Available in PDF Format for printing

Appendix B – Forms

ADMINISTRATION MANUAL

New York State Alternate Assessment
(November 2006)

Date of Birth: _____/_____/_____
Last Name: __________________________ First Name: _________________________
Student ID#: _______________________________________________________________
District of Residence: ________________________________________________________
School Name: ______________________________________________________________
Name of Service Provider: ___________________________________________
(Only needed for a student in an out-of-district placement)

Student most often receives instruction in the following setting (check one below):

School   Home   Hospital or  Other: _________________________ (specify)

(check only one grade for the student based on student’s birth date)

NYSAA Level

Birth Date Range

Content Areas Assessed

Grade 3

September 1, 1997-August 31, 1998

ELA, Mathematics

Grade 4

September 1, 1996-August 31, 1997

ELA, Mathematics, Science

Grade 5

September 1, 1995-August 31, 1996

ELA, Mathematics, Social Studies

Grade 6

September 1, 1994-August 31, 1995

ELA, Mathematics

Grade 7

September 1, 1993-August 31, 1994

ELA, Mathematics

Grade 8

September 1, 1992-August 31, 1993

ELA, Mathematics, Science, Social Studies

Secondary

September 1, 1988-August 31, 1990

ELA, Mathematics, Science, Social Studies

 

Administration Period for 2006–07 NYSAA: January 2 – March 9, 2007

Type of Support
 

Details

Assistive technology

____________________________________________

Testing accommodation(s)

____________________________________________

Communication system

____________________________________________

Other (specify)

____________________________________________

 

Page

NYSAA Student Page _________
Table of Contents _________
Parent/Family/Guardian Survey  _________
The following are required as applicable _________
Informed Consent for Photographing, Video/Audio Tape Recording _________
Informed Consent for Incidental Photographing, Video/Audio Tape Recording* _________
The following documents must be included for each content area assessed.  
Data Summary Sheet for the first ELA AGLI _________
First Piece of Verifying Evidence** for the first ELA AGLI with label _________
Second Piece of Verifying Evidence** for the first ELA AGLI with label _________
Data Summary Sheet for the second ELA AGLI _________
First Piece of Verifying Evidence** for the second ELA AGLI with label _________
Second Piece of Verifying Evidence** for the second ELA AGLI with label _________
Data Summary Sheet for the first Mathematics AGLI _________
First Piece of Verifying Evidence** for the first Mathematics AGLI with label _________
Second Piece of Verifying Evidence** for the first Mathematics AGLI with label _________
Data Summary Sheet for the second Mathematics AGLI _________
First Piece of Verifying Evidence** for the second Mathematics AGLI with label _________
Second Piece of Verifying Evidence** for the second Mathematics AGLI with label _________
Data Summary Sheet for the first Science AGLI _________
First Piece of Verifying Evidence** for the first Science AGLI with label _________
Second Piece of Verifying Evidence** for the first Science AGLI with label _________
Data Summary Sheet for the second Science AGLI _________
First Piece of Verifying Evidence** for the second Science AGLI with label _________
Second Piece of Verifying Evidence** for the second Science AGLI with label _________
Data Summary Sheet for the first Social Studies AGLI _________
First Piece of Verifying Evidence** for the first Social Studies AGLI with label _________
Second Piece of Verifying Evidence** for the first Social Studies AGLI with label _________
Data Summary Sheet for the second Social Studies AGLI _________
First Piece of Verifying Evidence** for the second Social Studies AGLI with label _________
Second Piece of Verifying Evidence** for the second Social Studies AGLI with label _________

*This form must be signed and kept on file by the district.
**Supporting evidence is required when verifying evidence is a Data Collection Sheet.

2006–07
New York State Alternate Assessment (NYSAA)
Parent/Family/Guardian Survey

Surveys are available in PDF format for printing in the following languages:

Arabic Bengali Chinese Haitian-Creole
Korean Russian Spanish Urdu

Dear Parent/Family/Guardian:

Your child is participating in an alternate assessment this year. Your child’s lead special education teacher (LSET) is required to let you know some of the assessment activities for your child. These activities will focus on English language arts (ELA), mathematics, science, and/or social studies. Your child’s teacher needs to know how you think your child is doing with these content areas at home. This is an opportunity to share concerns about the educational needs of your child and how you and your child’s teacher can work together to meet those needs.

