Name: _________________ Date: ___________ #____

Retake Request Checklist

Ms. Siroky, may I please retake the ________________________ (quiz/test)?

⃞ 1. Make corrections​ on a separate piece of paper, showing all work.

⃞ 2. Study​ the corrections with a parent/guardian or sibling.

⃞ 3. Staple​ this checklist (1) and the corrections (2) to the front of the original test (3).
(Order: 1, 2, 3)

⃞ 4. Get a parent/guardian signature​ here: ___________________________

⃞ 5. Sign up​ for the retake on the clipboard in the classroom before dismissal on
Thursday.

⃞ 6. Come into the 5th grade classroom by 7:15am​ on the Friday morning for which you
signed up. ​Review​ the corrections with Ms. Siroky first.

⃞ 7. Retake​ the test.

By signing below, I acknowledge that I have completed all the necessary steps to
improve my performance. I recognize that if I have not done what is required, I will not
be able to retake yet. I understand that the retake assessment may vary from the
original, but that it will still assess the same standard(s).

I am ready and able to do my best on this retake.

Student signature​: _____________________________________________