DOCUMENTATION OF APPROPRIATE INSTRUCTION
ELEMENTARY GRADES	

STUDENT’S NAME:_______________________________DATE:_______________

CHECK ALL ITEMS THAT APPLY TO THE STUDENT

____ 	The student has participated in a scientifically research based reading program.

____  	The student has participated in a scientifically research based math program.

____	The student has received standards based instruction by a highly qualified teacher.

____ 	The student’s data has been reviewed and appropriate instructional strategies have been implemented in the classroom based on the student’s needs.

____ 	The student has participated in small group instruction.

____ 	The student has participated in a school enrichment program.

____ 	The student has participated in a tutorial program.

____ 	The student has participated in a private educational program.

____	The student has received private speech therapy services. 

____	Other______________________________________________________________________

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Name of person completing this form: ______________________________________________________