The State Education Department developed Alternate Grade Level Indicators (AGLIs) for students to ensure access to the core curriculum. An AGLI is a description of student performance expectations for students with severe cognitive disabilities. AGLIs are used to measure a level of mastery of the knowledge, skills, and understandings aligned with the grade level core curriculum established for all students by the New York State Board of Regents.

Your child’s teacher has indicated one AGLI on which your son or daughter is working within a particular content area. Please check all boxes that apply to your child's performance level and describe what your child knows and is able to do concerning the skill or skills listed.

This survey may take as little as 10 minutes of your time to complete.

  • It is preferred that the survey be completed with your child’s LSET during a meeting at the school, home, or another location.

  • If that is not possible, you could engage in a telephone conference with your child’s LSET.

  • The third, but least preferred method of completing the survey, would be for the LSET to ask that you complete the survey and return it to the LSET.

Thank you for your time and assistance.

Student Name: _____________________________________

2006-07
New York State Alternate Assessment (NYSAA) Parent/Family/Guardian Survey

(LSET must complete this document as part of an interview with parents/family/guardians or by sending it home to be completed by the parent/family/guardian)

Content Area ELA
(LSET writes one AGLI below) 		Mathematics
(LSET writes one AGLI below)
Students targeted Alternate Grade Level Indicator (AGLI), as listed by teacher. An AGLI is a description of student performance expectations for students with severe cognitive disabilities. AGLIs are used to measure a level of mastery of the knowledge, skills, and understandings aligned with the core curriculum established for all students by the New York State Board of Regents.   
If applicable, does your child demonstrate this knowledge, skill, or understanding:
1. at home? Yes No Sometimes Yes No Sometimes
2. in the community? Yes No Sometimes Yes No Sometimes
Is your child able to do this without any help? Yes No Sometimes Yes No Sometimes
What level of support does your child need to do this?

None Verbal DirectionPhysical  Assistance

None Verbal Direction
Physical  Assistance 

Please describe how and if you see your child making progress, at home and/or in the community, toward meeting the AGLIs that the teacher has written above. (Continue on back if needed.)   

Student Name: ____________________________________

Content Area

Science
(LSET writes one AGLI below)

Social Studies
(LSET writes one AGLI below)

Students targeted Alternate Grade Level Indicator (AGLI), as listed by teacher. An AGLI is a description of student performance expectations for students with severe cognitive disabilities. AGLIs are used to measure a level of mastery of the knowledge, skills, and understandings aligned with the core curriculum established for all students by the New York State Board of Regents.
If applicable, does your child demonstrate this knowledge, skill, or understanding:
1. at home? Yes No Sometimes Yes No Sometimes
2. in the community? Yes No Sometimes Yes No Sometimes
Is your child able to do this without any help? Yes No Sometimes Yes No Sometimes
What level of support does your child need to do this? None Verbal Direction
Physical  Assistance 		None Verbal DirectionPhysical  Assistance
Please describe how and if you see your child making progress, at home and/or in the community, toward meeting the AGLIs that the teacher has written above. (Continue on back if needed.)   
 

Student Name:_______________________________________________

To be completed by the Lead Special Education Teacher:

Person providing survey information about the student:

___________________________________________________________________________________
Signature Relationship to student   Date

Person recording answers to survey questions:

_________________________________________________________________________________
Signature Relationship to student   Date

Parent/family/guardian meeting at school
Parent/family/guardian meeting at home
Telephone conference
Parent/family/guardian completed the survey at home Other____________________________________

Parent/family/guardian was unavailable or unwilling to complete the survey. LSET documents date and method of attempts to engage parent/family/guardian below .

Method (phone call, written communication, home visit, etc.)

Arabic Bengali Chinese Haitian-Creole
Korean Russian Spanish Urdu

To the Parent/Family/Guardian of: _______________________________
                                                            (Student’s name)

Your child is currently participating in the New York State Alternate Assessment (NYSAA).

During this process, your child’s teacher may find it necessary to record how your son or daughter performs the assessment tasks by taking photographs, video tapes, or audio tapes.

Your signed permission below will allow these records to be used as part of the assessment. Any reproduction of your child’s assessment records for training purposes by the State Education Department will require that all identifying information be removed.

