PP-781 CAREERASSESSMENT 6.07 ROANOKE COUNTY PUBLIC SCHOOLS 5937 COVE ROAD ROANOKE, VA 24019 (540)562-3900
CAREER ASSESSMENT PERMISSION SHEET
Date: ___________ Student’s Name: Date of Birth: School: ___________ Case Manager: _____________________________ _____________________________ _____________________________
Participation:
_______
Please Initial the ONE that applies:
I DO want my child to participate in a career assessment provided by Roanoke County Public Schools. I DO NOT want my child to participate in a career assessment.
_______
Transportation:
Please Initial the ONE that applies:
It may be necessary for the career assessment to be completed in a different school, then the student’s home school, so a Roanoke County Public School bus will be used. _______ I DO grant permission for my child to be transported to and from the student’s home school to the career assessment lab located within another Roanoke County Public School. I DO NOT grant permission for my child to be transported to and from the student’s home school to the career assessment lab located within another Roanoke County Public School. I WILL provide the transportation personally to and from the student’s home school to the career assessment lab located within another Roanoke County Public School. I will be notified of the time and date of the assessment. I GIVE my permission for my child to transport himself/herself to and from the student’s home school to the career assessment lab located within another Roanoke County Public School.
_______
_______
_______
Parent Signature:
____________________________
Date:
____________
PP-781 CAREERASSESSMENT 6.07
CAREER ASSESSMENT REFERRAL INFORMATION SHEET
INFORMATION for the Case Manager: MAKE SURE ALL QUESTIONS ON BOTH SIDES HAVE BEEN COMPLETED AND PERMISSION PAGE IS SIGNED!!!!!!! REFERRAL SHEET COMPLETED BY: ______________________________ PLEASE USE INK AND PRINT LEGIBLY!! NAME: __________________________________________________________DOB:_____/_____/_____ (FIRST) (MIDDLE) (LAST) DATE: ___________
Student ID # ______________
SEX: M
F
AGE: _____
SCHOOL: ________
GRADE: _______
PARENT/GUARDIAN:_________________________________________ PHONE:________________ (FIRST & LAST NAMES OF PARENTS LIVING AT SAME ADDRESS) (HOME) SPECIAL EDUCATION SERVICES: Disability: _____________________ Related Services:________________ CURRENTLY ON MEDICATION? YES NO LIST MEDICATIONS:___________________________________________________________________ WEARS GLASSES/CONTACTS? YES NO Wheelchair Special transportation needs Seizures ADD/ADHD Advanced Studies Modified Standard PSYCHOLOGICAL TEST RESULTS
DATE:_________ TEST: __________________ VIQ: ________ PIQ: ________ FSIQ: ________
% served: ______
SPECIAL CONSIDERATIONS OR NEEDS?
YES YES YES YES Standard Special Curriculum
NO NO NO NO
PURSUING TYPE OF DIPLOMA: (Circle One)
STANDARDIZED TEST RESULTS
DATE:_________ TEST: __________________ Subject Areas: READING: MATHEMATICS Scores: %ile or ___________ ___________ SS
PP-781 CAREERASSESSMENT 6.07
EDUCATIONAL EVALUATION NARRATIVE INFORMATION: (PLEASE check all that apply)
A. STUDENT HAS DIFFICULTY:
_____ None Applicable
_________ starting assigned tasks _________ completing assigned tasks _________ shifting attention to new tasks _________ seeing written work on the chalkboard _________ finding his/her way around the building _________ laborious handwriting _________ low frustration tolerance _________ impulsiveness _________ poor care of materials _________ poor personal appearance _________ temper outbursts _________ create classroom problem _________ fluctuate w/ intellectual functioning daily _________ ask that instructions be repeated _________ be confused with multiple step directions _________ be unable to report what he/she has read _________ require extra help from the teachers _________ misinterpret simple words and sentences
B.
STUDENT EXHIBITS:
_____ None Applicable
C. STUDENT IS LIKELY TO: _____ None Applicable
D. INSTRUCTIONAL STRENGTHS AND WEAKNESSES:
STRENGTH __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
SKILL AREAS
Reading Comprehension Verbal Expression Written Expression Mathematical Computation Time Management/Work Pace Organizational Skills Following Written Instructions Following Verbal Instructions Motivation Retention of Information School Attendance Peer Relationships Relationships w/ Authority Figures Attention to Tasks
WEAKNESS ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________
In the following space, please list any additional comments that have not already been covered on this referral that you feel are important. .
Thank you for taking the time to complete this referral