Vermilion Local School District

Vermilion Elementary School

1285 Douglas Street

Vermilion, OH 44089

Title I Multi-Criteria Student Selection Form for Kindergarten

Student:                                Teacher: 

Date of Assignment:  

CRITERION 1 – Standardized Test

Name of Test:  

Score:   Administration Date:  

CRITERION 2 – Teacher Referral

Completed by: (Classroom Teacher)   Date:  

Check the box beside an item if the student exhibits the behavior listed, but only if the child exhibits the behavior all or most of the time. Then count the total number of boxes checked and input that number at the bottom of the form.

• 1. Uses language to communicate ideas, feelings, questions or to solve problems.
• 2. Uses language to pretend or create.
• 3. Responds to questions.
• 4. Follows directions.
• 5. Shows interest in books.
• 6. Uses picture cues and/or context cues to construct meaning from text (e.g. when being read to).
• 7. Exhibits book-handling skills (e.g. knows how to hold a book and understands the direction of print).
• 8. Reads environmental print (e.g. cereal boxes, logos, signs).
• 9. Responds to texts (e.g. talks about books, laughs, makes predictions, intones, questions or compares.
• 10. Identifies letters in the alphabet (e.g. recognizes letter name).
• 11. Recognizes that there is a relationship between letters and sound (e.g. recognizes the sound of a letter or gives a word that starts with a letter).
• 12. Recognizes that written spellings represent spoken words.
• 13. “Reads” simple books (e.g. easy, beginning books, or predictable books).
• 14. Scribbles with intended meaning.
• 15. Uses some letters in writing (e.g. letters from own name).
• 16. Uses letter-sound correspondence to write (i.e. invented spelling).
• 17. Shares writing with others (e.g. tells others about the intended meaning in drawings and writing).
• 18. Recognizes first name in print.

  Total (Boxes Checked) + 0.00 Test Score  = 0.00 Selection Score