I, (parent/family/guardian’s name) _____________________________, grant permission for __________________________ (Teacher’s name) to take photographs, video tapes, and/or audio tapes of my son/daughter as necessary for his/her NYSAA datafolio.
 

______________________________________________________________________________

Parent/Family/Guardian’s signature Date
(within the administration period)

NOTE: This form is required and must be included in the datafolio when photographic, video/audio tape evidence is submitted. If this permission form is not included in the datafolio, the AGLI will not be scored.

Arabic Bengali Chinese Haitian-Creole
Korean Russian Spanish Urdu

To Parents/Family/Guardians:

Your child’s teacher will be administering the New York State Alternate Assessment (NYSAA) to students in your child’s classroom this year. We request your consent to have your child appear in photographs, video tapes and/or audio tapes in a limited way.

NYSAA requires lead special education teachers (LSETs) to collect student work and/or evidence of a student performing an assessment task through observation sheets, photographs, video or audio tapes. It may be necessary for your child’s teacher to record the voice or image of the student who is being assessed during classroom activities with other students in the room. Therefore, there may be limited occasions when your child might appear in photographs, video or audio tapes that would be included in other student datafolios. Please note that your child would not be identified by name.

Your signature below gives your permission for your child’s teacher to take photographs, video or audiotapes that may include your child in an indirect (incidental) manner for the purposes of developing other student datafolios.

STUDENT’S NAME: __________________________________________________

SCHOOL NAME: _____________________________________________________

TEACHER’S NAME: __________________________________________________

I, (Parent/Family/Guardian’s name) ___________________________________________, grant permission for _____________________________(Teacher’s name) to take photographs, video tapes and/or audio tapes of my son/daughter. I understand that my child’s voice or visual image may appear in a limited way in another student’s NYSAA datafolio but he/she will not be identified by name.

______________________________________________________________________________
Parent/Family/Guardian’s signature Date

NOTE: This form must be signed and kept on file by the school district. It should not be submitted in the datafolio.

2006-07 NYSAA VIDEO AND AUDIO TAPE CLIP SUMMARY FORM

Student Name (one student per tape): _____________________________________________________

Name of Lead Special Education Teacher (LSET):__________________________________________

School Name: _________________________________________________________

Label the video/audio tape with the above information. Attach a copy of this summary to the video/audio tape. Record a marker at the beginning of the tape and include: student’s name, date of performance, content area, AGLI text and assessment task. When the assessment task is completed, a 2nd marker must be recorded at the end of the clip indicating level of accuracy and level of independence for the assessment task demonstrated.

Clip # Audio/ Video Date of Task Content Area AGLI Code # Clip Length (90 sec. or less) Staff Initials Level of Accuracy Level of Independence
         
         
         
         
         
         
         
         
         

NOTE: Only VHS compatible equipment will be provided at scoring sites. If any other video format is submitted it will be the responsibility of the LSET to provide the necessary equipment and technical support to allow scoring of the evidence. Otherwise, the evidence may not be scored.

2006-07 NYSAA
DATA SUMMARY SHEET 		Grade 3 - ELA 3
Student’s Name: Date of Birth:
School Name:
Required Component: Reading
Choice Component (select one):
Students will read, write, listen and speak for literary response and expression. Students will read, write, listen and speak for social interaction.
Alternate Grade Level Indicator (Choose one AGLI for the selection indicated above)
AGLI Code:
AGLI Text:

 

Assessment task:

 

 

The following is helpful to scorers when determining connection to grade level content:
 

This assessment task is the same as one listed on page ___ of the NYSAA Frameworks.

This assessment task is comparable to one listed on page ___ of the NYSAA Frameworks.
This is an original assessment task developed by LSET.

Dates Student Performance
(record the last 3 dates of documented data) 		Date 1: Date 2: Date 3:
% Rating % Rating % Rating
Level of Accuracy   
Level of Independence   
Scoring Rubric Level 100% - 80% 79% - 60% 59% - 30% 29% - 0%
Rating 4 3 2 1

Verifying evidence (VE) must confirm the student’s name, date of student performance, content area, AGLI text, assessment task, level of accuracy and level of independence. Failure to record all required elements on both the Data Summary Sheet and the verifying evidence may disqualify the student from receiving a reportable score.

