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LOS ANGELES UNIFIED SCHOOL DISTRICT GIFTED/TALENTED PROGRAMS REF-5228.1 ATTACHMENT A November 5, 2010 APPLICATION FOR IDENTIFICATION AS GIFTED IN THE INTELLECTUAL ABILITY CATEGORY Org. Code Dist. Type or print legibly. STUDENT IDENTIFICATION NUMBER Special Education English Language Development Eligibility: Copy of IEP or 504 Plan ELD Level:_ Classification: RFEP IFEP EO I. Last Name First Name M.I. Sex Grade Birth Date Ethnicity School Track Student Language: Home Language: Parent/Guardian Name Work Phone: Home Phone: Current Street Address (Must be a residential address within LAUSD) City Zip Code II. REFERRAL Print Name & Title: Signature: III. SCREENING All items must be completed; see reverse side. Previous GATE assessment? Yes No If yes, complete below: Result: Year: School: Category: PROTOCOL STUDENT ACADEMIC PERFORMANCE DATA: Under Grades column, report as follows: CST Elementary—report grades from 2nd & 3rd reporting period under Achievement (4/4) CAT/6 Secondary—report grade point average of 1st & 2nd semester (3.5 GPA; 3.0 Honors or AP) APRENDA-3 CST—California Standards Test, N/PR—National Percentile Rank on the CAT/6 or APRENDA-3. Report two previous consecutive years of scores and grades; must submit supporting documentation for all reported scores and grades. Other English-Language Arts YEAR GRADE English/Reading/EL Mathematics Science (Secondary) Social Science (Secondary) CST Grades N/PR CST Grades N/PR CST Grades N/PR CST Grades N/PR IV. SCREENING COMMITTEE REPORT (A member should have understanding of candidate’s economic, linguistic, and cultural background.) Verification of excellence. (Checklist on reverse side must be completed.) Recommended; obtain parent consent. Not recommended; discontinue screening. A minimum of three committee member signatures required. Signature of Teacher (required): Date: Signature of Administrator or Designee (required): Date: Signature of committee member (required; include title): Date: Signature of committee member (include title): Date: ------------------------FOR DISTRICT OFFICE USE ONLY. DO NOT WRITE BELOW THIS LINE. ------------------------ V. PSYCHOLOGIST’S COMMENTS: Signature: Print Name: Date: VI. DISTRICT DETERMINATION OF ELIGIBILITY [ ] Eligible in the Intellectual Ability Category as: [ ] Gifted [ ] Highly Gifted [ ] Not eligible for participation. COMMENTS: _________________________________________ ______________________________ ____________ Signature of District Gifted/Talented Staff Member Print Title Date Please type or print in black ink. Duplicate this form (double-sided) before obtaining signatures. LOS ANGELES UNIFIED SCHOOL DISTRICT GIFTED/TALENTED PROGRAMS ATTACHMENT A -2- REF-5228.1 November 5, 2010 TEACHER QUESTIONNAIRE FORM A. CHECKLIST FOR IDENTIFICATION AS GIFTED/TALENTED. This is a list of characteristics frequently found in students identified as gifted or talented, including students from diverse backgrounds. The checklist will be used as part of the information considered in determining student eligibility to participate in the Gifted/Talented Programs. From your observations of this student, indicate how often each trait applies by checking the appropriate column. 1 2 3 4 5 1) No opportunity to observe 2) Seldom/Never 3) Occasionally 4) Frequently 5) Consistently Strong powers of reasoning, ability to make comparisons and generalizations, and ability to see cause- and-effect relationships. Ability to concentrate, to become totally submerged and absorbed in an assignment, project, or activity. Approaches tasks in different, unusual, and original ways. Ability to use humor to make a point, to change a situation to gain an advantage, to connect diverse knowledge. Displays keen powers of perception and observation that can frequently detect fallacies and inconsistencies. Thinks of and asks questions which involve logical-thinking process. Shows fluency in his/her native language; uses expressive speech and extensive vocabulary. Improvises with commonplace materials and objects. Shows a “street sense” and is recognized by others as a youngster who has the ability to “make it” in the dominant society. Uses body language and gestures expressively; has ability to interpret body language. Displays inner conflicts about academic achievement. Enjoys group activities and problem solving; shows originality. Relates well to peers and is respected by them and is seen as a leader (may lead in negative way). Uses richness of imagery in informal language. Is sensitive and empathetic to the feelings of others but is impatient with illogical, sloppy, or disorganized thinking. Possesses a sense of justice and fairness, intuitively understands why certain behavior is good and another is bad. Is more sensitive to social and moral issues, particularly those in which the student’s sense of reason seems to be violated. Likes flexibility in scheduling and experience: is resistant to routine drill. Demonstrates high-level social skills and leadership qualities. Enjoys competition but also works in cooperation with others. B. TEACHER COMMENTS ARE REQUIRED to verify advanced performance in the required subject areas; must be detailed and individualized: Teacher Checklist and Comments Completed by (print name) Print Title Signature: Date: Please type or print in black ink. Duplicate this form (double-sided) before obtaining signatures.
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