SAC Data Summary Sheet (for Assessors and Schools)
Published 20 October 2015
Student Name:
School:
▼indicates a drop-down menu where one item is to be selected from the choices given.
For Level C Assessors and Psychologists: complete Tab 7 and Tabs 8-11 as needed, and save as a PDF for school application use.
For Schools:
1. Boxes enlarge as you type, and you will be able to copy and paste statements easily onto the SAC Application web pages from your saved electronic
document. You may add to any comments provided by independent Level C assessors or psychologists. Underline or bold items if this finished sheet is
to be printed for student files, as highlighting prints well only in colour.
2. Draft applications online may be saved and edited. Each application must be complete before it can be submitted.
3. Double-check that the student's name, NSN and DOB is correct and the same as their data in your SMS (Student Management System – KAMAR,
MUSAC, etc.) as their identification data must match when an entry file is sent later in Term 1.
4. Read through the User Guide and the Help notes on each online tab for further information. The tabs required to be completed online are:
All applicants: complete Tabs 1, 2, 3, 4.
For Sensory / Medical / Physical disability add Tab 5.
For a Learning disability add Tab 6 (data from School Evidence / Alternative Evidence) or Tab 7 (data from a
Level C / psychologist report), AND the Tabs for the Learning SACs (Reader: Tab 8 and 9. Computer/Writer:
Tab 10 and 11. Extra Time: Tab 6 or 7, plus 9 and 11 if not already completed).
1. Applicant
Academic Year: 201_
NSN:
First name:
Last name:
DOB:
Gender:
Year level:
Transfer from (if applicable): ▼
NZ curriculum level 3 4 5 6 7 8 (not NCEA level) in - English:▼
Maths:▼
(NB: Level 1 NCEA <=> NZC level 6)
Credits achieved already - Internal:
External:
I understand that NZQA may amend applications, or decline late applications.
Yes
No
Submitter's email:
2. SAC
Select Conditions
Sensory
Vision
Hearing
Medical
Physical
Learning
Attention deficit
Autism Spectrum
Depression / Anxiety
Diabetes
Epilepsy
Tourette syndrome
Other
Arm / Hand
Back / Leg
Head injury
DCD (Dyspraxia)
Muscular / Neurological
Cerebral palsy
Pregnancy / Baby care
School Evidence
or
Independent Assessment
Describe the Sensory /Medical /Physical conditions, and their ongoing
impact (1000 char):
SACs Requested (consult the Documentation Requirements for the SACs possible for the various Conditions above)
Vision
Hearing
Other
Braille paper
Enlarged paper
Special paper
Signing supervisor
Signing reader
Reader
Computer OR Writer
Separate Accommodation
Extra Time
Rest Breaks
Any additional requirements or comments (if needed, Rest Beaks must be requested here if Extra Time is ticked above as well)
(1000 char):
3. Documentation
Is the documentation for the application held at the school?
If not, explain why:
Yes
No
4. Trials
The applicant has been using SAC successfully since: ▼now ▼unknown ▼(year/month):
If “Unknown” give reason.
SACs Trialled
Vision
Hearing
Other
None
Braille paper
Enlarged paper
Special paper
Signing supervisor
Signing reader
Reader
Computer
Writer
Separate Accommodation
Extra Time
Rest Breaks
How will the requested SAC remove barriers to achieving NCEA?: (1000char)
5. Reports (Sensory / Medical / Physical only)
Report 1 (select NA if not available)
NA
Report 2 (select NA if not available)
Written by:
Written by:
Qualifications:
Qualifications:
Date:
Date:
Funded through the Ministry of Education (ORS, SHHNF or laptop)?
Yes
NA
No
6. School Evidence
How was the applicant screened? Include tests and results: (1000 char)
Compared to an average student of the same age at the same level, the applicant's (select one for each section)
Oral language is
▼Above average
▼Average
Written language is
Listening
comprehension is
▼Above average
▼Average
▼Below average
▼Below average
▼Above average
Reading comprehension ▼Above average
is
▼Average
▼Average
▼Below average
▼Below average
Current and previous support offered (indicate all that apply)
None
Reading recovery
Private tutoring
Teacher aide time
Speech/language therapy RTLit
Reader
Computer or Writer
Describe the effectiveness of this support:(1000 char)
Describe the applicant’s observed need:(1000 char)
RTLB
Extra Time
7. Independent Assessment
All dates on this screen must be no earlier than January of (the year for which you are applying minus 3)
