30
_____________________________________________________________________________ Appendix E: Assessment Blackline Masters E–1 Appendix E: Assessment Blackline Masters Self-Assessment Checklist ......................................................................................... E–2 Self-Assessment Rating Scale ................................................................................... E–4 Peer-Assessment Checklist ........................................................................................ E–6 Self-Assessment Checklist and Goal-Setting .......................................................... E–8 Long-Term Goal-Setting ............................................................................................ E–10 Anecdotal Notes ........................................................................................................ E–12 Observation Checklist ............................................................................................... E–14 Checklist and Comments 1 ...................................................................................... E–16 Checklist and Comments 2 ...................................................................................... E–18 Rating Scale 1 ............................................................................................................. E–20 Rating Scale 2 ............................................................................................................. E–22 Rating Scale 3 ............................................................................................................. E–24 Rubric ........................................................................................................................... E–26 Rubric and Checklist .................................................................................................. E–28

Appendix E: Assessment Blackline Masters - · PDF fileE Appendix E: Assessment Blackline Masters –1 ... to short text and record main points 6. 2- ... variety of classroom, school,

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_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–1

Appendix E: Assessment Blackline Masters Self-Assessment Checklist ......................................................................................... E–2

Self-Assessment Rating Scale ................................................................................... E–4

Peer-Assessment Checklist ........................................................................................ E–6

Self-Assessment Checklist and Goal-Setting .......................................................... E–8

Long-Term Goal-Setting ............................................................................................ E–10

Anecdotal Notes ........................................................................................................ E–12

Observation Checklist ............................................................................................... E–14

Checklist and Comments 1 ...................................................................................... E–16

Checklist and Comments 2 ...................................................................................... E–18

Rating Scale 1 ............................................................................................................. E–20

Rating Scale 2 ............................................................................................................. E–22

Rating Scale 3 ............................................................................................................. E–24

Rubric ........................................................................................................................... E–26

Rubric and Checklist .................................................................................................. E–28

________________________________________________________________________________

E-2 G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s

Self-Assessment Checklist

Name: Udo Klasse: 4 Datum: d e r 2 . M ä r z

Ich kann … Ja! Noch nicht

talk about how German words and English words are sometimes similar

tell when someone has not understood what I have said

use gestures to help myself made understood

ask for help when I am stuck

make mistakes in German and not get discouraged

check my work to fix mistakes

Note: This sample self-assessment checklist allows students to indicate their ability to perform

various criteria.

_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–3

Self-Assessment Checklist

Name: Klasse: Datum: Ich kann … Ja! Noch

nicht

________________________________________________________________________________

E-4 G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s

Self-Assessment Rating Scale

Name: Sophia Klasse: 5 Datum: der 3. März

Ich kann Nie Manchmal Meistens Immer

• talk about a story

• describe the characters

• talk about the problem

• talk the about the ending

• draw a picture about the story

• _____________________________

• ______________________________

Note: This self-assessment rating scale demonstrates how students can assess their performance as it relates to particular outcomes. The teacher decides whether or not to follow up with other activities, such as goal-setting.

_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–5

Self-Assessment Rating Scale

Name: Klasse: Datum:

Ich kann Nie Manchmal Meistens Immer

________________________________________________________________________________

E-6 G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s

Peer-Assessment Checklist

Name: Nicole Klasse: 6 Datum: d e r 3 . M ä r z

Mein Partner / Patnerin Janelle Aufgabe: Gedicht “Mein Name”

Mein Partner/Meine Partnerin kann … Ja! Noch nicht

write a descriptive word in German for each letter in her name

write descriptive words that are positive and describe her well

use a dictionary or vocabulary list to find words to use

use a dictionary to check the spelling of the words

draw pictures that match the descriptive words she used

Gute Arbeit: You picked really good German words to describe yourself—some of

them were from our new vocabulary list.

Was besser sein könnte: Check your spelling using a dictionary or our

vocabulary lists. We wrote lots of these words down in our learning logs so they

might be there.

