LOS ANGELES UNIFIED SCHOOL DISTRICT
REFERENCE GUIDE
REF-105701.0
Office of Data and Accountability Page 11 of 14 January 25, 2021
Attachment A
ELPAC Assessment Recommendation Form
Students Needing DESIGNATED SUPPORTS
Some students may need access to designated supports to participate in the ELPAC assessments. These designated supports must be
documented via Attachment A. The decision must be signed by both the teacher and a school administrator. A copy of Attachment A
must be forwarded to the school’s ELPAC coordinator and stored in a secure location prior to the first day of the onset of testing.
School: School Code: Date:
Student Name: Student SSID: Grade:
If the student has an IEP, check to indicate that the case carrying teacher has been consulted regarding recommendations included on
this form. If not, do not proceed.
Reason for Designated Support/s: (include description of injury as appropriate for students with temporary or recent injuries)
EMBEDDED DESIGNATED SUPPORTS:
Color Contrast:
Reverse Contrast
Black on Rose
Medium Gray on Light Gray
Yellow on Blue
Mouse Pointer (Size and Color):
Large, black XL, black
Large, green XL, green
Large, red XL, red
Large, white XL, white
Large, yellow XL, yellow
Print Size:
1.5 X 2.5 X
1.75 X 3 X
Masking
Pause or Replay Audio – Listening domain
Pause or Replay Audio – Speaking domain
Streamline
Turn Off Universal Tools
NON-EMBEDDED DESIGNATED SUPPORTS:
Amplification
Color Contrast
Color Overlay
Designated Interface Assistant (DIA)
Magnification
Medical Supports
Noise Buffers
Pause or Replay Audio – Listening domain
Pause or Replay Audio – Speaking domain
Print on Demand (contact Student Testing Branch)
Read-Aloud Items (Writing Domain)
Separate Setting
Simplified Test Directions
Translated Test Directions (PDFs only)
Teacher Signature: ________________________________________________ Date: ________________
School Administrator: ______________________________________________ Date: ________________
Date Entered In TOMS: _______________ Name: ___________________________ Title: ________________
