Student Last Name: ________________________
Berea Tutoring
Teacher Referral Form
Date:____________ Student: _______________________________________________
Grade Level: _______ Age: ________ School: ________________________________________
Parents/Guardians: _____________________________________________________________
Phone(s): __________________________ City of Residence: ____________________________
Referring Teacher: ________________________________________________________________
Phone: _________________________ Email: _____________________________________________
Is this student receiving extra support anywhere outside of the regular classroom (ex. Intervention, Special
Education, After-school tutoring, In-school tutoring, etc)? If so, where?
The goal of the tutoring program is to provide supplemental education in order to bring a student up to grade
level. Our volunteers are trained and receive weekly guidance and support, but they are college students not
professionals. On a scale from 1 (not at all) to 5 (life-changing), in your professional opinion how much do you
think this student could benefit from an after-school tutoring program? Please comment if necessary.
Scores and Ranges (if applicable/available):
MAP score (reading): ______________
MAP score (math): __________________
Lexile Range:________________ Other: ____________________
We thank you so much for taking the time to complete the attached referral forms. The information you provide
will be passed on to the tutors so that they can better choose materials during the tutoring session. During the
school year, if you ever have any more information to share or desire any information from us, feel free to
contact the tutoring team. Our goal is to create a system of communication so that each student is receiving the
most effective education possible.
Please return this form to CELTS by the date requested to give our team enough time to process the
paperwork and contact the parents/guardians.
Thank you,
Berea Tutoring Program
CELTS, Berea College
CPO 2170
859 985 3805
Student Last Name: ________________________
Third Grade Pre-Assessment
(Adapted from the Common Core Standards. http://www.corestandards.org/)
Reading/Writing
Part One:
Place a “P” next to specific skills which the student is able to do at a proficient level. Place a “NW” next to
skills that would be beneficial for the student to practice. Leave unobserved skills blank.
Phonics
__ Use and apply K-2 standards for phonics. [Please leave comments if this needs work.]
__ Identify and know the meaning of the most common prefixes and derivational suffixes. (RF.3.3.A)
__ Decode words with common Latin suffixes. (RF.3.3.B)
__ Decode multi-syllable words. (RF.3.3.C)
__ Read grade-appropriate irregularly spelled words. (RF.3.3.D)
Fluency
__ Use and apply K-2 standards for fluency. [Please leave comments if this needs work.]
__ Explain how specific aspects of a text's illustrations contribute to what is conveyed by the words in a fiction
or non-fiction piece of text. (RL.3.7; RI.3.7; RI.3.5)
__ Read grade-level text with purpose and understanding. (RF.3.4.A)
__ Read grade-level prose and poetry orally with accuracy, appropriate rate, and expression. (RF.3.4.B)
__ Use context to confirm or self-correct word recognition and understanding, rereading as necessary.
(RF.3.4.C)
Vocabulary
__ Use and apply K-2 standards for vocabulary. [Please leave comments if this needs work.]
__ Use sentence-level context as a clue to the meaning of a word or phrase. (L.3.4.A)
__ Determine the meanings of unknown words by using root words and affixes. (L.3.4.B; L.3.4.C)
__ Use glossaries or beginning dictionaries to determine or clarify the meaning of words and phrases. (L.3.4.D)
__ Distinguish the literal and nonliteral meanings of words and phrases in context (e.g.,take steps). (L.3.5.A;
RL.3.4; RI.3.4)
__ Distinguish shades of meaning among related words that describe states of mind or degrees of certainty
(e.g., knew, believed, suspected, heard, wondered). (L.3.5.C)
Comprehension
__ Use and apply K-2 standards for comprehension. [Please leave comments if this needs work.]
__ Ask and answer questions to demonstrate understanding of a text. (RL.3.1; RI.3.1)
__ Refer to parts of stories, dramas, and poems when writing or speaking about a text, using terms such as
chapter, scene, and stanza (RL.3.5)
__ Recount key details of stories and non-fiction text. (RL.3.2; RI.3.2)
__ Determine the central message or main idea and explain how it is conveyed. (RL.3.2; RI.3.2)
__ Describe characters in a story (e.g., their traits, motivations, or feelings) and explain how their actions
contribute to the sequence of events. (RL.3.3)
__ Distinguish his own point of view from that of the author, narrator or those of the characters. (RL.3.6;
RI.3.6)
