2018-19 Howe Public Schools ELA/Reading/Math Tutoring Referral Form
Complete each question associated with subject area of tutoring. Please include 2018 OSTP test data for students in 3rd-8th & HS (where applicable), current letter grades, and specific reason for tutoring referral.
* Required
Student Name
*
Your answer
Grade
*
Choose
K
1
2
3
4
5
6
7
8
9
10
11
12
Is this student on an IEP?
*
Yes
No
Subject(s) referred:
*
Choose one or both.
Reading/ELA
Math
Required
Reading/ELA OSTP
Please check performance level from Spring 2018 State Assessment if available
Advanced
Proficient
Basic
Below Basic
Math OSTP
Please check proficiency level from Spring 2017 State Assessment if available
Advanced
Proficient
Basic
Below Basic
Current Letter Grade in Reading
Your answer
Please state specific reason(s) for Reading referral.
These comments will be printed on the referral letter to the parent.
Your answer
Current Letter Grade in ELA
Your answer
Please state specific reason(s) for ELA referral.
*
These comments will be printed on the referral letter to the parent.
Your answer
Current Letter Grade in Math
Your answer
Please state specific reason(s) for Math referral.
*
These comments will be printed on the referral letter to the parent.
Your answer
Additional Factors Impacting Academically At-Risk Student (for our records only)
*
attendance/tardies
grade retention
low socioeconomic status
lack of parental involvement
not applicable
Other:
Required
This student would benefit from the following frequency of weekly tutoring:
*
One Day a Week
Two Days a Week
Three Days a Week
Four Days a Week
Required
Your name
*
Your answer
Comments:
(Private comments that will not be shared with parent.)
Your answer
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