<p> CHILD STUDY COMMITTEE DELIBERATIONS</p><p>Student DOB School Grade Date of referral to Child Study Committee Meeting Date Reason for referral to Child Study Committee</p><p>Referral Source</p><p>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) ______</p><p>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.</p><p>WRITTEN EXPRESSION – Discuss the nature of writing instruction in the classroom and amount of direct instruction.</p><p>MATHEMATICS - Discuss the nature of math instruction in the classroom and amount of direct instruction.</p><p>Form 10-6 RV 11/04 Student’s Name: ______</p><p>CHILD STUDY COMMITTEE DELIBERATIONS - CONTINUED MOTOR SKILLS – </p><p>WORK HABITS AND ORGANIZATION -</p><p>SPEECH/LANGUAGE/FLUENCY/VOICE-</p><p>SOCIAL/EMOTIONAL & BEHAVIOR</p><p>ENVIRONMENTAL FACTORS -</p><p>OTHER CONCERNS – </p><p>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?______</p><p> Language(s) spoken in home ______Form 10-7</p>