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Adult Independent Study - Work Assignment Sheet
World History 1Assignment 1 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
ASSIGNMENT GRADE1A Complete Geography Handbook Activity.
1B Using glossary, complete Key Terms Worksheet 1-1.
1C MT: Read Pg. 121-129. Complete Activity Reading NoteTaking Guide for Chapter 1, Section 1: The First Civilization.
1D Complete Section Quiz 1-1.
1E Complete Critical Thinking Worksheet 1.
1F Using the glossary, complete Key Terms Worksheet for Chapter 1 - Section 2.
1G Complete Geography Activity 1.
1H MT: Read Pg. 134-141. Complete Activity Reading Note-Taking Guide for Chapter 1, Section 2: The Civilization of the Greeks.
1I Complete Section Quiz 1-2.
1J Complete Critical Thinking Worksheet 2.
ASSIGNMENT GRADE1K Using the glossary, complete Key Terms for Chapter 1- Section 3Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 2 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
1L MT: Read Pg. 144-151. Complete Activity Reading Note-Taking Guide for Chapter 1, Section 3; Rome and the Rise of Christianity.
1M Complete Section Quiz 1-3
1N Complete Critical Thinking Worksheet 3.
1O Using the glossary, complete Key Terms Worksheet for Chapter 1- Section 4.
1P MT: Read Pg. 152-159. Complete Activity Reading Note-Taking Guide for Chapter 1, Section 4: New Patterns of Civilization.
1Q Complete Section Quiz 1-4.
1R Complete Critical Thinking Worksheet 4.
1S Complete Chapter Review for Chapter 1 ------
1T Complete Chapter Test for Chapter 1.
Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 3 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
ASSIGNMENT GRADE2A Using the glossary, complete Key Terms Worksheet for Chapter 2 - Section 1.
Revolution.
2B MT: Read Pg. 175-182. Complete Active Note-Taking Guide for Chapter 2, Section 1: The Glorious
2C Complete Section Quiz 2-1.
2D Complete Critical Thinking Worksheet 5.
2E Using the glossary, complete Key Terms Worksheet for Chapter 2 - Section 2.
2F MT: Read Pg. 183-189. Complete Active Reading Note-Taking Guide for Chapter 2, Sections 2: The Enlightenment.
2G Complete Section Quiz 2-2.
2H Complete critical Thinking Worksheet 6.
ASSIGNMENT GRADECircle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 4 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
2I Using the glossary, complete Key Terms Worksheet for Chapter 2 - Section 3.
2J MT: Read Pg. 190-197. Complete Active Note-Taking Guide for Chapter 2, Section 3: The American Revolution.
2K Complete Section Quiz 2-3.
2L Complete Critical Thinking Worksheet 7.
2M Complete Chapter 2 Test Review Guide ------
2N Complete Chapter 2 Test.
Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 5 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
ASSIGNMENT GRADE3A Using the glossary, complete Key Terms Worksheet for Chapter 3 - Section 1.
3B MT: Read Pg. 211-218. Complete Active Reading Note-Taking Guide for Chapter 3, Section 1: The French Revolution Begins.
3C Complete Section Quiz 3-1.
3D Complete Critical Thinking Worksheet 8.
3E Using the glossary, complete the Key Terms Worksheet for Chapter 3 - Section
3F MT: Pg. 219-225. Complete Active Reading Note-Taking Guide for Chapter 3, Section 2: Radical Revolution and Reaction.
3G Complete Section Quiz 3-2.
3H Complete Critical Thinking Worksheet 9.
Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 6 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
ASSIGNMENT GRADE3I Using the glossary, complete Key Terms Worksheet for Chapter 3 - Section 3.
3J MT: Read Pg. 228-235. Complete Active Reading Note-Taking Guide for Chapter 3, Section 3: The Age of Napoleon.
3K Complete Geography Activity 3.
3L Complete Section Quiz 3-3.
3M Complete Critical Thinking Worksheet 10.
3N Complete Chapter 3 Test Review Guide. ------
3O Complete Chapter 3 Test.
Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 7 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
ASSIGNMENT GRADE4A Using the glossary, complete Key Terms Worksheet for Chapter 4 - Section 1. 4
4B MT: Read Pg. 253-270. Complete Active Reading Note-Taking Guide for Chapter 4, Section 1: The Industrial Revolution.
4C Complete Section Quiz 4-1.
4D Complete Critical Thinking Worksheet 11.
4E Using the glossary, complete the Key Terms Worksheet for Chapter 4 - Section 2.
4F MT: Read Pg. 264-270. Complete Active Reading Note-Taking Guide for Chapter 4, Section 2: Reaction and Revolution.
4G Complete Section Quiz 4-2.
4H Complete Critical Thinking Worksheet 12.
Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 8 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
ASSIGNMENT GRADE4I Using the glossary, complete Key Terms Worksheet for Chapter 4 - Section 3.4J MT: Read Pg. 271-279. Complete Active Reading Note-Taking Guide for
Chapter 4, Section 3: National Unification and the National State.4K Complete Geography Activity 4.
4L Complete Section Quiz 4-3.
4M Complete Critical Thinking Worksheet 13.
4N Using the glossary, complete the Key Terms Worksheet for Chapter 4 – Section 4.
4O MT: Read Pg. 280-285. Complete Active Reading Note-Taking Guide for Chapter 4, Section 4: Culture: Romanticism and Realism.
4P Complete Section Quiz 4-4.
4Q Complete Critical Thinking Worksheet 14.
4R Complete Chapter 4 Test Review Guide. ------
4S Complete Chapter 4 Test Form A.
