Work Sample Cover Page by vqa11744

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									                                     Work Sample Cover Page


Student:                                          Date of Work Sample:

Standard:

Benchmark:

Application:

Task:

Criteria for success:

Performance (score) on this work sample:

Real-world nature of task:



Age-appropriate materials:



Prompting:
Prompting Key: Level: (Continuous, Frequent, Limited, Independent)
               Type: (Verbal, Gestural, Physical)

Settings and Interactions:




                 Ohio Alternate Assessment for Students With Disabilities Administration Manual
            Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                    1
                        Data Chart: Event Recording Using Tally Format
                                       (Only one data chart per entry)

Student:                                            Standard:

Benchmark:

Application:

Task:

Criteria for success:

Real-world nature of task:



Age-appropriate materials:



Settings and Interactions:



Prompting Key: Level: (Continuous, Frequent, Limited, Independent), Type: (Verbal, Gestural,
Physical)
                                                                    Number of
                                       Tally of        Tally of     Correct            Percent
          Tally of                                                  Response
 Date                                                                                  Correct
                                                                                                                Prompting
          Correct Response             Incorrect       No           Total number of
                                       Response        Response     opportunities to   Response
                                                                    respond




Note: If a section of the data chart above represents instruction/practice and another section represents
assessment, please circle the dates that represent the assessment period. If no distinction is made, all data
on the chart will be reviewed for scoring purposes.

                Ohio Alternate Assessment for Students With Disabilities Administration Manual
           Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                   2
                        Data Chart: Event Recording Using Trial Format
                                      (Only one data chart per entry)

Student:                                           Standard:

Benchmark:

Application:

Task:

Criteria for success:

Real-world nature of task:



Age-appropriate materials:



Settings and Interactions:



Scoring Key: Correct = C, Incorrect = I, No Response = NR
Prompting Key: Level: (Continuous, Frequent, Limited, Independent), Type: (Verbal, Gestural,
Physical)
 Trials   1    2     3     4     5      6    7    8      9   10     Number of        Percent               Prompting
                                                                    Correct          Correct
                                                                    Response         Response
                                                                    Number of
 Date
                                                                    opportunities to
                                                                    respond




 Note: If a section of the data chart above represents instruction/practice and another section represents
assessment, please circle the dates that represent the assessment period. If no distinction is made, all data
                             on the chart will be reviewed for scoring purposes.


                Ohio Alternate Assessment for Students With Disabilities Administration Manual
           Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                   3
                    Data Chart: Event Recording Using a Rate Calculation
                                       (Only one data chart per entry)

Student:                                             Standard:

Benchmark:

Application:

Task:

Criteria for success:

Real-world nature of task:



Age-appropriate materials:



Settings and Interactions:




Prompting Key: Level: (Continuous, Frequent, Limited, Independent), Type: (Verbal, Gestural,
Physical)

                                                                     Number of
               Tally of identified
 Date                                   Start time   Stop time   identified behaviors        Rate         Prompting
                   behaviors
                                                                      Total time




Note: If a section of the data chart above represents instruction/practice and another section represents
assessment, please circle the dates that represent the assessment period. If no distinction is made, all data
on the chart will be reviewed for scoring purposes.



                Ohio Alternate Assessment for Students With Disabilities Administration Manual
           Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                   4
                                        Checklist: Task Analysis

Student:                                             Standard:

Benchmark:

Application:

Task:

Criteria for success:

Real-world nature of task:



Age-appropriate materials:



Settings and Interactions:



Scoring Key: Check (√) boxes when task step is completed correctly
Date:

Task Steps (Each step should relate directly to task. Use as many steps as needed, but at least   Check below
3 steps.)
1

2

3

4

5

6

7

8

Number of Correct Steps

Total Number of Steps

Percent Correct Steps

Prompting:
Prompting Key: Level: (Continuous, Frequent, Limited, Independent),
               Type: (Verbal, Gestural, Physical)




                 Ohio Alternate Assessment for Students With Disabilities Administration Manual
            Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                    5
                                  Captioned Photos Cover Page


Student:                                                   Date of Photos:

Standard:

Benchmark:

Application:

Task:

Criteria for success:

Real-world nature of task:



Age-appropriate materials:



Prompting:
Prompting Key: Level: (Continuous, Frequent, Limited, Independent)
               Type: (Verbal, Gestural, Physical)

Settings and Interactions:



(Attach at least two photos with captions indicating a description of the student’s level of performance on
the task.)