Note: This peer-assessment checklist allows students to give each other feedback about particular aspects of their work. Comments written should be constructive and specific.

_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–7

Peer-Assessment Checklist

Name: Klasse: Datum: Mein Partner/ Meine Partnerin:

Aufgabe:

Mein Partner kann/Meine Partnerin kann … Ja! Noch nicht

Gute Arbeit:

Was besser sein könnte:

________________________________________________________________________________

E-8 G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s

Self-Assessment Checklist and Goal-Setting

Name: Julia Klasse: 4 Datum: der 1. Oktober Ich kann…

Ja!

Noch nicht

Was ich machen werde ...

say hello and goodbye

Say hello and goodbye in German to at least three people each day.

listen to other people’s opinions

Write down in my learning log the opinion of one person from my group.

tell others my opinion

Learn words to help me express my opinion.

get along with group members

Make sure that everyone has a chance to speak next time we work in groups.

Note: Self-Assessment Checklist and Goal-Setting allows students to assess their abilities and set goals to improve.

_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–9

Self-Assessment Checklist and Goal-Setting

Name: Klasse: Datum: Ich kann …

Ja!

Noch nicht

Was ich machen werde ...

________________________________________________________________________________

E-10 G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s

Long-Term Goal-Setting

Name: Robert Klasse: 4 Datum: der 1. Okober

Goal #1:

By the end of this term, I would like to: know what to say to ask for directions in

German.

To achieve this goal, I will: look up the words I need to know and write a role-

play to perform with a friend.

My teacher can help me: with my pronunciation and make sure I am saying

things properly.

My parents can help me by: practising my role-play with me at home.

Goal #2:

By the end of this term, I would like to: learn more about what life was like in

Germany in the Middle Ages.

To achieve this goal, I will: research on the Internet and find books in the library.

My teacher can help me by: finding a helpful book in the library and finding

good websites on the Internet.

My parents can help me by: helping me understand the books I’m reading.

Note: This goal-setting sheet allows students to set long-term goals for their own learning and

could be included in students’ learning logs.

_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–11

Long-Term Goal-Setting

Name: Klasse: Datum: Goal #1:

By the end of this term, I would like to:

To achieve this goal, I will:

My teacher can help me:

My parents can help me:

Goal #2:

By the end of this term, I would like to:

To achieve this goal, I will:

My teacher can help me:

My parents can help me:

G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s E–12

Ane

cdot

al N

otes

Stud

ent

Nam

e Da

te

Act

ivity

O

utco

me

Yes

Not

Ye

t C

omm

ents

M

iche

l Ja

n. 8

S

tude

nts

liste

n to

sh

ort t

ext

and

reco

rd

mai

n po

ints

6.2

Lang

uage

Com

pete

nce/

List

enin

g—lis

ten

to

and

unde

rsta

nd th

e m

ain

poin

ts o

f an

oral

pr

esen

tatio

n on

a fa

mili

ar to

pic

in s

truct

ured

and

un

stru

ctur

ed s

ituat

ions

(Gra

de 4

)

See

med

to u

nder

stan

d th

e te

xt in

gen

eral

but

m

isse

d on

e m

ain

poin

t.

Josh

Ja

n. 8

S

tude

nts

liste

n to

sh

ort t

ext

and

reco

rd

mai

n po

ints

6. L

angu

age

Com

pete

nce/

List

enin

g—lis

ten

to

and

unde

rsta

nd th

e m

ain

poin

ts o

f an

oral

pr

esen

tatio

n on

a fa

mili

ar to

pic

in s

truct

ured

and

un

stru

ctur

ed s

ituat

ions

(Gra

de 4

)

Mad

e so

me

erro

rs, f

ollo

wed

som

e co

mm

ands

co

rrec

tly; w

ill d

o m

ore

revi

ew o

f voc

abul

ary.

Ali

Jan.

