TARGETED SERVICES

Continual Learning Plan K - 8

To be Completed by Referring Teacher:

Student Name _______________________________________________________ Gender ______ Grade _________
MARSS #_______________________________________ Classroom Teacher _______________________________
School _________________________________________ School YR: _____ - _____ or Summer YR _____________
Current Services the Student is Receiving (Student does not need these for Targeted Services)
(__) Title I - (__) Special Education with IEP in (__) LD (__) EBD (__) ELL - (__) 504 Plan

Current Status/Indicators of Need for Targeted Services Program

Initial Referral: (To be completed by the day-school teacher at the time of initial referral to TS program)
Referral Criteria - Minnesota State GI Student: (To be completed by classroom teacher)

_____ (1) performs substantially below the performance level for pupils of the same age in a
locally determined achievement test;
_____ (2) is behind in satisfactorily completing coursework or obtaining credits for graduation;
_____ (3) is pregnant or is a parent;
_____ (4) has been assessed as chemically dependent;
_____ (5) has been excluded or expelled according to sections 121A.40 to 121A.56;
_____ (6) has been referred by a school district for enrollment in an eligible program or a program
pursuant to section 124D.69;
_____ (7) is a victim of physical or sexual abuse;
_____ (8) has experienced mental health problems;
_____ (9) has experienced homelessness sometime within six months before requesting a
transfer to an eligible program;
_____ (10) speaks English as a second language or has limited English proficiency; or
_____ (11) has withdrawn from school or has been chronically truant; or
_____ (12) is being treated in a hospital in the seven-county metropolitan area for cancer or other
life threatening illness or is the sibling of an eligible pupil who is being currently
treated, and resides with the pupil's family at least 60 miles beyond the outside
boundary of the seven-county metropolitan area.
Assessment Scores
Date
Reading
Math
NWEA _________________________________
MCA _________________________________
Other _________________________________

Date
Reading
Math
_________________________________
_________________________________
_________________________________

Other Indicators of need:

Recommended Targeted Program Goals/Outcomes

Using the initials provided (NY, IP, P), identify areas of concern in the Initial Referral column:
NY = Not Yet at Grade Level IP = In Progress P = Proficient at Grade Level NA = Not Applicable.
Personal & Social
Day-school Performance Status
Current Goal
_______ _______ Shows comfort/confidence with self
_______ _______ Follows classroom expectation/routines
_______ _______ Uses materials purposefully/respectfully
_______ _______ Makes independent personal choices
_______ _______ Interacts easily with peers & adults
_______ _______ Follows Directions
_______ _______ Completion of Assignments
_______ _______ ________________________________
_______ _______ ________________________________
_______ _______ ________________________________

River Bend Education District

Targeted Services Completion Status

Status
Comments
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________

Updated 4-25-2014

TARGETED SERVICES

Continual Learning Plan K - 8

Language & Literacy

Day-school Performance Status
Current Goal
_______ _______ Word Attack
_______ _______ Comprehension
_______ _______ Expresses ideas
_______ _______ Mechanics of writing
_______ _______ Vocabulary
_______ _______ Listening Skills
_______ _______ Editing Skills
_______ _______ Research Skills
_______ _______ ________________________________
_______ _______ ________________________________

Targeted Services Completion Status

Status
Comments
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________

Mathematics
Day-school Performance Status
Current Goal
_______ _______ Number Recognition
_______ _______ Addition/Subtraction
_______ _______ Multiplication/Division
_______ _______ Estimation
_______ _______ Measurement
_______ _______ Patterns & Relationships
_______ _______ Problem Solving
_______ _______ Number Sense
_______ _______ Uses strategies to solve math problems
_______ _______ Basic operations and math facts
_______ _______ Reads and interprets graphs or charts
_______ _______ Problem Solving
_______ _______ Percentages, probability, and ratios
_______ _______ Demonstrates algebraic thinking
_______ _______ ________________________________
_______ _______ ________________________________

Targeted Services Completion Status

Status
Comments
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________
_____________ ________________________________

Signatures/Comments
Referring Teacher: _____________________________________________ School YR: _____ - _____ Date: _______
Comments:

Targeted Services Teacher: ______________________________________ School YR: _____ - _____ Date: ________
Comments:

Parent: ____________________________________________________________________________ Date: ________

Comments:

River Bend Education District

Updated 4-25-2014