ELL RTI Multi-Source Data Organizer

Student Information
Name: Godwin
Date of Birth:
Age: 15-10 Grade: 10
School
Native Language: Vietnamese
Race/ethnicity: Vietnamese / Respondent Information
Name:
Date:
Position:
School:
Reason for Referral (be specific):
ELL staff reports concerns about Godwin’s withdrawn and socially isolated behavior, unwillingness to communicate with adults and peers and a preoccupation with guns and knives (as evidenced through drawings). Academic concerns include difficulty with reading basic material and in written language.
Does the student’s rate and manner of learning English differ from peers of similar background? If yes, explain how.
Yes,
Initial Hypothesis
H.1. Godwin is progressing at a rate comparable to other ELL peers with similar language proficiency in L1 and L2 and immigration history and educational background.
(NOTE: The first hypothesis should be to assume that there is nothing wrong with the child, but rather in the system. In other words, assume the null hypothesis until data supports a different hypothesis.)
I. Family Information
Name of Interviewer:
Information Gathered From:
How was the information gathered:
XFace to face
£  Telephone
XInterpreter used
Name of parents
Who does the student currently live with? Parents
Who else lives in the home? A preschool-aged brother and a pre-school aged sister.
What language is primarily spoken in the home? Vietnamese
Where were the parents born? Vietnam
If they immigrated here, when and under what circumstances? As refugees of the Vietnam War
How many years of schooling did the mother have?
How many years of schooling did the father have? Is literate in Vietnamese, was an officer in the Vietnamese army and was a POW
Who is the primary caregiver of the student? Mother
What language is typically spoken by the parents? Vietnamese
In the home? Vietnamese
In the community? Vietnamese
At work? Vietnamese
What are the normal kinds of activities do the parents share with the student? Eating, watching TV
What is the occupation of the father? Appliance repairman
What is the occupation of the mother? Homemaker
Does the family have extended family in the community? Yes
Is the family involved in a church or community organization? They have a Vietnamese-speaking case worker through Community Mental Health after a referral for Godwin in the 8th grade for some reported gang-type activities.
What do you think are your student’s strengths? Artistic, interested in history
Do you have any concerns about your student’s progress at school? Concerns with reading and written language, he is not as far behind in math
Do you have any other kinds of concerns about your student? His preoccupation with guns and violence as evidenced through his drawings and in his journals
Does the family qualify for the free and reduced lunch program?
Yes
II. Health and Early Development
Name of Interviewer:
Information Gathered from: Parents and Godwin
Were there any complications during pregnancy or at birth?
No prenatal care. Was under much stress throughout pregnancy due to the war.
At what age did the student learn to walk? Mother reported delays in all developmental milestones. He walked at approximately 3 yrs. Of age. He did not speak until he was almost four.
At what age was the student potty trained?
Does the student have any health problem?
Do you have any concerns with the student’s hearing or vision? (The school nurse should do a screening during the pre-referral process)
Has the student had any serious illnesses, accidents, or surgeries? Godwin and his family lived in a refugee camp for three years where they witnessed much violence. Godwin was fearful during the entire time.
In comparison to other students that you know or siblings, did the student learn to do things (sit, walk, eat solid foods, talk, etc.,) at the same age as the other students? NO
III. Language History
Name of Interviewer:
Information Gathered from: Godwin, parents, and interpreter
What language did the student first speak?: Vietnamese
At what age did the student first speak? Almost four years old.
What language(s) does the student hear in the home? Mostly Vietnamese, some English on TV.
Do the parents have any concerns about the student’s language development:
In L1? YES
In L2? Parents cannot evaluate progress in English. Teachers report he is progressing fine in oral English (although he is only at a conversational level of English after being in the country for more than five years).
If so, specify: Interpreter reports that Godwin’s oral Vietnamese is not typical of his region. To ascertain whether this was a learned speech pattern, she interviewed the parents and found their speech typical of the reason. They expressed their concern of Godwin’s Vietnamese.
Does the student understand directions and respond to questions at home?
Does the student ever struggle to get words out or repeat sounds?
Does the student ever say things that do not make sense? Sometimes his oral English is hard to understand because of unusual phrasing.
Can the student talk about complex or abstract ideas appropriate for their age? No
If the student switches back and forth between languages (code-switching), does it make sense? He does not do much code switching.
Can the student follow several directions in a row?
Did anyone in the family have trouble learning to speak? Yes, younger siblings
IV. Student’s Language Use
Name of Interviewer:
Information Gathered from:

Activity

/ Native Language / English / Both
Playing with friends at home / NA
Playing with friends at school / X
Watching TV / X
Listening to the radio / X
Using the computer / X
Reading books or magazines / X
Playing sports / NA
Playing cards or games / X
At church, temple, or mosque / X
At a restaurant / X
Listening to music / X
Going shopping / X
Other community activities / X
V. Educational History
Name of Interviewer:
Information Gathered From:
Updated Language Proficiency Scores in L1 and L2 (no more than 6 months):
How old was the student when she/he first attended school? Moved to U.S. at 9 with no previous formal schooling.
Did the student attend a formal preschool (private, Head Start, etc.)? No. Lived in a refugee camp.
Circle below each age that the student was in school outside of the United States.
3 4 5 6 7 8 9 10 11 12 13 14 15
16 17 18
Circle below each age that the student was in school in the United States.
3 4 5 6 7 8 9 10 11 12 13 14 15
16 17 18
Did the student learn to read in the native language? Yes/No (circle one) NO
Was the school in the native country: Rural/Urban (circle one) No School
Was the school in the native country: Private/Public (circle one)
Was the student ever held back a grade or level? Yes/No (circle one)
List any kind of difficulties the student has experienced in school? Language, fitting in.
How long has the student been in the current school? Two years.
Have all the student’s educational records been obtained from previous schools? Yes. Attended 5 – 6 grade in Los Angeles Unified School District.
List grade across the top

Name of school
Number of days attended school / Attendance has been good
Language of instruction for literacy / Gr. 5, some Vietnamese instruction
Language of instruction for math
ESL Services and type (e.g., pull-out) / Yes / Yes / Yes / Yes / Yes / Yes
List any other special services
After reviewing records, list any other significant information
Eng. Language Prof. Score / Grade 10 – LAS 4
Native Language Prof. Score
Achievement
Scores/Name of Test
Report card comments
Any other significant information
Are there examples of current classroom work in reading, writing and math as well as a comparison to the work of a like peer (similar cultural, linguistic and immigration background)?

Attach separate page if needed for educational history.

VI. Previous Interventions
List the specific interventions that have been implemented in the past, the duration, and the outcome.
Preferral meetings have been held annually but teams have always decided against formal referral due to his second language status and wanting to give him adequate time to acquire English.
Typical interventions have been provided (preferential seating, peer tutor, individualized help) as well as referral to Community Mental Health to deal with adjustment issues. None of the interventions have assisted his academic or social progress.
VII. Interventions to be Implemented
Date of Pre-Ref.
Meeting #1 / Specific
Concern/
Subject / Inter-
vention
Goal 1 / Inter-
vention
Goal 2 / Type of
Instruction
(1:1, small
group, etc.) / Baseline
Test
Date / Post-
Test
Date / Outcome
Date of Pre-Ref. Meeting #2
Post-Intervention Hypothesis
Date of Follow-up Meeting:
Team Members:
Key Decision One
If the team feels that after implementing appropriate interventions and monitoring progress, that the problems may not be the result of cultural, linguistic, economic, or environmental issues, then revise the hypothesis and begin to look more closely at the student by
_____ Planning and implementing more pre-referral interventions OR
_XXXX Refer for formal psychoeducational evaluation and formulate new hypothesis
H.2.
Godwin may have an intrinsic disorder causing difficulties in his acquisition of academic English and basic skills.
Does the above data support a suspicion of a disability? YES. After considering developmental milestones, experiential background, progress in language acquisition and academic skills, even though Godwin has had interrupted formal education, it appears that his difficulties maybe caused by something other than his cultural and linguistic differences and there may be an intrinsic disorder.
If yes, proceed to Section VIII – Next Steps
List team members making the decision:
VIII. Next Steps
Key Decision 2
Can traditional evaluation procedures be used or does the team need to adapt procedures given the student’s background?
Evaluation Hypothesis
H3 Godwin may have an intrinsic disorder negatively impacting his academic achievement and language acquisition.
Determine the language(s) of assessment? (Remember, while the student may seem orally fluent in English, unless the student has scored within the high intermediate fluency or advanced fluency range, we may be missing valuable information and severely underestimating a student’s ability with an English-only or nonverbal-only cognitive assessment.)
Identify domains for assessment:
Cognitive, all academic areas
Language(s) for cognitive assessment: English as there are no Vietnamese assessments available. An interpreter will be used throughout the assessment process.
Language(s) for academic assessment (unless the student has had formal instruction in L1, there is no need to assess in L1; in other words, the language of academic assessment should match the language of formal instruction):
English with an interpreter available
Language(s) for communication (not language proficiency) assessment: English with an interpreter available
Language(s) for other assessments (list specific assessment areas):
Who are the professionals that will complete the assessments?
What assessment instruments will be used? Are they appropriate to use with an ELL student?
Will an interpreter/translator be used in the assessment process? It yes, have they received training?
Yes. They have received training on interpreting during the standardized assessment process.
List the name of the ESL specialist who will gather previous language proficiency scores (no more than 6 months old) or administer new proficiency tests in both L1 and L2?

1

Julie Esparza Brown ELL Pre-referral Multi-Source Data Organizer

Revised 4/06