15

Co-

oper

ativ

e gr

oup

lang

uage

5.2

Enc

oura

ge, S

uppo

rt, a

nd W

ork

with

Oth

ers/

C

o-op

erat

e w

ith O

ther

s—ap

prec

iate

that

ev

eryo

ne in

a g

roup

has

to w

ork

toge

ther

to

achi

eve

grou

p ta

sks

and

act a

ccor

ding

ly

(Gra

de 4

)

Con

sist

ently

and

acc

urat

ely

used

turn

-taki

ng

voca

bula

ry.

Jann

a Ja

n. 1

5 S

mal

l gro

up

disc

ussi

on

5.2

Enc

oura

ge, S

uppo

rt, a

nd W

ork

with

Oth

ers/

C

o-op

erat

e w

ith O

ther

s—ap

prec

iate

that

ev

eryo

ne in

a g

roup

has

to w

ork

toge

ther

to

achi

eve

grou

p ta

sks

and

act a

ccor

ding

ly

(Gra

de 4

)

Som

etim

es a

cted

out

of t

urn

and

spok

e w

hen

othe

rs w

ere

talk

ing.

Mar

ika

Jan.

17

Sm

all g

roup

di

scus

sion

5.

2 E

ncou

rage

, Sup

port,

and

Wor

k w

ith O

ther

s/

Co-

oper

ate

with

Oth

ers—

appr

ecia

te th

at

ever

yone

in a

gro

up h

as to

wor

k to

geth

er to

ac

hiev

e gr

oup

task

s an

d ac

t acc

ordi

ngly

(G

rade

4)

Unp

rodu

ctiv

e an

d ac

ted

out o

f tur

n to

day.

Will

disc

uss

with

her

afte

r cla

ss. C

heck

aga

in n

ext

clas

s.

Mar

ika

Jan.

25

Sm

all g

roup

di

scus

sion

6.

1 Li

ngui

stic

Ele

men

ts/V

ocab

ular

y—ex

perim

ent

with

and

use

voc

abul

ary

and

expr

essi

ons

in a

va

riety

of c

lass

room

, sch

ool,

and

com

mun

ity

cont

exts

(Gra

de 4

)

Use

d so

me

exce

llent

exp

ress

ions

whi

le

pres

entin

g a

role

-pla

y.

Mic

hel

Jan.

25

Sha

ring

circ

le

6.1

Ling

uist

ic E

lem

ents

/Voc

abul

ary—

expe

rimen

t w

ith a

nd u

se v

ocab

ular

y an

d ex

pres

sion

s in

a

varie

ty o

f cla

ssro

om, s

choo

l, an

d co

mm

unity

co

ntex

ts (G

rade

4)

Impr

oved

spo

ntan

eous

use

of a

ppro

pria

te

voca

bula

ry.

Not

e: T

hese

ane

cdot

al n

otes

allo

w te

ache

rs to

gat

her i

nfor

mat

ion

abou

t sev

eral

diff

eren

t stu

dent

s as t

heir

perf

orm

ance

re

late

s to

diff

eren

t lea

rnin

g ou

tcom

es a

t diff

eren

t tim

es. I

n th

is sa

mpl

e, w

here

ver a

n un

satis

fact

ory

perf

orm

ance

was

ob

serv

ed, t

he te

ache

r pla

nned

ano

ther

opp

ortu

nity

to o

bser

ve th

e sa

me

stud

ent c

ompl

ete

an a

ctiv

ity in

whi

ch th

e sa

me

lear

ning

out

com

e is

add

ress

ed. T

he in

form

atio

n pr

ovid

ed b

y us

ing

this

type

of t

ool c

an b

e us

ed to

mod

ify

futu

re in

stru

ctio

n or

to d

iscu

ss st

uden

ts’ l

earn

ing.

A p p e n d i x E : B l a c k l i n e M a s t e r s E–13

Ane

cdot

al N

otes

Stud

ent

Nam

e Da

te

Act

ivity

O

utco

me

Yes

Not

Ye

t C

omm

ents

G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s E–14

Obs

erva

tion

Che

cklis

t

Stud

ent

Dat

e A

ctiv

ity

Out

com

e St

uden

t dem

onst

rate

s th

at h

e or

she

has

met

th

e ou

tcom

e.

