Attachment 1: ESI-R Datasheet and Roster SY15-16 [Optional Form for use by teachers and schools to facilitate requesting booklets from OEC and data reporting]
School/Center / Teacher
Last Name / Child
Last Name / Child
First Name / Date of Birth
MM/DD/YY / New 4: NPS PreK 14-15?
Y or N / New 4: If yes, list previous school / All 4s: Bklt needed:
P or K / GOLD
HLSS
#.# / ESI-R admin:
E or S / Date 1st Screen:
MM/DD/YY / RndAge
#.## / Sc
ore
## / OK
X / RS
X / RF
X / Date
Rescreen:
MM/DD/YY / RndAge
#.## / Sc
ore
## / OK
X / RS
X / RF
X
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Codes: Rnd Age — Rounded Age # — Enter Numerals RS — Rescreen RF — Refer P — ESI-P K — ESI-K E — English S — Spanish
To calculate Rounded Age, see ESI-R manual or online at (cut/paste): www.pearsonassessments.com/hai/images/agecalculator/agecalculator.htm
Optional Instructions: [This form is provided for the convenience of schools teachers to order booklets from OEC, and to collect provide ESI-R results for Power School entry.]
1) Teacher completes Datasheet portion. Teacher enters (estimated) Date of Screen, calculates Rounded Age, and enters Rounded Age in Roster portion.
2) Teacher enters GOLD Home Language Survey Score, determines if screening will be in Spanish (see separate chart), enters code E or S. (All except Spanish receive English)
3) School staff member counts number & type of booklets needed (P or K, in English or Spanish), picks booklets up at OEC designated location, delivers booklets to teachers.
4) Teacher administers & scores ESI-R, completes remainder of the Roster, and provides this form to their school’s Power School data entry staff member according to dates indicated on ESI-R Timeline ESI-R SY15-16 Attachment 1—Datasheet and Roster DRAFT 2015-07-30