Two pieces of verifying evidence are required for each AGLI (see Administration Manual for complete VE requirements). Verifying evidence must confirm data for LAST TWO DATES of student performance documented on this Data Summary Sheet.

2006-07 NYSAA
DATA SUMMARY SHEET

Grade 3 - ELA
(cont'd)

 3
Student’s Name: Date of Birth:
School Name:
Required Component: Listening
Choice Component (select one):
Students will read, write, listen and speak for literary response and expression. Students will read, write, listen and speak for social interaction.
Alternate Grade Level Indicator (Choose one AGLI for the selection indicated above)
AGLI Code:
AGLI Text:

 
Assessment task:

 

 

The following is helpful to scorers when determining connection to grade level content:

This assessment task is the same as one listed on page ___ of the NYSAA Frameworks.

This assessment task is comparable to one listed on page ___ of the NYSAA Frameworks.
This is an original assessment task developed by LSET.

Dates Student Performance
(record the last 3 dates of documented data) 		Date 1: Date 2: Date 3:
% Rating %  Rating% Rating
Level of Accuracy   
Level of Independence   
Scoring Rubric Level 100% - 80% 79% - 60% 59% - 30% 29% - 0%
Rating 4 3 2 1

Verifying evidence (VE) must confirm the student’s name, date of student performance, content area, AGLI text, assessment task, level of accuracy and level of independence. Failure to record all required elements on both the Data Summary Sheet and the verifying evidence may disqualify the student from receiving a reportable score.

Two pieces of verifying evidence are required for each AGLI (see Administration Manual for complete VE requirements). Verifying evidence must confirm data for LAST TWO DATES of student performance documented on this Data Summary Sheet.

2006-07 NYSAA
DATA SUMMARY SHEET

Grade 3 - MATHEMATICS

3
Student’s Name: Date of Birth:
School Name:
Required Component: Number Sense and Operations
Choice Component (select one):
Number Sense
Operations
Alternate Grade Level Indicator (Choose one AGLI for the selection indicated above)
AGLI Code:
AGLI Text:

 
Assessment task:

 

 

The following is helpful to scorers when determining connection to grade level content:

This assessment task is the same as one listed on page ___ of the NYSAA Frameworks.
This assessment task is comparable to one listed on page ___ of the NYSAA Frameworks.
This is an original assessment task developed by LSET.

Dates Student Performance
(record the last 3 dates of documented data) 		Date 1: Date 2: Date 3:
% Rating % Rating %  Rating
Level of Accuracy   
Level of Independence   
Scoring Rubric Level 100% - 80% 79% - 60% 59% - 30% 29% - 0%
Rating 4 3 2 1

Verifying evidence (VE) must confirm the student’s name, date of student performance, content area, AGLI text, assessment task, level of accuracy and level of independence. Failure to record all required elements on both the Data Summary Sheet and the verifying evidence may disqualify the student from receiving a reportable score.

Two pieces of verifying evidence are required for each AGLI (see Administration Manual for complete VE requirements). Verifying evidence must confirm data for LAST TWO DATES of student performance documented on this Data Summary Sheet.

2006-07 NYSAA
DATA SUMMARY SHEET

Grade 3 - MATHEMATICS (cont'd)

3
Student’s Name: Date of Birth:
School Name:
Required Component: Measurement
Choice Component (select one):
Units of Measurement
Units/Estimation
Alternate Grade Level Indicator (Choose one AGLI for the selection indicated above)
AGLI Code:
AGLI Text:

 
Assessment task:

 

 

The following is helpful to scorers when determining connection to grade level content:

This assessment task is the same as one listed on page ___ of the NYSAA Frameworks.
This assessment task is comparable to one listed on page ___ of the NYSAA Frameworks.
This is an original assessment task developed by LSET.

Dates Student Performance
(record the last 3 dates of documented data) 		Date 1: Date 2: Date 3:
% Rating % Rating % Rating
Level of Accuracy   
Level of Independence   
Scoring Rubric Level 100% - 80% 79% - 60% 59% - 30% 29% - 0%
Rating 4 3 2 1

Verifying evidence (VE) must confirm the student’s name, date of student performance, content area, AGLI text, assessment task, level of accuracy and level of independence. Failure to record all required elements on both the Data Summary Sheet and the verifying evidence may disqualify the student from receiving a reportable score.

