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DOCUMENTATION OF "O" (Other) SCORE CODE
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NOTE: ALWAYS contact Blake or Amy in the Assessment Dept. before marking the score code as “O”. This form must be completed for every instance in which a score code of “O” (Other) is submitted. Submit this documentation to the Assessment Dept. when you return your materials. If the reason(s) for the student’s test being scored as “Other” is related to discipline/code of conduct, the “Locally Determined Disciplinary Action” document must also be completed. Retain a copy of this completed document at the testing campus for five years
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Use blue or black ink pens ONLY
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Date:​Campus:
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Campus Coordinators:
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Test Administration:​
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Test Administrator:
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Monitor:
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Student Name:
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Student TSDS ID #:
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Test Booklet #:
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Reason for “Other” Score Code: Check one and complete the Description of Circumstances section below.
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Description of circumstances resulting in the Score Code of "Other":
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Parent notified – include date/method of notification and person contacting (No parent notification required for LEP Postponement, Foreign Exchange Student Waiver, or HSEP):​
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Principal Signagure (Required)Campus Coordinator(s) Signature(s) (Required)
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