Lees

a Se

pt. 2

3 Si

ngin

g G

erm

an s

ongs

7.

1 Se

lf-Id

entif

y/Va

luin

g G

erm

an la

ngua

ge a

nd th

e cu

lture

s of

G

erm

an-s

peak

ing

peop

les

(Gra

de 4

)

Yes

N

ot Y

et

M

arc

Sept

. 23

Sing

ing

Ger

man

son

gs

7.1

Self-

Iden

tify/

Valu

ing

Ger

man

lang

uage

and

the

cultu

res

of

Ger

man

-spe

akin

g pe

ople

s (G

rade

4)

Ye

s

Not

Yet

Andr

eas

Sept

. 23

Sing

ing

Ger

man

son

gs

7.1

Self-

Iden

tify/

Valu

ing

Ger

man

lang

uage

and

the

cultu

res

of

Ger

man

-spe

akin

g pe

ople

s (G

rade

4)

Ye

s

Not

Yet

Su

Mei

O

ct. 1

W

ord

stud

y 6.

1 Li

ngui

stic

Ele

men

ts/S

ound

-Sym

bol S

yste

m—

cons

iste

ntly

us

e, in

stru

ctur

ed s

ituat

ions

, all

elem

ents

of t

he s

ound

-sym

bol

syst

em (G

rade

4)

Ye

s

Not

Yet

Jack

O

ct. 1

W

ord

stud

y 6.

1 Li

ngui

stic

Ele

men

ts/S

ound

-Sym

bol S

yste

m—

cons

iste

ntly

us

e, in

stru

ctur

ed s

ituat

ions

, all

elem

ents

of t

he s

ound

-sym

bol

syst

em (G

rade

4)

Ye

s

Not

Yet

Ali

Oct

. 10

Secr

et w

ord

gam

e 6.

1 Li

ngui

stic

Ele

men

ts/S

ound

-Sym

bol S

yste

m—

cons

iste

ntly

us

e, in

stru

ctur

ed s

ituat

ions

, all

elem

ents

of t

he s

ound

-sym

bol

syst

em (G

rade

4)

Ye

s

Not

Yet

May

a O

ct. 1

0 Se

cret

wor

d ga

me

6.1

Ling

uist

ic E

lem

ents

/Sou

nd-S

ymbo

l Sys

tem

—co

nsis

tent

ly

use,

in s

truct

ured

situ

atio

ns, a

ll el

emen

ts o

f the

sou

nd-s

ymbo

l sy

stem

(Gra

de 4

)

Ye

s

Not

Yet

Phili

p O

ct. 1

0 Se

cret

wor

d ga

me

6.1

Ling

uist

ic E

lem

ents

/Sou

nd-S

ymbo

l Sys

tem

—co

nsis

tent

ly

use,

in s

truct

ured

situ

atio

ns, a

ll el

emen

ts o

f the

sou

nd-s

ymbo

l sy

stem

(Gra

de 4

)

Ye

s

Not

yet

Sim

one

Oct

. 25

Ded

uce

wor

d pa

ttern

rule

6.

4 La

ngua

ge L

earn

ing

Stra

tegi

es/C

ogni

tive—

iden

tify

and

use

a va

riety

of c

ogni

tive

stra

tegi

es to

enh

ance

lang

uage

lear

ning

(e

.g.,

use

men

tal i

mag

es to

rem

embe

r new

info

rmat

ion,

repe

at

wor

ds o

r phr

ases

in th

e co

urse

of p

erfo

rmin

g a

lang

uage

task

) (G

rade

4)

Ye

s

Not

yet

Nou

r O

ct. 2

7 D

educ

e w

ord

patte

rn ru

le

6.4

Lang

uage

Lea

rnin

g St

rate

gies

/Cog

nitiv

e—id

entif

y an

d us

e a

varie

ty o

f cog

nitiv

e st

rate

gies

to e

nhan

ce la

ngua

ge le

arni

ng,

(e.g

., us

e m

enta

l im

ages

to re

mem

ber n

ew in

form

atio

n, re

peat

w

ords

or p

hras

es in

the

cour

se o

f per

form

ing

a la

ngua

ge ta

sk)

(Gra

de 4

)

Ye

s

Not

yet

Not

e: I

n ca

ses w

here

the

stud

ent d

oes n

ot d

emon

stra

te a

par

ticul

ar c

riter

ion,

the

teac

her s

houl

d pl

an a

n ap

prop

riate

in

terv

entio

n.

