS Level 5 | | |Reading STAR below 40th percentile |
| | |AVMR NID Level 5 | | | |
| | |AVMR Structuring No. Level 5 | | | |
| | |AVMR Add/Sub Construct Level 5 | | | |
| | |AVMR Mult/Div Construct 5 | | | |
| | |AVMR Place Value Construct 5 | | | |
| | |Math MCA (D or P) | | | |
Based on the checklist above, your child qualifies for Grade 6 Title/At Risk assistance in: Reading Math
Please sign and return this form if you agree to assistance for your child.
___________________________ __________ _________________________ __________
Parent Signature Date Classroom Teacher Signature Date
................
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