Appendix D(1)

STUDENT ACCOMMODATION TEAM REFERRAL PLAN

(STUDENT AT RISK)

School District of Fort Atkinson

MEETING DATE:  _______________           REFERRING INDIVIDUAL:__________________________

                                                                         DATE OF REFERRAL:______________________________

STUDENT’S NAME: _____________________ ID NO.______________ BIRTHDATE: _____________

SEX:   Male    Female       SCHOOL: ______________________________     GRADE:________________

PARENT/GUARDIAN NAME: ____________________________________________________________

ADDRESS: ____________________________________________________________________________

TELEPHONE NUMBER: (HOME) ______________________            (WORK)_____________________

I.                                DESCRIBE THE NATURE OF THE CONCERN:

II.                             DESCRIBE THE MODIFICATIONS YOU HAVE ATTEMPTED TO DEAL WITH THESE CONCERNS.

Appendix D(2)

III.                           EVALUATION FINDINGS (to be completed at the Student at Risk staffing).

IV.                          DETERMINATION OF ELIGIBILITY CRITERIA FOR CHILD AT RISK (grades 5-12):

Check all identification guidelines which apply to this student.

_____ One or more years behind their age group or grade level in the number of credits earned

                                 or

                  _____ Two or more years behind their age group or grade level in ___Reading or ___ Math

                  And at least one of these:

                  _____ Dropout (ceased to attend for 20 or more days)

                  _____ Parent

                  _____ Adjudicated delinquent

                  _____ A habitual truant per Wisconsin truancy laws (“Habitual Truant” is a student who is

                              absent from school without an acceptable excuse for part or all of 5 or more school days

                              during a school semester).

DISPOSITION OF CASE:

_____        Met State Child At Risk Guidelines (Complete Section V)

_____        Did not meet State Child At Risk Guidelines (Complete Section V)

Appendix D(3)

V.                             RECOMMENDATIONS:

VI.                          PARTICIPANTS: (must be a group of persons knowledgeable about the child and the results of

the evaluation data).

_________________________________                      __________________________________

__________________________________                   __________________________________

__________________________________                   ­­­­­­­­­­­­­­­­­­­­­ __________________________________

Signature of Student at Risk Coordinator:______________________________________________________

Date of next review: ______________________________________________________________________