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Assessment/Evaluation

Medical Statement fillable form

Medical Statement 

Test Manual/ Test Kit Request

When requesting a test manual or kit to be checked out fill out this request form and submit it to Cindy Laureano. Test kits cannot be ponied, but must be picked up at the BESC in L2.

Word Document (Read Only): This form can be filled out by hand and either scanned and attached via email or sent via the PONY.

Writable PDF

Screening Forms

Screening Permission Form (English)

Screening Permission (Spanish)

Screening Permission (Somali)

Screening Permission (Vietnamese)

Screening Permission (Russian)

Screening Permission (Chinese)

Screening Results Form (English)

Screening Results (Spanish)

Screening Results (Somali)

Screening Results (Vietnamese)

Screening Results (Russian)

Screening Results (Chinese)

Evaluation Calendar

60 Day School Calendar (updated 3/1/19)

Corrective Action Form 

The Corrective Action Form (CAF) is used when an initial evaluation goes over 60 school days. If an initial evaluation goes over 60 school days the case manager needs to submit the completed form to the records clerk. You do not need to submit a CAF if you have completed the written agreement to extend the timeline for a Specific Learning Disabilty eligibility evaluation.

Corrective Action Form (CAF) 

Written Agreement Table

Written Agreement Table 

Kaufman Test of Educaional Achievement, Third Edition (KTEA-3)

 Academic Evaluation Report Templates (Modifiable Word documents):

 Academic Report - SLD  (Word)

  Academic Report - SLD (Google Doc)

 Academic Report - Not SLD  (Word)

 Academic Report - Not SLD (Google Doc)

 Academic Report - No KTEA  (Word)

 Academic Report - No KTEA (Google Doc)

 KTEA Training document

 KTEA-3 Training Updated 9/2018 

Progress Monitoring for Specific Learning Disability