SCHOOL BUILDING LEVEL COMMITTEE
GIFTED FORMS
St. Landry Parish School Board
Revised by:
August 2016


Checklist for Gifted Evaluations

Student:

School:

Section 1: Referral Information

Two-Page Screening Packet

Copy of Student’s Schedule

Section 2: Screening Data

A. Academic Performance

Copy of Cum. Card (Grade progression and cumulative attendance)

State-wide/District-wide Test Scores (Student and Class Report)

Current Report Card

Behavior Reports/Plans (contents of discipline folder including intervention data)

DIBELS Student History and/or other Universal Screening data

C. Screenings Instruments

Parish SBLC Instrument

Parish Parent Interview Instrument


FOR PAC USE ONLY

Coordinator / Race / Gender / Case #

ST. LANDRY PARISH – PUPIL APPRAISAL CENTER

CHILD IDENTIFICATION

Screening Packet - Page 1

CHILD FIND
STUDENT / / /
First / Middle / Last
PHYSICAL ADDRESS
Street / Highway / City / State / Zip Code
MAILING ADDRESS
(if different)
Street / Highway / P. O. Box / City / State / Zip Code
DOB / AGE / RACE / GENDER
Years Months
District
Number / PRIMARY LANGUAGE
HEAD OF HOUSEHOLD - FATHER MOTHER GRANDPARENT FOSTER OTHER
FATHER
First / Middle / Last
MOTHER
First / Middle / Maiden / Last
GUARDIAN
First / Middle / Last
Home Phone / Work Phone / Emergency Phone
and/or Cell Phone
SCHOOL / TEACHER / GRADE
Referred by / Position / Race / Gender

COMPLETE FOR RE-EVALUATION or WAIVER ONLY:

Exceptionality / Sped. Teacher / Case # / Date of Last Evaluation
REASON FOR REFERRAL: / SPECIFY CONCERNS:
Initial Evaluation
Reevaluation / Mandatory Reevaluation
Results of Manifestation Determination
Declassification
Significant Change of Placement
New Concern
Gifted
Talented
Waiver
Preschool Screening
Court Decision / Due Process Hearing Decision
Other:

*Race: W-White B-Black H-Hispanic AI-American Indian A-Asian Revised August 2016

Screening Packet - Page 2
Student’s Name

¨CURRENT SCREENING RESULTS (Attach all necessary dated forms and documentation)

Area / Date / Normal/
Pass / At Risk/ Failed / No Concern / Date Corrected/Comments
Hearing
Vision
Sensory Processing
Health
Speech/Language
Motor
Assistive Technology
Soc./Emotional/ Behavior
Educational
¨REFERRAL RESULTS (Attach all necessary dated forms and documentation)
RTI Results must include: current scientifically research-based intervention(s) implemented with fidelity and evidenced by data sheets, computer-generated records, or other permanent products; monitoring documentation of the student’s progress relative to peers, at reasonable intervals; and graphed evidence that the student’s rate of progress relative to peers is not adequate. (LA Bulletin 1508, 2009)
Lack of Progress Considerations must include: current data-based documentation that the student’s lack of educational progress is not primarily due to: lack of appropriate, explicit and systematic instruction in reading which includes the essential components of reading instruction: phonics, phonemic awareness, fluency, comprehension, and vocabulary; (e.g., if more than 50% of the class falls below benchmark on universal screening, lack of appropriate instruction might be suspected); lack of appropriate instruction in math (e.g., if more than 50% of the class falls below benchmark on universal screening, lack of appropriate instruction might be suspected); limited English proficiency; environmental or economic disadvantage (e.g., if a majority of low income students in the class fall below benchmark on universal screening, environmental or economic disadvantage as a primary factor might be suspected); or cultural factors (e.g., for students from culturally and linguistically diverse backgrounds, there is evidence that the school and classroom teacher have been sensitive toward the students’ diverse learning needs). (LA Bulletin 1508, 2009)
¨ALL OTHER FORMS AND DOCUMENTATION LISTED ON Mandatory Evaluation CHECKLIST
¨GIFTED AND TALENTED SCREENING (Attach all necessary dated forms and documentation)
Gifted - include: Universal Screening, High Potential Checklist, Standardized Test Scores, etc.
Talented - must include: State Approved Screening Form and Parish Screening Instrument
Notification of SBLC Meeting sent on /

