Fillable Alternate Assessment Decision Conrmation Worksheet (California)

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Alternate Assessment Decision Conrmation Worksheet (California)

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Alternate Assessment
Decision Conrmation Worksheet
This document conrms the decision of the individualized education
program (IEP) team that the student is eligible to participate in the
California Alternate Assessments (CAAs) and the Alternate English
Language Prociency Assessments for California (Alt-ELPAC). For more
information, refer to the Alternate Assessment IEP Team Guidance web
page at https://www.cde.ca.gov/ta/tg/ca/caaiepteamrev.asp.
Participation in Alternate Assessments
Does the student have a significant cognitive disability and an IEP?
If yes, continue with this conrmation worksheet. If no, the student is not eligible to take alternate
assessments.
If yes, the IEP team conrms that a review of the student’s records and IEP indicates a disability or
multiple disabilities that signicantly impact intellectual functioning and adaptive behavior. Adaptive
behavior is dened as behavior that is essential for a person to live independently and to function
safely in daily life. Sources of evidence may include, but are not limited to, results of the following:
Yes No
• Individual cognitive ability test
• Adaptive behavior skills assessment
• Informal assessments
• Individual reading assessments
• Districtwide alternate assessments
• Achievement tests
• Language assessments, including
English learner (EL) language
assessments, if applicable
If yes, the student is eligible for the following assessments:
• CAA for English language arts/literacy
• CAA for Mathematics
• CAA for Science
• Initial Alt-ELPAC, if the student’s Home Language Survey indicates a
primary language other than English
• Summative Alt-ELPAC, if the student is identied as an EL
Alignment with Standards
Students eligible for an alternate assessment should be learning content aligned with the
California Common Core State Standards (CA CCSS), the California Next Generation Science
Standards (CA NGSS), or, as applicable, the 2012 California English Language Development
Standards (2012 CA ELD Standards).
Goals and instruction listed in the IEP for this student are aligned with the enrolled grade-level
CA CCSS, CA NGSS, and 2012 CA ELD Standards.
Sources of evidence may include, but are not limited to, the following:
• Progress monitoring data
• Present levels of academic and functional performance,
goals, and objectives from the IEP
• Data from scientic research-based interventions
• Examples of curriculum, instructional objectives,
and materials
The IEP team confirms that the student is or will be learning content aligned with the
standards listed above.
California Department of Education • November 2019
Alternate Assessment Participation Decision Worksheet (continued)
Instruction and Supports
Students eligible for an alternate assessment require extensive, direct individualized instruction and
substantial supports to achieve measurable gains in the grade- and age-appropriate curriculum.
The student (a) requires extensive repeated, individualized instruction and support that is not of
a temporary nature; and (b) uses substantially adapted materials and individualized methods of
accessing information in alternative ways to acquire, maintain, generalize, demonstrate, and transfer
skills across academic content.
Sources of evidence may include, but are not limited to, the following:
• Examples of curriculum, instructional objectives,
and materials, including work samples from both
school- and community-based instruction
• Teacher-collected data and checklists
• Present levels of academic and functional performance,
goals, objectives, and post-school outcomes from the
IEP and the transition plan for students aged sixteen
and older
The IEP team confirms that the student is or will be receiving extensive direct
individualized instruction and substantial supports to achieve measurable gain.
IEP Team Statement of Assurance: Our decision was based on multiple pieces of evidence that,
when taken together, demonstrated that the Alternate Assessment is the most appropriate assessment
for this student. The student has been determined to be the most signicantly cognitively impaired; the
student has been shown to require extensive, direct individualized instruction and substantial supports
to achieve measurable gains on the challenging state alternate academic achievement/performance
content standards for the grade in which the student is enrolled; the student was not identied solely
on the basis of the student’s previous low academic achievement or the student’s previous need for
accommodations to participate in general state or districtwide assessments; and that any additional
implications of this decision were discussed thoroughly.
Each of us agrees with the IEP team decision to use the Alternate Assessment:
Name: Position: Date:
Name:
Position: Date:
Name:
Position: Date:
Name: Position: Date:
Name: Position: Date:
Parent/Guardian:
Date:
California Department of Education • November 2019
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Completed 4 June 2021

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