6146.21 Form 1

20__ Connecticut MASTERY TEST (CMT)

Direct Assessment of Writing Test

Form to Request Review of Student Paper by CSDE s Scoring Contractor

DISTRICT ____________________________________________________________________

SCHOOL _____________________________________________________________________

STUDENT NAME ______________________________________________________________

STUDENT DATE OF BIRTH _____________________________________________________

GRADE ___________________________   STUDENT GENDER _______________________

Paper has been reviewed by trained personnel within the school district

         ___Yes            ___No

District reviewer(s) concluded that the paper has been mis-scored

          ___Yes            ___No

Superintendent s Name __________________________________________________________

Superintendent s Telephone _______________________________________________________

Superintendent s Signature _______________________________________________________

Send requests to:    CMT Testing Coordinator

CSDE

P.O. Box 2219, Room 344

Hartford, CT 06145-2219

Or Fax   860-713-7030

Deadline to receive this form is ________________________