Assessment Data/Special Factors
(This form can generate more than one printed page)
Name
IEP Date
Level
Score
CA Standards Tests
ELA
Math
Science
History
Writing
(The following items no longer appear on Form 3b, and do not print. They are listed for archival reference.)
CAT-6
ELA
Mathematics
Other
Other
CMA
ELA
Mathematics
Science
History
Writing
CAPA
ELA
Mathematics
Science
Other
CELDT
Listening
Speaking
Reading
Writing
Other Assessment Data
(e.g., curriculum assessment, other district assessment)
Does student require assistive technology devices and/or services?
Yes
No
Yes
No
If yes, specify:
Does student require low incidence services, equipment and/or materials to meet educational goals?
Yes
No
Yes
No
If yes, specify:
Considerations if the student is blind or visually impaired
Student not visually impaired
Considerations if the student is deaf or hard of hearing
Student not hearing impaired
If the child is an English Learner, consider the language needs of the child as those needs relate to the IEP
Does student's behavior impede learning of self or others?
Yes
No
Yes
No
(If yes, describe)
If yes, specify positive behavior interventions, strategies, and supports
Behavior Goals
Behavior Support Plan (BSP) attached
Behavior Intervention Plan (BIP) attached
Areas of need to be addressed in goals for the student to receive educational benefit