Two pieces of verifying evidence are required for each AGLI (see Administration Manual for complete VE requirements). Verifying evidence must confirm data for LAST TWO DATES of student performance documented on this Data Summary Sheet.

2006-07 NYSAA
DATA SUMMARY SHEET

Grade 4 - ELA

4
Student’s Name: Date of Birth:
School Name:
Required Component: Reading
Choice Component (select one):
Students will read, write, listen and speak for literary response and expression.
Students will read, write, listen and speak for social interaction.
Alternate Grade Level Indicator (Choose one AGLI for the selection indicated above)
AGLI Code:
AGLI Text:
 

 
Assessment task:
 

 

 

The following is helpful to scorers when determining connection to grade level content:

This assessment task is the same as one listed on page ___ of the NYSAA Frameworks.
This assessment task is comparable to one listed on page ___ of the NYSAA Frameworks.
This is an original assessment task developed by LSET.

Dates Student Performance
(record the last 3 dates of documented data) 		Date 1: Date 2: Date 3:
% Rating % Rating %  Rating
Level of Accuracy   
Level of Independence   
Scoring Rubric Level 100% - 80% 79% - 60% 59% - 30% 29% - 0%
Rating 4 3 2 1

Verifying evidence (VE) must confirm the student’s name, date of student performance, content area, AGLI text, assessment task, level of accuracy and level of independence. Failure to record all required elements on both the Data Summary Sheet and the verifying evidence may disqualify the student from receiving a reportable score.

Two pieces of verifying evidence are required for each AGLI (see Administration Manual for complete VE requirements). Verifying evidence must confirm data for LAST TWO DATES of student performance documented on this Data Summary Sheet.

2006-07 NYSAA
DATA SUMMARY SHEET

Grade 4 - ELA
(cont'd)

4
Student’s Name: Date of Birth:
School Name:
Required Component: Writing
Choice Component (select one):
Students will read, write, listen and speak for information and understanding.
Students will read, write, listen and speak for literary response and expression.
Alternate Grade Level Indicator (Choose one AGLI for the selection indicated above)
AGLI Code:
AGLI Text:
 

 
Assessment Task:

 

 

The following is helpful to scorers when determining connection to grade level content:

This assessment task is the same as one listed on page ___ of the NYSAA Frameworks.
This assessment task is comparable to one listed on page ___ of the NYSAA Frameworks.
This is an original assessment task developed by LSET.

Dates Student Performance
(record the last 3 dates of documented data) 		Date 1: Date 2: Date 3:
% Rating % Rating % Rating
Level of Accuracy   
Level of Independence   
Scoring Rubric Level 100% - 80% 79% - 60% 59% - 30% 29% - 0%
Rating 4 3 2 1

Verifying evidence (VE) must confirm the student’s name, date of student performance, content area, AGLI text, assessment task, level of accuracy and level of independence. Failure to record all required elements on both the Data Summary Sheet and the verifying evidence may disqualify the student from receiving a reportable score.

Two pieces of verifying evidence are required for each AGLI (see Administration Manual for complete VE requirements). Verifying evidence must confirm data for LAST TWO DATES of student performance documented on this Data Summary Sheet.

2006-07 NYSAA
DATA SUMMARY SHEET

Grade 4 - MATHEMATICS

4
Student’s Name: Date of Birth:
School Name:
Required Component: Number Sense and Operations
Choice Component (select one):
Number Sense
Operations
Alternate Grade Level Indicator (Choose one AGLI for the selection indicated above)
AGLI Code:
AGLI Text:

 
Assessment task:

 

 

The following is helpful to scorers when determining connection to grade level content:

This assessment task is the same as one listed on page ___ of the NYSAA Frameworks.
This assessment task is comparable to one listed on page ___ of the NYSAA Frameworks.
This is an original assessment task developed by LSET.

