Sunset Elementary

LCMT Support Request

Name: __________________________ Age: _________ Grade: ____________

Teacher: _________________________

Active IEP? Yes No

Parent Notified of LCMT referral on __________________________________ (date)

Method of Notification: ____________________________

Primary Language of Student: _______________________ Primary Language in Home: _____________________

Specific Area(s) of Concern:

Reading Mathematics Language

Phonemic Awareness Number Sense Specify:

Phonics Computation _________________

Fluency Application _________________

Vocabulary Other

Comprehension

Other

Written Expression Behavioral Speech

Conventions Specify: Specify:

Organization __________________ _________________

Content __________________ _________________

Other Information:
Has this student ever received special education? Yes No If yes, when____________________

Has this student ever been retained? Yes No If yes, when____________________

Date of vision screening: __________________ Pass Fail Action________________________

Date of hearing screening: _________________ Pass Fail Action________________________

Attendance: Problem No Problem Comments: ________________________________

Health: Problem No Problem Comments: ________________________________

Attendance History:
Number of Absences
Number of Tardis
Number of Late Check Ins
Number of Early Outs

DIBELS Benchmarks:

WPM Accuracy Retell Retell Quality DAZE

BOY
MOY
EOY

Test History – CRT/SAGE/RISE Proficiency Scores:

Test 2017-2018 2016-2017 2015-2016

CRT/SAGE/RISE ELA
CRT/SAGE/RISE Math
SAGE/RISE Science

DIBELS Progress Monitoring:

Date
PM Grade Level
WPM
Date
PM Grade Level
WPM

Common Assessments/Data to Gather

Reading Writing Math Behavior Other

CORE Phonics Writing Samples Fluency Data Interventions you Encore Intervention
have started Data
DIBELS I-Ready Report Any anecdotal Student Attendance
evidence History
DAZE TTM Report Information from Hearing/Vision
parents
CRT/SAGE/RISE CRT/SAGE/RISE Classroom
Observations
SRI
Any Class comparison data showing student compared to others in class.

Teacher Signature: _____________________________ Date: _______________________

Admin. Signature: ______________________________ Date: _______________________

Date to Attend LCMT: ___________________________ Date: _______________________

 LCMT Checklist
LCMT Support Request Form:

Talked to parent

Vision/ hearing screening

Summary of interventions

Ongoing record of at least 2 interventions across a minimum of 3 weeks:

Include grade level of the intervention

What the intervention is

How it was implemented

The level of success of each intervention

Comparison samples to average student

Test scores and what skill was tested

DIBELS

Math Drilldown

Referral and At-Risk Form

LCMT Checklist
LCMT Support Request Form:

Talked to parent

Vision/ hearing screening

Summary of interventions

Ongoing record of at least 2 interventions across a minimum of 3 weeks:

Include grade level of the intervention

What the intervention is

How it was implemented

The level of success of each intervention

Comparison samples to average student

Test scores and what skill was tested

DIBELS

Math Drilldown

Referral and At-Risk Form