SBLC Meeting Date

/

SBLC Participants’ Signatures Required

/ /

Position

/ /

Race

/ /

Gender

/
/ / / Principal / / / / /
/ / / SBLC Chairperson / / / / /
/ / / PAC Representative / / / / /
/ / / Parent / / / / /
/ / /

Teacher

/ / / / /
/ / /

Teacher

/ / / / /
/ / /

Student

/ / / / /

Revised 2016

SBLC Gifted Screening

Vision (if a concern) / Hearing (if a concern) / Grade Point Average / Standardized Test Scores / Reading Level (DIBELS, etc) / Math Levels and fluency / Other Assessments

TEACHER: Name ______

Characteristics: Check those that apply / Comments or examples
Learns more easily than peers:
ð  Eager to learn
ð  Gives lots of information
ð  Retains/Retrieves information easily
ð  Carries out complex instructions
Shows advanced skills
ð  Reads and comprehends at advanced level
ð  Tells stories with lots of detail
ð  Has a larger vocabulary than peers. Uses descriptive language, etc.
ð  Advanced math skills calculation and reasoning
ð  Challenges the teacher with why, when
Curiosity and Creativity
ð  Quick to question with unusual and provocative questions
ð  Experiments and tries to discover the why and how
ð  Offers unique responses
ð  Active imagination
Strong interests
ð  Loses himself in area of interest
ð  Has unusual or advanced interests
ð  May be considered the “expert” in certain areas of interest
Advanced Reasoning/Problem Solving
ð  Keen observer (spots details other miss)
ð  Recognizes patterns
ð  Draws accurate and advanced conclusions
ð  Makes mental connects across curriculum and life experiences
ð  Sees cause and effect
ð  Good problem solver and question conventional methods (out of the box not rote)
Motivation
ð  Self-starter
ð  Persistent
ð  Independent
ð  Interacts well with adult conversation
ð  Does not follow the typical path
ð  Questions authority
Spatial Abilities
ð  Good sense of direction
ð  Figures out why and how things work
ð  Creates interesting shapes/patterns
ð  Likes to tinker with things (hands on)
Social Perceptiveness
ð  Sense of humor
ð  Good conflict resolution skills
ð  Keen sense of justice
ð  Responds to the needs of others
Leadership
ð  Accepts and carries out responsibilities
ð  Adapts easily to new situations
ð  Manipulates others
ð  Prefers older company

*Adapted from: Ann Harrison, STAGE, 1996. Revised, U-STARS-PLUS, 2004 Harrison, Coleman, Coltrane

Screening participants: Date: ______

______

______

______

Attach all supporting data!!!

INITIAL GIFTED PARENT INTERVIEW

STUDENT: ______PARENT:______

SCHOOL: ______DATE: ______

  1. How is your child doing in school? ______

______

  1. Does your child seem to like school? ______
  2. What are your child’s hobbies/interests/activities? ______

______

______

  1. Please check all that apply to your child in the following chart.

Ö / Characteristic / Comment
Has a good sense of humor
Wants to know how things work and asks many questions (why, when, how, and where)
Uses everyday things to make something new (creative and/or inventive
Has high energy and enthusiasm for learning new things
Becomes bored easily if not challenged
Assumes leadership roles easily
Is adventurous and sometimes acts before thinking
Has a long attention span when interested
Enjoys many different kinds of activities and has a variety of interests
Is a good problem solver

Revised 2016