File:  IKA-E - Parent Request for Refusal of State Assessments

DATE OF REQUEST: ____________________

STUDENT'S NAME: ___________________________________________________________

SCHOOL: ___________________________________________________________________

GRADE LEVEL: ______________________________________________________________

TEST BEING OPTED OUT:

___  CMAS (Colorado Measures of Success) DLM Mathematics Assessment
___  CMAS (Colorado Measures of Success) DLM English Language Arts Assessment
___  CMAS/CoAlt Science Assessment
___  CMAS/CoAlt Social Studies Assessment
___  College Proficiency Screener/Exam (e.g. PSAT/SAT)

REASON FOR OPTING OUT OF THE TEST:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

INFORMATION OF PARENT/GUARDIAN REQUESTING THE OPT-OUT

PARENT/GUARDIAN NAME: _________________________________________________________

CONTACT NUMBER/EMAIL: _________________________________________________________

I understand that by opting my child out of the test(s) indicated above, that the following may result:

•  My child's school's overall performance results may be impacted at the local, state and federal level.

•  My child will not have performance or growth data to demonstrate how he/she is performing as compared to others in the school, district, state or nation.

•  My child will not have growth data to demonstrate how he/she is learning across school years.

_____________________________________     ______________________________________
PARENT/GUARDIAN SIGNATURE                             SCHOOL PRINCIPAL SIGNATURE

_________________ DATE RECEIVED BY DISTRICT ASSESSMENT DEPARTMENT

Revised March 12, 2020