Assessors may supply all information for the next tabs. Otherwise schools will need to extract relevant data from older reports or forms.
Report written by:
Registered as: ▼Educational psychologist ▼Psychologist ▼NZCER Level C Assessor
Date:
Psychometric Test Battery (indicate all that apply)
WIAT II / III
Woodcock-Johnson III / IV Ach
(Australian Adaption)
WAIS IV
WISC IV / V
Woodcock-Johnson III / IV Cog
SLD number
SLD writing
SLD (indicate all that apply)
SLD reading
Other (specify):
Diagnosed cobormid conditions (e.g. ADHD, ASD) if any:
Compared to an average student of the same age at the same level, the applicant's
Oral language is
▼Above average
▼Average
Written language is
Listening
comprehension is
▼Above average
▼Average
▼Below average
▼Below average
▼Above average
Reading comprehension ▼Above average
is
▼Average
▼Average
▼Below average
Cognitive profile
(select one for each section)
Test (From test battery list above)
▼Below average
Date of testing
Result
Verbal ability
Percentile rank =
Non-verbal ability
Percentile rank =
General cognitive ability
▼FSIQ
▼GIA
(Select one)
▼ Percentile rank =
▼Standard Score =
Processing speed
Percentile rank =
Working memory
Percentile rank =
Is there a statistically significant difference between cognitive and academic performance?
Yes
No
What SACs does this Independent Report recommend?
School to complete if needed: If
you requested different SACs from those recommended, explain why (1000 char):
8. Reading
NB an assessment report may be out of date but data from it may be entered here as information additional to later tests.
Comprehension (at least one)
Date
Result
Assessment report.
Test (specify):
Percentile rank =
PAT (comprehension)
Stanine =▼
YARC
Percentile rank =
DRA
Age =▼
Other (specify):
Score/Description =
Comment on reading comprehension:(1000 char)
Accuracy (at least one)
Date
Result
Assessment report.
Test (specify):
Percentile rank =
PAT (vocabulary)
Stanine =▼
YARC
Percentile rank =
DRA
Age =▼
Other (specify):
Score/Description =
Comment on reading accuracy:(1000 char)
9. Reading Speed
(also required for Extra Time applications)
NB an assessment report may be out of date but data from it may be entered here as information additional to later tests.
Test (complete at least one)
Date
Result
Assessment report.
Test (specify):
Percentile rank =
YARC
Percentile rank =
DRA
Age =▼
Other (specify):
Score/Description =
Comment on reading speed and fluency:(1000 char)
10. Spelling / Expression
NB an assessment report may be out of date but data from it may be entered here as information additional to later tests.
Spelling (complete at least one)
Date
Result
Assessment report.
Test (specify):
Percentile rank =
SAST
Spelling age = ▼
Other (specify):
Score/Description =
Comment on spelling:(1000 char)
Written and Oral Expression
Oral language.
Not Available or Test name:
Date
Result
Percentile rank =
Comment on the quality of written expression with and without a writer, and with and without a
computer:(1000 char)
Comment on any discrepancy between oral and written expression:(1000 char)
11. Writing
(also required for Extra Time applications)
NB an assessment report test (DASH) may be >2 years but data from it may be entered here as information additional to PATOSS.
Test
Administered by
Date
Result
Handwriting PATOSS
words/minute =▼
Typing PATOSS
words/minute =▼
The applicant completes time-bound written language activities -
▼Always
▼Sometimes
▼Never
Comment on handwriting skills (grip, spacing, letter formation, slope, line adherence, size, legibility):(1000
char)
Comment on writing conventions (punctuation, grammar, upper/lower case, sentences, paragraphs):(1000
char)
Upon completing and submitting the application online, upload relevant documents for the applicant:
 the PATOSS for handwriting and for computer (if a Computer/Writer is requested)
 the Psychologist or Level C Assessor’s report (if Tab 7 was completed)
Save as e.g. Jo Smith Writing PATOSS somewhere on your computer. Don't have anything in the title except letters- no
dashes, no punctuation.

Click the applicant’s NSN on the submitted list, go into Documents.

Write “Jo Smith Writing PATOSS” in the Document name box.

Click Browse.

Find the relevant document on your computer.

Click Upload.
When successfully loaded, a line appears e.g. Jo Smith Writing PATOSS submitted by (your name) on (date).
Repeat for other documents if needed.