Prince William County Public Schools Special Education Department

CHILD STUDY COMMITTEE DELIBERATIONS

Student DOB School Grade Date of referral to Child Study Committee Meeting Date Reason for referral to Child Study Committee

Referral Source

CHILD STUDY COMMITTEE (must consist of at least 3 persons) 1. Administrator or designee (required) 2. Teacher(s) 3. Specialist(s) 4. Parent(s) 5. Other(s) / Referring source (unless confidentiality would be broken) ______

SUMMARY OF CHILD STUDY COMMITTEE DELIBERATIONS Minutes to include:  Additional information not included in referral  Delivery of instruction in the classroom  Role of parents (include parent input within each section when provided) READING – Discuss the nature of reading instruction in the classroom and amount of direct instruction.

WRITTEN EXPRESSION – Discuss the nature of writing instruction in the classroom and amount of direct instruction.

MATHEMATICS - Discuss the nature of math instruction in the classroom and amount of direct instruction.

Form 10-6 RV 11/04 Student’s Name: ______

CHILD STUDY COMMITTEE DELIBERATIONS - CONTINUED MOTOR SKILLS –

WORK HABITS AND ORGANIZATION -

SPEECH/LANGUAGE/FLUENCY/VOICE-

SOCIAL/EMOTIONAL & BEHAVIOR

ENVIRONMENTAL FACTORS -

OTHER CONCERNS –

STUDENT HISTORY  History of poor grades (cumulative records attached) ______ History of health concerns ______ Attendance concerns ______Current year  yes  no History of poor attendance  yes  no Excessive tardiness  yes  no Give # of days absent if greater than 15______Has a truancy referral been initiated  yes  no  Multiple school changes ______ Retentions ______ Previously received Special Education  yes  no If yes, what service?______

 Language(s) spoken in home ______Form 10-7