Dates Student Performance
(record the last 3 dates of documented data) 		Date 1: Date 2: Date 3:
% Rating %  Rating% Rating
Level of Accuracy   
Level of Independence   
Scoring Rubric Level 100% - 80% 79% - 60% 59% - 30% 29% - 0%
Rating 4 3 2 1

Verifying evidence (VE) must confirm the student’s name, date of student performance, content area, AGLI text, assessment task, level of accuracy and level of independence. Failure to record all required elements on both the Data Summary Sheet and the verifying evidence may disqualify the student from receiving a reportable score.

Two pieces of verifying evidence are required for each AGLI (see Administration Manual for complete VE requirements). Verifying evidence must confirm data for LAST TWO DATES of student performance documented on this Data Summary Sheet.

2006-07 NYSAA
DATA SUMMARY SHEET

Grade 4 - MATHEMATICS (cont'd)

4
Student’s Name: Date of Birth:
School Name:
Required Component: Measurement
Choice Component (select one):
Units of Measurement
Units/Estimation
Alternate Grade Level Indicator (Choose one AGLI for the selection indicated above)
AGLI Code:
AGLI Text:

 
Assessment task:

 

 

The following is helpful to scorers when determining connection to grade level content:

This assessment task is the same as one listed on page ___ of the NYSAA Frameworks.
This assessment task is comparable to one listed on page ___ of the NYSAA Frameworks.
This is an original assessment task developed by LSET.

Dates Student Performance
(record the last 3 dates of documented data) 		Date 1: Date 2: Date 3:
% Rating % Rating %  Rating
Level of Accuracy   
Level of Independence   
Scoring Rubric Level 100% - 80% 79% - 60% 59% - 30% 29% - 0%
Rating 4 3 2 1

Verifying evidence (VE) must confirm the student’s name, date of student performance, content area, AGLI text, assessment task, level of accuracy and level of independence. Failure to record all required elements on both the Data Summary Sheet and the verifying evidence may disqualify the student from receiving a reportable score.

Two pieces of verifying evidence are required for each AGLI (see Administration Manual for complete VE requirements). Verifying evidence must confirm data for LAST TWO DATES of student performance documented on this Data Summary Sheet.

2006-07 NYSAA
DATA SUMMARY SHEET

Grade 4 - SCIENCE

4
Student’s Name: Date of Birth:
School Name:
Required Component: Scientific Inquiry
Choice Component (select one):
Develop explanations of natural phenomena
Testing proposed explanations
Alternate Grade Level Indicator (Choose one AGLI for the selection indicated above)
AGLI Code:
AGLI Text:

 
Assessment task:

 

 

The following is helpful to scorers when determining connection to grade level content:

This assessment task is the same as one listed on page ___ of the NYSAA Frameworks.
This assessment task is comparable to one listed on page ___ of the NYSAA Frameworks.
This is an original assessment task developed by LSET.

Dates Student Performance
(record the last 3 dates of documented data) 		Date 1: Date 2: Date 3:
% Rating % Rating %  Rating
Level of Accuracy   
Level of Independence   
Scoring Rubric Level 100% - 80% 79% - 60% 59% - 30% 29% - 0%
Rating 4 3 2 1

Verifying evidence (VE) must confirm the student’s name, date of student performance, content area, AGLI text, assessment task, level of accuracy and level of independence. Failure to record all required elements on both the Data Summary Sheet and the verifying evidence may disqualify the student from receiving a reportable score.

Two pieces of verifying evidence are required for each AGLI (see Administration Manual for complete VE requirements). Verifying evidence must confirm data for LAST TWO DATES of student performance documented on this Data Summary Sheet.

2006-07 NYSAA
DATA SUMMARY SHEET

Grade 4 - SCIENCE

4
Student’s Name: Date of Birth:
School Name:
Required Component: Living Environment and Physical Setting/Earth Science
Choice Component (select one):
Change in organisms over time
Interactions among components of air, water and land
Alternate Grade Level Indicator (Choose one AGLI for the selection indicated above)
AGLI Code:
AGLI Text:

 
Assessment task:

 

 

The following is helpful to scorers when determining connection to grade level content:

This assessment task is the same as one listed on page ___ of the NYSAA Frameworks.
This assessment task is comparable to one listed on page ___ of the NYSAA Frameworks.
This is an original assessment task developed by LSET.

Dates Student Performance
(record the last 3 dates of documented data) 		Date 1: Date 2: Date 3:
% Rating % Rating %  Rating
Level of Accuracy