                 Ohio Alternate Assessment for Students With Disabilities Administration Manual
            Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                    6
                                                 Observation

Student:                                                       Date of Observation:

Standard:

Benchmark:

Application:

Task:

Criteria for success:

Real-world nature of task:



Age-appropriate materials:



Setting:

Describe the student’s performance of this task. Please include information regarding his/her interaction
with others (if appropriate) and the level and type of prompting required for success. Impressions or
interpretations during the observation should be differentiated from actual facts.
(Prompting levels are Continuous, Frequent, Limited, Independent. Prompting types are Verbal, Gestural, Physical.)




Signature:                                                     Position:




                 Ohio Alternate Assessment for Students With Disabilities Administration Manual
            Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                    7
                                               Interview

Student:                                                          Date of Interview:

Person interviewed:                                               Position:

Interview conducted by:                                           Position:

Standard:                                          Benchmark:



Application:

Task:

Criteria for success:

Real-world nature of task:



Age-appropriate materials:




1. What was the student asked to do?



2. How successful was the student in performing the task/activity?



3. What level of prompting was required by the student to perform the task/activity?



4. In what setting did the task/activity take place?



5. Who did the student interact with while performing the task/activity?



Other comments:




                 Ohio Alternate Assessment for Students With Disabilities Administration Manual
            Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                    8
                                             Peer Review

Student:                                                          Date of peer review:

Standard:                                          Benchmark:



Application:

Task:

Criteria for success:

Real-world nature of task:



Age-appropriate materials:



 What was the student asked to do?




 How successful was the student in performing the task/activity?




 What kind and how much prompting or help was required by the student?




 In what setting did the task/activity take place?




 Who interacted with the student while performing the task/activity?




 Other comments:




Peer Reviewer’s Signature:




                 Ohio Alternate Assessment for Students With Disabilities Administration Manual
            Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                    9
                                      Video/Audio* Cover Page

Student:                                            Date of Video/Audio:

Standard:

Benchmark:

Application:

Task:

Criteria for success:

Real-world nature of task:



Age-appropriate materials:



Prompting:
Prompting Key:    Level: (Continuous, Frequent, Limited, Independent)
                  Type: (Verbal, Gestural, Physical)

Settings and Interactions:




*Note: Video and audio media can only be accepted in the following formats: VHS tapes, audio cassette
tapes, CDs and DVDs.

(Include video or audio with script indicating a description of the student’s level of performance on the
task.)




                 Ohio Alternate Assessment for Students With Disabilities Administration Manual
            Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                   10
            Student List for Ohio’s Alternate Assessment Administration
           Optional form for planning purposes only—not to be submitted as part of the COE

Year of Assessment:



Student Name                 Grade Check all Subject          Indicate number          Entry Form
                                   Areas that will be         of entries for           # to be used
                                   assessed                   Subject Area             (1-4)
                                                              assessed
                                              ELA Reading         _____                  _____
                                              ELA Writing         _____                  _____
                                              Math                 _____                 _____
                                              Science              _____                 _____
                                              Social Studies       _____                 _____

                                              ELA Reading           _____                _____
                                              ELA Writing           _____                _____
                                              Math                  _____                _____
                                              Science               _____                _____
                                              Social Studies        _____                _____

                                              ELA Reading           _____                _____
                                              ELA Writing           _____                _____
                                              Math                  _____                _____
                                              Science               _____                _____
                                              Social Studies        _____                _____

                                              ELA Reading           _____                _____
                                              ELA Writing           _____                _____
                                              Math                  _____                _____
                                              Science               _____                _____
                                              Social Studies        _____                _____

                                              ELA Reading           _____                _____
                                              ELA Writing           _____                _____
                                              Math                  _____                _____
                                              Science               _____                _____
                                              Social Studies        _____                _____

                                              ELA Reading           _____                _____
                                              ELA Writing           _____                _____
                                              Math                  _____                _____
                                              Science               _____                _____
                                              Social Studies        _____                _____




              Ohio Alternate Assessment for Students With Disabilities Administration Manual
         Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                11
           Master Planner for Ohio’s Alternate Assessment Administration

The Master Planner form is a tool that can aid the educational team in planning for
administration of the Alternate Assessment. It is structured to include critical components that
will guide the educational team in:

• selecting the standard, benchmark, and, if appropriate, the application of standards-based
knowledge and skills;

• brainstorming about the types of evidence to be collected;

• deciding who will be responsible; and

• planning when/where the task will occur.

