Appendix C, continued (Page 1/3)

Virginia Department of Education

Documentation of Need for Paper/Pencil standards of Learning Assessment

Directions: This form must be completed for students with disabilities or those with medical conditions whoneed a paper/pencil test but who do NOT meet the following criteria:

o attend school in a location where a secure nehvork connection or the required technology is notavailable to access an online test, such as special situation schools, homebound, residential facilities,hospitals, night schools, or Govemor Schools.

' require an accommodation in the Individualized Education Plan (lEP) or 504 Plan that necessitates apaper/pencil format such as large-print test, braille test, or flexible schedule (multiple testing sessionsrequiring more than one school day).

o have a documented medical condition, such as a seizure disorder where exposure to a computer willaggravate the student's condition.

For a student with disabilities, this form should be completed by the lndividual Education program (lEp)tearn/504 committee. For a student with medical conditions, this form should be cornpleted bf a team composedof the Division Director of Testing, building principal, course content teacher, parent, and othlr appropriateschool staff, A separate form must be completed for each SOL Assessment, and a copy of each signed andcompleted fotm must remain in the student's education record and on file in the office of the Division Director ofTesting.

Section I: Student Information

Student Name: Date of Birth:

State Testing Identifier (STI): Current Grade of Enrollment:

SOL Assessment Considered for Paper/Pencil:

Section II: School Division Information

School Division Name: School Name:

Course Content Teacher: Date:

Section llI: Eligibility Determination

Eligibility for paper/pencil administration of SOL assessments is determined based on a student's clisability or thestudent's medical need. Section IIIA should be completed by student's IEP or 504 team if the needfor apaper/pencil qdministration is bqsed on on identified disability. Section IttB should be iomplered Ly a rcamcomposed of the Division.Director of Testing, building principal, parent, and orher oppropiiot" school staffif amedical condition is the basisfor the needfor a paper/pencil lest.

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Appendix C, continued

Section lllA: (Completefor a Student with a Disability)

(Page 2/3)

The student's IEP Team/504 Committee must determine that a student is eligiblefor a paper/pencil assessment

based on cmswers to the following three questions. A response of " No " for any question indicates that the student is

NOT eligible for a paper/pencil assessment in the content area listed in Section I of this form.

1) Does the student have a current IEP/504 Plan or is one being developed?

EYes trNo

2) As a result of a disability, the student requires an accommodation other than large printtest, braille, or multiple test sessions, that can only be provided in a paper/pencil format.

List accommodation requiring a paper/pencil administration:

EYes trNo

3) Does the student require paper/pencil classroom tests in order to access content?

EYes trNo

JustiJication Statement: The IEp Team/504 Committee must also provide a justification statement as to why the

IEp Team or 504 Committee has determined that the impact of the student's disability prevents qccess to online

SOL assessments even with accommodations. Dqta shiuld be referencedfrom the student's edrcational record

including the most recent evaluation information, teacher observations, and classroom and state assessment

performance historY.

Signed:

Course Content Teacher

Date

Date

Date

Date

Date

Date

Special Education Teacher

Parent

Building Administrator or Designee

Other

Other

This completedform must be retqined in the student's education record

and on file in the ffice of the Division Director of Testing'

B8

Appendix C, continued (Page 3/3)

Section lllB: (Completefor u Student with u Medical Condition)

The school team must determine that e student is eligible for a paper/pencil assessment based on answers to thelhree questions below. A response of "No" for any question indicates that lhe student is NOT eligible.for apaper/pencil assessment in the content area listed in Section I of this form.

l) Does the student have a current medical condition documented by a physician or other healthprofessional? (Letter must be attached.)

DYes trNo

2) As a result of the medical condition, is the student unable to demonstrate his/her individualachievement on the online Standards of Learning test for the assigned course and grade level?

EYes trNo

3) Does the student require paper/pencil classroom tests in order to access content?

DYes trNo

Justification Stolement: The school team must also provide a justiJication stqtement as to why it has determinedthqt the impact of the student's medical condition prevents access to online SOL assessments. Data should bereferenced.from teqcher observations andfrom classroom qnd slate assessment performance history. A letterfi"om the studenl's physician must also be attached which documents the curent medical condition that preventsqccess to online SOL assessments.

Signed:

DateDivision Director of Testing

DateBuilding Administrator or Designee

Course Content TeacherDate

Parent

OtherDate

Other

This completedform must be retained in ffice of the Division Director of Testing.

Date

Date

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