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Social Development Commission
4041 N. Richards Street
Milwaukee, WI 53212
(P) 414-906-2836 (F) 414-906-2300
www.cr-sdc.org
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Referral Form for the Social Development Commission's
Wisconsin Competency Based High School Equivalency Diploma (DPI 5.09 Option) |
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PI 5.09 High School Equivalency Diploma based on completion of a program approved by the State Superintendent.
(1) A TCS district, college, university, community based organization, federal job corps center or the department of corrections may submit a plan to the State Superintendent requesting approval of a program for determining high school equivalency. The program shall be designed to determine whether a person has attained the knowledge and skills generally associated with graduation from high school, including employability skills, career awareness, citizenship, and each of the subject areas under s. 118.33 (1) (a), Stats., except physical education.
Further information can be found at: http://www.legis.state.wi.us/rsb/code/pi/pi005.pdf
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Referral Forms and Required Documentation are due by
January 1st for the spring semester -OR- August 1st for the fall semester
Referrals will be reviewed and considered in the order in which they are received.
Incomplete referrals will not be considered.
Questions should be directed to: Jake Gorges 414-906-2836
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Referral Date |
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Student's First Name |
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Student's Last Name |
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Student's Address |
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Student's City, State and Zip code |
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Student's Phone Number |
i.e. 414-123-4567 |
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Student's Date of Birth |
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Student's E-mail Address (if known) |
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Referring Agency |
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Education Site |
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Referring Instructor |
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Referring Instructor's Phone Number |
i.e. 414-123-4567 |
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Referring Instructor's E-mail Address |
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Along with the other eligibility requirements for the Social Development Commission's 5.09 program,
the student being referred must meet three (3) of the following four (4) criteria: |
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Special Education Needs |
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Ethnic Minority Status |
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Low Income |
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Unemployed / Underemployed / Structurally Displaced Worker / or Limited Career ~ Workplace Opportunities |
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Please Select One: |
Student will attend class Monday through Thursday
from 8:30 a.m. to 12:30 p.m. |
Student will attend class Monday through Thursday
from 4:30 p.m. to 8:30 p.m. |
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Student must meet ALL of the criteria below: |
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Student has demonstrated consistent attendance and effort the entire academic semester prior to being referred. |
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Student has demonstrated mastery in addition, subtraction, multiplication, and division of whole numbers independently, a working knowledge of decimals and fractions, and their math level is assessed at a TABE Level D or A (5.0 or higher). |
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Student's reading level is assessed at a TABE Level D or A (5.0 or higher). |
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Student is able to use a computer and is familiar with computer vocabulary. |
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Student has been working to obtain a GED / HSED via other available options and has not been successful. |
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Student is familiar with classroom instruction and consistently demonstrates good classroom etiquette. |
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Student is willing / able to work independently and collaboratively with others and in groups. |
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Please remember to provide any / all relevant information for this student including but not limited to:
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A list of all education / training programs attended
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Documentation of exceptional educational needs
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High school transcript and IEP
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Documentation of testing accommodations
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Copy of student's Personal Education Plan or other tool used to set goals
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Documentation of grievances petitioned by student and / or instructor
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Behavioral / disciplinary action plans
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Date of most recent TABE Assessment: TABE Type: |
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TABE Subject |
TABE Form |
TABE Level |
Number Correct |
Grade Equivalent |
Scale Score |
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Reading |
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Math |
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Language |
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Official Practice Test, Wide Range Achievement Test, Student Achievement in Reading
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General Education Development Test Results
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Date(s) |
Subject |
Type(s) or Test(s) Administered
(OPT, WRAT, STAR, or GED TEST)
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Score(s) |
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Reading |
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Social Studies |
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Science |
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Math |
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Writing |
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Instructor's reason for referral: Please explain in 100 - 200 words why you are referring this student to the PI 5.09 program. Include information regarding the referring student's attendance, work ethic, ability to cooperatively work with peers, academic strengths / weaknesses, and behavioral observations:
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Questions to be completed by the student
Copy and past student answers in fields below |
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1. How long have you been working towards your GED (list locations and approximate dates of attendance)?
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2. Do you have a documented disability? If so, please explain below - documentation is required.
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3. Do you have approved GED testing accommodations? If so, what are the approved accommodations?
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Please copy and paste a 100 - 200 word writing sample written by the referred student expressing why enrolling in the PI 5.09 program is a better option than attempting the five GED tests. The student must include their personal goals, career goals, and post-secondary educational goals.
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