Writing/Verbal Skills
__ Use and apply K-2 standards for writing. [Please leave comments if this needs work.]
__ Explain the function of nouns, pronouns, verbs, adjectives, and adverbs. (L.3.1.A)
__ Form and use regular and irregular plural nouns. (L.3.1.B)
__ Use abstract nouns (e.g., childhood). (L.3.1.C)
Student Last Name: ________________________
__ Form and use regular and irregular verbs. (L.3.1.D)
__ Form and use the simple (e.g., I walked; I walk; I will walk) verb tenses. (L.3.1.E)
__ Ensure subject-verb and pronoun-antecedent agreement. (L.3.1.F)
__ Form and correctly use comparative and superlative adjectives and adverbs. (L.3.1.G)
__ Use coordinating and subordinating conjunctions. (L.3.1.H)
__ Produce simple, compound, and complex sentences. (L.3.1.I)
__ Capitalize appropriate words in titles. (L.3.2.A)
__ Use commas in addresses. (L.3.2.B)
__ Use commas and quotation marks in dialogue. (L.3.2.C)
__ Form and use possessives. (L.3.2.D)
__ Spell grade-level words and to add suffixes to base words. (L.3.2.E; L.3.2.F)
__ Choose words and phrases for effect. (L.3.3.A)
__ Recognize differences between the conventions of spoken and written standard English. (L.3.3.B)
Part Two:
Thinking about the student’s test scores, performance in class, and your observations, please order the
categories in order of need for this particular student {1 (most needed)—6 (least needed)}
_____ Phonemic Awareness
_____ Phonics
_____ Fluency
_____ Vocabulary
_____ Comprehension
_____ Writing/Verbal Skills
Comments about this student’s reading/writing skill level:
Student Last Name: ________________________
Math
Part One:
Place a “P” next to specific skills which the student is able to do at a proficient level. Place a “NW” next to
skills that would be beneficial for the student to practice. Leave unobserved skills blank.
Operations and Algebra
__ Use and apply K-2 standards for operations and algebra. [Please leave comments if this needs work.]
__ Use multiplication and division within 100 to solve word problems in situations involving equal groups,
arrays, and measurement quantities. (3.OA.A.3)
__ Determine the unknown whole number in a multiplication or division equation relating three whole numbers.
(3.OA.A.4)
__ Apply properties of operations as strategies to multiply and divide. (3.OA.B.5)
__ Understand division as an unknown-factor multiplication problem. (3.OA.B.6)
__ Fluently multiply and divide within 100 (3.OA.C.7)
__ Recall from memory all products of two one-digit numbers. (3.OA.C.7)
__ Solve two-step word problems using the four operations, variables and estimation strategies. (3.OA.D.8)
Base Ten Operations
__ Use and apply K-2 standards for base ten operations. [Please leave comments if this needs work.]
__ Round whole numbers to the nearest 10 or 100. (3.NBT.A.1)
__ Fluently add and subtract within 1000. (3.NBT.A.2)
__ Multiply one-digit whole numbers by multiples of 10 in the range 10-90. (3.NBT.A.3)
Fraction Operations
__ Describe a fraction a/b as the quantity (a) formed when a whole is divided into equal parts (b). (3.NF.A.1)
__ Represent a fraction on a number line from 0 to 1. (3.NF.A.2.A; 3.NF.A.2.B)
__ Describe two fractions as equivalent if they are the same size, or the same point on a number line.
(3.NF.A.3.A)
__ Generate simple equivalent fractions, e.g., 1/2 = 2/4, 4/6 = 2/3. (3.NF.A.3.B)
__ Express whole numbers as fractions, and recognize fractions that are equivalent to whole numbers.
(3.NF.A.3.C)
__ Compare two fractions (using symbols >, =, or <) with the same numerator or the same denominator by
reasoning about their size (3.NF.A.3.D)
Measurement and Data
__ Use and apply K-2 standards for measurement and data. [Please leave comments if this needs work.]
__ Tell and write time to the nearest minute and measure time intervals in minutes. (3.MD.A.1)
__ Solve word problems involving addition and subtraction of time intervals in minutes. (3.MD.A.1)
__ Measure and estimate liquid volumes and masses of objects using standard units of grams (g), kilograms
(kg), and liters (l). (3.MD.A.2)
__ Draw and use a scaled graph to represent a data set with several categories. (3.MD.B.3)
__ Measure area of plane figures by counting unit squares. (3.MD.C.6)
__ Relate area to the operations of multiplication and addition. (3.MD.C.7)
__ Solve real world and mathematical problems involving perimeters of polygons. (3.MD.D.8)
Geometry
__ Use and apply K-2 standards for geometry. [Please leave comments if this needs work.]
__ Categorize shapes according to shared attributes. (3.G.A.1)
__ Partition shapes into parts with equal areas. Express the area of each part as a unit fraction of the whole.
(3.G.A.2)
Student Last Name: ________________________
Part Two:
Thinking about the student’s test scores, performance in class, and your observations, please order the
categories in order of need for this particular student {1 (most needed)—6 (least needed)}.
_____ Counting and Cardinality
_____ Operations and Algebra
_____ Base Ten Operations (Place Value and Decimals)
_____ Fraction Operations
_____ Measurement and Data
_____ Geometry
Comments about this student’s math skill level: