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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