St. Lucie Public Schools
Exceptional Student Education (772) 429-4570
Student Eligibility/Summary Checklist
Name:_____________________________ ID#:_______________ Date:____________________
School:____________________________ Grade:_____________ DOB:____________________
Directions: For consideration of Plan B eligibility a minimum full scale score of 115 on an individual IQ test is
required.
Students must score a minimum total of 10 points for eligibility. The Problem Solving/Response to Intervention (PS/RtI)
Team minutes and other relevant documentation should be attached to this form.
AREA
POINTS
Intellectual Assessment:___________________________ Date:________ Score:_______
115-120 = 2 Points; 121-123 = 3 Points; 124-126 = 4 Points; 127-129 = 5 Points
Gifted Checklist
Date:___________
Majority of 4’s = 3 Points; Majority of 3’s = 2 Points; Majority of 2’s = 1 Point
Need for Program
Parent Checklist
Yes = 3 Points; No = 0 Points
Date: ___________________
Majority of 3’s = 2 Points
Achievement Assessment: ______________________________ Date: _____________
3 Points = Stanines 8-9…Standard Scores 118-129+…Percentiles 88-99+…FSA Level 5
2 Points = Stanines 6-7…Standard Scores 104-117…Percentiles 61-87…FSA Level 4
1 Point = Stanines 4-5…Standard Scores 89-103…Percentiles 23-58…FSA Level 3
Grade Point Average
2 Points = Graded 3.5-4.0…….Ungraded: Majority of 4’s and 3’s
1 Point = Graded 3.0-3.4…….Ungraded: Majority of 3’s
0 Points = Graded 2.5-2.9…….Ungraded: Majority of 2’s
TOTAL POINTS EARNED (Minimum of 10 points required for eligibility)
____________________________
does
does not meet eligibility requirements for gifted at this time.
Committee Members Signatures:
___________________________________________ ________________________________________
___________________________________________ ________________________________________
___________________________________________ ________________________________________
XED0108 Rev. 5/16