A p p e n d i x E : B l a c k l i n e M a s t e r s E–15

Obs

erva

tion

Che

cklis

t

Stud

ent

Date

A

ctiv

ity

Out

com

e St

uden

t dem

onst

rate

s th

at h

e or

she

has

met

th

e ou

tcom

e.

Ye

s

Not

Yet

Ye

s

Not

Yet

Yes

N

ot Y

et

Yes

N

ot Y

et

Yes

N

ot Y

et

Yes

N

ot Y

et

Yes

N

ot Y

et

Yes

N

ot Y

et

Yes

N

ot Y

et

Yes

N

ot Y

et

________________________________________________________________________________

E-16 G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s

Checklist and Comments 1

Grade: 4 Date: May 3 Activity: Individual Q and A

Specific Outcome: 6.5 Language Use Strategies/interactive—identify and use a

variety of interactive strategies (e.g., use the other speaker’s words in

subsequent conversation)

Has met the outcome: Student Names: Yes Not Yet

• Jan • Al • Freddie • Kevin • Marissa • Su Mei • Ab • Elise • Nour • Benjamin • Lydia • Franco

Notes for future planning: Do a role-play activity in which we talk about productive

strategies students can use when speaking German (e.g., use non-verbal means to

communicate; use familiar repetitive patterns from stories, songs, and rhymes;

compensate for avoiding difficult structures by rephrasing). Students then record the

ideas in their learning logs and set goals for using them. Note: This checklist and comments tool demonstrates how a teacher can gather information on

several students’ performances as they relate to one learning outcome. The teacher can also plan for future instruction.

_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–17

Checklist and Comments 1

Grade: Date: Activity:

Specific Outcome:

Has met the outcome: Student Names: Yes Not Yet

• • • • • • • • • • • •

Notes for future planning:

________________________________________________________________________________

E-18 G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s

Checklist and Comments 2

Grade: 4 Date: October 5 Activity: Interview a classmate about interests and hobbies

Specific Outcome(s): 6.3 Sociocultural/Sociolinguistic Elements/Register—

experiment with formal and informal uses of language in familiar contexts

Lance can: (Student name) Yes Not Yet

• ask classmate appropriate questions

• respond to classmate’s answers

• pronounce words comprehensibly

• use intonation to express inquiry

• use appropriate vocabulary related to hobbies and interests

• • • • •

Done well: Seems to have a good understanding of the vocabulary.

Could improve: Seems not to understand intonation and how it can affect meaning.

Note: This checklist and comments tool demonstrates how a teacher can record information about student performance against several criteria. In this sample, the student is being assessed against the same criteria found in the sample rubric. The teacher could use a checklist to check student performance part of the way through a task, such as a telephone conversation.

_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–19

Checklist and Comments 2

Grade: Date: Activity:

Specific Outcome(s):

can: (Student name) Yes Not Yet

Done well:

Could improve:

________________________________________________________________________________

E-20 G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s

Rating Scale 1

Grade: 4 Date: March 10 Activity: Group classroom scavenger hunt

Specific Outcome: 5.2 Encourage, Support, and Work with Others/Co-operate

with Others—appreciate that everyone in a group has to work together to

achieve group tasks and act accordingly

Student meets the outcome:

Student Names: Never Sometimes Usually Always

• Jeremy

• David

• Raj

• Sunita

• Alicia

• Kendra

• Taylor

• Billy

• Dimitri

• Kim

• Tran

• Frida

• Tim

• Tania

• George

• Lilly

• Hannah

• Wes

Note: This sample rating scale demonstrates how a teacher can record the levels of performance for several students, based on a particular outcome.