ASSIGNMENT GRADE
Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 9 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
5A Using the glossary, complete the Key Terms Worksheet for Chapter 5 -Section 1.
5B MT: Read Pg. 295-300. Complete Active Reading Note-Taking Guide for Chapter 5, Section 1: The Growth of Industrial Prosperity.
5C Complete Geography Activity 5.
5D Complete Section Quiz 5-1.
5E Complete Critical Thinking Worksheet 15.
5F Using the glossary, complete the Key Terms Worksheet for Chapter 5 - Section 2. MT: Read Pg. 301-309. Complete Active Reading Note-Taking Guide for Chapter 5, Section 2; Culture: The Emergence of Mass Society
5H Complete Section Quiz 5-2.
5I Complete Critical Thinking Worksheet 16.
Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 10 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
ASSIGNMENT GRADE5J Using the glossary, complete Key Terms Worksheet for Chapter 5 -Section 3.
5K MT: Read Pg. 312-318. Complete Active Reading Note-Taking Guide for Chapter 5, Section 3: The National State and Democracy.
5L Complete Section Quiz 5-3.
5M Complete Critical Thinking Worksheet 17.
5N Using the glossary, complete the Key Terms Worksheet for Chapter 5 - Section 4.
5O MT: Read Pg. 319-325. Complete Active Reading Note-Taking Guide for Chapter 5, Section 4: Culture: Toward the Modern Consciousness.
5P Complete Section Quiz 5-4.
5Q Complete Critical Thinking Worksheet 18.
5R Complete Chapter 5 Test Review Guide. ------
5S Complete Chapter 5 Test Form A.
ASSIGNMENT GRADE6A Using the glossary, complete Key Terms Worksheet for Chapter 6 - Section 1.Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 11 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
6B Complete Geography Activity 6.
6C MT: Read Pg. 335-341. Complete Active Reading Note-Taking Guide for Chapter 6, Section 1: Colonial Rule in Southeast Asia.
6D Complete Section Quiz 6-1.
6E Complete Critical Thinking Worksheet 19.
6F Using the glossary, complete the Key Terms Worksheet for Chapter 6 -Section 2.
6G MT: Read Pg. 342-349. Complete Active Reading Note-Taking Guide for Chapter 6, Section 2: Empire Building in Africa.
6H Complete Section Quiz 6-2.
6I Complete Critical Thinking Worksheet 20.
Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 12 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
ASSIGNMENT GRADE6J Using the glossary, complete Key Terms Worksheet for Chapter 6 - Section 3.
6K MT: Read Pg. 354-359. Complete Active Reading Note-Taking Guide for Chapter 6, Section 3: British Rule in India.
6L Complete Section Quiz 6-3.
6M Complete Critical Thinking Worksheet 21.
6N Using the glossary, complete Key Terms Worksheet for Chapter 6 - Section 4.
6O MT: Read Pg. 362-369. Complete Active Reading Note-Taking Guide for Chapter 6, Section 4: National Building in Latin America.
6P Complete Section Quiz 6-4.
6Q Complete Critical Thinking Worksheet 22.
6R Complete Chapter 6 Test Review Guide. ------
6S Complete Chapter 6 Test.
ASSIGNMENT GRADE7A Using the glossary, complete Key Terms Worksheet for Chapter 7 - Section 1.Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 13 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
7B Complete Graphic Activity 7.
7C MT: Read Pg. 379-386. Complete Active Reading Note-Taking Guide forChapter 7, Section 1: The Decline of the Qing dynasty.
7D Complete Section Quiz 7-1.
7E Complete Critical Thinking Worksheet 23.
7F Using the glossary, complete the Key Terms Worksheet for Chapter 7- Section 2.
7G MT: Read Pg. 387-393. Complete Active Reading Note-Taking Guide forChapter 7, Section 2: Revolution in China.
7H Complete Section Quiz 7-2.
7I Complete Critical Thinking Worksheet 24.
ASSIGNMENT GRADE7J Using the glossary, complete Key Terms Worksheet for Chapter 7 - Section 3.
7K MT: Read Pg. 396-403. Complete Active Reading Note-Taking Guide for
Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature
Adult Independent Study - Work Assignment Sheet
World History 1Assignment 14 of 14 Page ____ of ____
Student: _________________________ Teacher: __________________2-Week Assignment Period: From ___________________ to ___________________
(Occasional 1-week Period)
Total Attendance Hours Earned for this Assignment: Academic Hours ___________ SIS Claimed Attendance (Apportionment) Hours ___________
Chapter 7, Section 3: Rise of Modern Japan.7L Complete section Quiz 7-3.
7M Complete Critical Thinking Worksheet 25.
7N Complete Chapter 7 Test Review Guide. ------
7O Complete Chapter 7 Test.
8A Complete Student Evaluation.
Circle comments:
1. Must redo assignments until mastery of 80%. Assignment2. Discussion and supplemental review exercises required.3. Passed assignments at 80% or higher.4. Produced superior work consistently5. Discussed, reviewed, and corrected assignments with student.6. Audio-visual or computer assignment.7. Individual or group discussion.8. Review / Preparation for a test9. Reading Assignment10. No work completed during the assignment period.11. Student shows improved study skills, attitude, and interpersonal skills.
12. Other:_______________________________________________
Student Status Report to Parents
On Track / No misses / Great Job On Track / 1 miss On Probation / 2 misses (no more misses allowed) Excellent work produced Good work / Some re-dos Too many re-dos / Slow down Please call me (_______)________________________
Other ________________________________________
_________________________________Parent Signature