Aurora Charter School

Empowerment Committee

Empowerment Committee
PROBLEM IDENTIFICATION
SCREENING SUMMARY

Student: _____________________________________ Form Completed Date: _______________

BACKGROUND DATA
HEALTH INFORMATION
Vision & Hearing Screening
Results:

PREVIOUS SCHOOLS/SERVICES
Pre-Referral Interventions Dates: __________
Title 1 Dates: __________
SPED Eval / Services Dates: __________________
Previous Schools Attended/Dates: ________________

Vision: ____________
Hearing:____________
ADHD
Asthma
Other Diagnosis:
________________
ATTENDANCE
# Days Absent Last Year: _____
# Days Absent Current Year:
________
Other Concerns:

Retained Dates: __________

Home Schooled Dates: __________
Other
GRADES

MATH
ABOVE
MEETS
BELOW
Other Concerns:

READING

WRITING

WIDA W-APT SCORES

DATE

OVERALL

LISTENING

SPEAKING

READING

WRITING

CBM SCORES
DATE:

MCA SCORES
DATE

READING

MATH

PROBLEM IDENTIFICATION SUMMARY

Team Met to Review these Data on:
_____________

Prioritized Area of Concern:

_____________________

Problem Statement:
___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________
Team Member Responsible for FollowUp:_____________________________________________________________