School Board of St. Lucie County
Request for Reevaluation for Additional Programs
Please address all items on this form. If item is not appropriate, please indicate this with N/A. Do not leave any item blank. Space has
been provided for your observations/comments.
DEMOGRAPHICS
Student Name
Other ID
DOB
Ethnicity
Gender
Grade/School
Parent/Guardian Name:
Address (Street, City, Zip)
Homeroom Teacher
Reading Teacher
Math Teacher
ASSESSMENT DATA
BENCHMARK
Please attach F.A.I.R. Student Score Detail Box
Pretest
1st Qtr
2nd Qtr
4th Qtr
Reading
Math
Science
Writing
SRI – Read 180 students only
Window 1
Window 2
Window 3
FCAT – SSS
Grade
Level
Level
Level
Level
STANFORD-10
3
Total Reading
Total Math
4
5
Score Score -
6
7
8
9
10
11
Percentile Percentile -
Based on the attached data and IEP objectives, what has been the response to instruction and intervention?
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Based on the specialized instruction that is being provided, what is the consensus of the team regarding the need
for an additional program?
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Recommendation of IEP team.
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Team Members Present:
1. _____________________________________________________ Title __________________________________
2. _____________________________________________________ Title __________________________________
3. _____________________________________________________ Title __________________________________
4. _____________________________________________________ Title __________________________________
5. _____________________________________________________ Title __________________________________
6. _____________________________________________________ Title __________________________________
7. _____________________________________________________ Title __________________________________
8. _____________________________________________________ Title __________________________________
9. _____________________________________________________ Title __________________________________
Rev. 3/10
STS0133