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Gifted Application Form Intellectual by klEiJ9G

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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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