This form may be utilized to revise and update the team and be flexible in addressing the
individual needs of the child during the administration period. Special thanks to Kathe Shelby,
Director, and Cathy LaForme, Cuyahoga Special Education Regional Resource Center for
permission to use this planning tool.

Please note that this is an optional form for planning purposes only. This form should
not be submitted as part of the COEs.




               Ohio Alternate Assessment for Students With Disabilities Administration Manual
          Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                 12
                               Master Planner for Ohio’s Alternate Assessment Administration
                                  Optional form for planning purposes only--not to be submitted as part of the COEs

Student Name                                                       Subject Area                                            Entry # (circle) 1 2 3 4

Academic Content Standard (Different standard for each entry)

(Select Benchmark for grades 3 – 8 and OGT)

Grade Level               Benchmark Letter

Benchmark                                                                                                                        ____________

Application of the Standard-Based Knowledge/Skill

                          Tasks                                Type of Evidence           Materials           Interaction/Partners      Setting
                     (Different tasks)                          (Different types)      (Age appropriate)              (who)          (when & where)
# 1 What will student do (Real world task) and how well
is student expected to do it? (Criteria)




# 2 What will student do (Real world task) and how well
is student expected to do it? (Criteria)




# 3 Optional What will student do (Real world task)
and how well is student expected to do it? (Criteria)




                                          Ohio Alternate Assessment for Students With Disabilities Administration Manual
                                     Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                                                            13
                  Teacher Checklist for Alternate Assessment COE
             This checklist is for teacher use only. Do not include it in the COE.

Steps for Completion of COE                            Entry       Entry       Entry          Entry
                                                       1:          2:          3:             4:
Standard selected and documented on Entry
sheet
Benchmark selected and documented on Entry
sheet
Application written on Entry Sheet
2 – 3 types of evidence for each standard

  Task One description and type of evidence
   entered on Entry Sheet
 Evidence of Task One includes:
      o Documentation of student
         performance
      o Use of age-appropriate materials
      o Real-world related task
      o Documentation of prompting
      o List of settings and interactions
 Task Two description and type of evidence
   entered on Entry Sheet
 Evidence of Task Two includes:
      o Documentation of student
         performance
      o Use of age-appropriate materials
      o Real-world related task
      o Documentation of prompting
      o List of settings and interactions
Task Three description and type of evidence
entered on Entry Sheet (optional)
 Evidence of Task Three includes:
      o Documentation of student
         performance
      o Use of age-appropriate materials
      o Real-world related task
      o Documentation of prompting
      o List of settings and interactions




             Ohio Alternate Assessment for Students With Disabilities Administration Manual
        Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                               14
           Electronic Forms Available for Ohio’s Alternate Assessments

1. There are electronic versions of the entry forms (pages B-4 to B-7) available for
   download at the Department of Education’s Web site at:

   http://www.ode.state.oh.us/ Follow link to statewide testing, then to ―Alternate
   Assessment.‖

              At this link, follow links to ―online entry form.‖ The online entry form is a
               downloadable Microsoft Word document which allows a user to utilize pull
               down menus, checkboxes, and text fields to type in information for a
               student. Teachers may download this document and ―save as‖ a separate
               document for each student. This online form is designed to ease data
               entry for users.

              To download the online entry form document, place your mouse over the
               link to ―electronic versions of entry forms,‖ right click, and select “Save
               Target As” to save the document to your hard drive.

2. There are Microsoft Word documents containing all of the sample forms on pages B-
   8 to B-21 available for download. These documents are simply provided to give
   teachers a template on which they may base their data collection forms. Teachers
   may download this document and ―save as‖ a separate document for each student.
   These sample data collection forms are not required for use on the Alternate
   Assessment, they are simply provided as a tool or resource for use by teachers.

              To download these sample forms, place your mouse over the link to
               ―electronic versions of sample data collection forms,‖ right click and select
               “Save Target As” to save the document to your hard drive.

3. The complete Alternate Assessment Administration Manual, including Participation
   Guidelines and Appendices with Standards-based Applications can be viewed and
   downloaded at

   http://www.ode.state.oh.us/ follow link to statewide testing, then to ―Alternate
   Assessment‖


4. District IRN information is available at http://www.ode.state.oh.us/data/irn.asp




           Ohio Alternate Assessment for Students With Disabilities Administration Manual
      Downloadable Version of Data Collection and Planning Forms (Microsoft Word Format)
                                             15

								
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