_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–21

Rating Scale 1

Grade: Date: Activity:

Specific Outcome:

Student meets the outcome: Student Name: Never Sometimes Usually Always

________________________________________________________________________________

E-22 G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s

Rating Scale 2

Grade: 4 Date: November 12 Activity: Unit: German Fairy Tales Specific Outcome(s): 1.1 Discover and Explore/Experiment with Language;

3.2 Select and Process/Identify Personal and Peer Knowledge; 6.1 Linguistic

Elements/Vocabulary; 6.2 Language Competence/Writing; 6.5 Language Use

Strategies/Productive

Student Name: Tania Criteria: Never Sometimes Usually Always

• was able to share basic information about a story read as a group

• identified the characters in the story correctly

• used descriptive words to describe the character

• wrote words and phrases clearly and correctly

• used illustrations to provide relevant details about the story

Note: This sample rating scale demonstrates how a teacher could record information about the quality of a student’s performance as it relates to learning outcomes.

_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–23

Rating Scale 2

Grade: Date: Activity:

Specific Outcome(s):

Student Name: Criteria: Never Sometimes Usually Always

________________________________________________________________________________

E-24 G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s

Rating Scale 3

Grade: 4 Date: March 10 Activity: Reading out some familiar words

Specific Outcome(s): 6.1 Linguistic Elements/Sound-Symbol System—consistently

use, in structured situations, all elements of the sound-symbol system

Levels of performance and corresponding criteria: Demonstrated excellent pronunciation on all words—no errors Demonstrated good pronunciation on almost all words—a few errors Demonstrated acceptable pronunciation on most words—several errors but

still comprehensible Demonstrated lots of errors—mostly incomprehensible

Name of Student: Name of Student: Saresh Derek Crystal Dakota Ellen Troy Jonathan Sam Jim Sal Rebecca Steven Janice Tran Polly

Note This rating scale provides an example of how a teacher can quickly indicate levels of students’ performances as they relate to one outcome.

_____________________________________________________________________________ A p p e n d i x E : A s s e s s m e n t B l a c k l i n e M a s t e r s E–25

Rating Scale 3

Grade: Date: Activity:

Specific Outcome(s):

Levels of performance and corresponding criteria:

Name of Student: Name of Student:

G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s E–26

Rubr

ic (G

rade

4)

Nam

e:

Jean

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6.3

Soci

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la

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.

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6.3

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A p p e n d i x E : B l a c k l i n e M a s t e r s E–27

Rubr

ic

Nam

e:

Da

te:

A

ctiv

ity:

Out

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G r a d e 4 t o G r a d e 6 G e r m a n L a n g u a g e A r t s E–28

Rubr

ic a

nd C

heck

list

Nam

e:

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Act

ivity

: Te

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6.3

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la

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.

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.

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.

6.3

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ts

– so

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l co

nven

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uent

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ses a

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an p

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ent f

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e sa

me

asse

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ent t

ool.

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com

bina

tion

of ru

bric

and

che

cklis

t rec

ords

info

rmat

ion

abou

t a st

uden

t’s p

erfo

rman

ce

acco

rdin

g to

spec

ific

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omes

, as w

ell a

s inf

orm

atio

n ab

out a

stud

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wor

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bits

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n a

stud

ent d

emon

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tes a

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man

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at is

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teac

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o re

cord

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ason

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id n

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orm

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cept

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stan

dard

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vide

a p

lan

for f

utur

e im

prov

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t.

A p p e n d i x E : B l a c k l i n e M a s t e r s E–29

Rubr

ic a

nd C

heck

list

Nam

e:

Da

te:

A

ctiv

ity:

Out

com

e Ex

celle

nt

Very

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d A

ccep

tabl

e Lim

ited

Wor

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d in

depe

nden

tly

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orke

d w

ith s

ome

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tanc

e

w

orke

d w

ith m

inim

al a

ssist

ance

requ

ired

cons

tant

sup

ervi

sion

and

assis

tanc

e