I will leave this as a word document so that you can change the numbers according to your grade level expectations. In grade one, students only have to solve addition and subtraction problems to 20.
The first section gives an addition and subtraction problem to solve (up to 20). After selecting tools and solving, it then asks the student to show (in pictures) how they were solved and to write a number sentence. If the child cannot draw it but explains orally, the teacher can scribe in the box.
The second section of the assessment also has a picture that can be interpreted as an addition and subtraction problem. The students are asked to apply their knowledge to write an addition story and number sentence, as well as a subtraction story and number sentence. Upon conferencing, you can take note of whether or not the child notices the relationship between addition and subtraction and how the number sentences (part, part, whole/ whole, part, part) are related.
A third section, just gives 3 addition and subtraction number sentences to solve, and a conference to determine what strategies are being used.
Finally, an open-ended application question, asks the child to create an addition or subtraction story, using the number 20. This enables the child to go higher if needed.