RTI/SST Additional Form
Rev. 10/11
Stafford County Public Schools - Department of Student Services
31 Stafford Avenue, Stafford, Virginia 22554
(540) 658-6500 FAX (540) 658-6042
ENGLISH AS A SECOND LANGUAGE (ESL)
ADDITIONAL DATA WORKSHEET
STUDENT :
DATE:
LAST
FIRST
/
/
MIDDLE
STUDENT IDENTIFICATION NUMBER:
D. O. B.:
SCHOOL:
GRADE:
/
/
Place of birth
Date of entry to the U.S.
Number of years of formal education in native country
Number of years in U.S. schools
Has the student returned to his/her (or parents’) native country for a significant period of time?
What was the first language spoken by the student?
What languages are spoken or understood by the student?
How long has the student spoken English?
What language(s) are spoken in the home?
Parents’ primary language(s)
Does the parent need an interpreter in order to communicate?
What ESL services or assistance have been provided?
Do the results of evaluation by the ESL teacher indicate lack of expected progress in the English language for the student’s
chronological age level? If not, explain.
What is the student’s current proficiency level in English?
______________________________________________________________________
Signature of Classroom Teacher
Date
______________________________________________________________________
Signature of ESL Teacher
Date
Please attach this form to the referral form.
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