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Documentation Tools for
At-Risk Intervention Documentation Form Reg Ed. This form is to be filled out by a regular education teacher on behalf of the student being considered for referral for evaluation for special education services. The information listed on this form should show whether or not evaluation is necessary. The form specifies the areas of concern, and provides information about the student's primary language, attendance, and health history (hearing, sight, and general) that might cause or contribute to the student's low performance. The form also includes information on interventions (backed up by data records) that the teacher has used in the regular classroom to help improve the performance of the student. At least two teacher interventions are required before a student may be referred for evaluation. The form is then signed by the principal, and the principal decides further remedial action, e.g., classroom interventions, 504 interventions, referral for evaluation for special education. The regular education teacher should contact the parents regarding the teacher's concern, and parents must be informed that a referral for evaluation is being made. Guidelines for Completing
Form. Referral for Evaluation for Special Education Services Form SpEd 1. This form is to be filled out by the school principal on behalf of a student who has not yet been placed in special education. This form specifies the person making the referral: parents, teacher, or other. If this is a parent, the areas of parental concern should be listed. After this form is filled out, and further evaluation is deemed necessary, it is signed by the school principal, and given to the school psychologist or the person assigned to conduct the evaluation. Guidelines for Completing
Form. Prior Notice and Consent for Evaluation/Re-evaluation Form SpEd 2. This form is to be filled out by the school principal on behalf of a student who has not yet been placed in special education. The form is then sent to the student's parents for a signature. A copy of the Procedural Safeguards must be sent with this form. The form informs parents that the student has been referred for evaluation that could possibly lead to placement within the special education program. The form requests permission to evaluate the student in specific areas: intellectual, academic, communication, behavioral, motor, social, etc. All areas that will be evaluated must be checked. Any area not checked cannot be evaluated. If one of these areas is evaluated at a time different from the initial or three-year evaluation, this form must be completed by the special education, or speech and language teacher, and signed by parents. After the form is signed by the parents, it is given to the school psychologist or the person assigned to conduct the evaluation. This form is also used for parental consent of the evaluation of a student atthe time ofthe student's three-year evaluation. At this point, the special education teacher will fill out the form. Guidelines for Completing
Forms. Procedures Safeguards: Parent Pamphlet. This pamphlet lists in detail the rights of the student receiving special education services as specified under IDEA 97. This pamphlet must be sent to the parents with the Prior Notice and Consent for Evaluation/Re-evaluation form and the Notice of Meeting form, and the major points of the pamphlet must be discussed with the parents at every meeting. Guidelines for Distribution
and Discussion. Prior Notice for Identification and Determination of Eligibility (All Classifications, except LD) Form SpEd 3. This form is to be filled out by the special education teacher or the school psychologist. The form is to be filled out after every re-evaluation is performed, documenting that the IEP team has determined that the student is eligible to receive special education services under a specific classification (autism, communication disorder, deaf/blindness, developmental delay, emotional disturbance, hearing impairment/deafness, intellectual disability, multiple disabilities, orthopedic impairment, other health impairment, traumatic brain injury, visual impairment). If all members of the IEP team agree with the eligibility and classification of the student, the form is signed by each member. Also, parents are reminded that they have received the Procedural Safeguards with the referral for evaluation and are encouraged to ask the special education teacher if there are any questions. Guidelines for Completing
Form. Prior Notice for Identification and Determination of Eligibility for Learning Disability Form SpEd 3a. This form is to be filled out by the school psychologist, or whoever performed the evaluation. It is to be filled out after every re-evaluation is performed. The form lists all the achievement and ability tests given and the areas where severe discrepancies are shown. The form documents that the IEP team has determined that the student is eligible to receive special education services under the classification of a specific learning disability. If all members of the IEP team agree with the eligibility and classification of the student, all members sign the form. Also, parents are reminded that they have received the Procedural Safeguards with the referral for evaluation and are encouraged to ask the special education teacher if there are any questions. Guidelines for Completing
Form. Notice of Meeting Form SpEd 4. Prior to every IEP meeting, this form is filled out by the person calling the meeting (i.e., principal, for initial placement meeting; and, special education, for regular IEP meetings) and must be sent to the parents. A copy of the Procedural Safeguards must also be sent with this form. This form informs parents of the date, time, and place of the meeting. The form also includes the purpose of the meeting, a list of individuals who have been invited to attend the meeting, and their positions. If parents have been contacted by phone and confirmed attendance at the meeting (and there is not enough time to send the notice), this form is filled out for the file with the note, "Contacted and confirmed by phone (date)." Guidelines for Completing
Form. Individualized Education Program (IEP) Form SpEd 5a. This form is to be filled out by the special education teacher in conjunction with the IEP team during the IEP meeting. It lists the special education services and related and supplementary services that the student will receive, student participation in CORE and SAT testing, and special factors to be considered. Parents are reminded that they have received the Procedural Safeguards with the referral for evaluation. The major points of the Safeguards are discussed and the parents are encouraged to ask the special education teacher if they have any questions. The Present Level of Educational Performance section has space for the summary of all areas of academic performance. After that there are sections that contain goals for specific areas of disability. Each section includes: the Measurable Annual Goals, student assessment, parent notification and Short Term Objectives and Benchmarks. When completed it is to be signed by IEP team participants. Guidelines for Completing
Form. Individualized Education Program (IEP) Form SpEd 5b. This form is to be filled out by the special education teacher in conjunction with the IEP team during the IEP meeting. It lists the special education services and related and supplementary services that the student will receive, student participation in CORE and SAT testing, and special factors to be considered. Parents are reminded that they have received the Procedural Safeguards with the referral for evaluation. The major points of the Safeguards are discussed and the parents are encouraged to ask the special education teacher if they have any questions. Information about each area affected by the disability is contained within a single section. In each section there is a place for Present Level of Educational Performance, Measurable Annual Goals, student assessment, parent notification and Short Term Objectives and Benchmarks. When completed it is to be signed by IEP team participants. Guidelines for Completing
Form. Transition Plan Form SpEd 5c. This form is to be filled out by the special education teacher, in conjunction with the IEP team, during the IEP meeting, on behalf of students who are 14 years of age or older. The purpose of this form is to create a plan that will progress the student toward independence after high school. Guidelines for Completing
Form. Prior Notice and Consent for Initial Placement in Special Education Form SpEd 6. This form is to be filled out by the special education teacher for the first IEP meeting. It identifies specific special education services that the student will be receiving. Parents are reminded that they have received the Procedural Safeguards with the referral for evaluation and are encouraged to ask the special education teacher if there are any questions. The parent then signs the form, giving or not giving consent for the student to receive these services. Guidelines for Completing
Form. Prior Notice of Change of Placement in Special Education Form SpEd 7. This form is to be filled out by the special education teacher. It specifies that a change of placement will occur for the student (i.e., institutional to special class). Parents are reminded that they have received the Procedural Safeguards with the referral for evaluation and are encouraged to ask the special education teacher if there are any questions. Guidelines for Completing
Form. Re-evaluation Data Review Form SpEd 8. This form is filled out by the special education teacher at the time of every three-year evaluation. This form is used to gain parental consent for the re-evaluation, and must also be signed by all IEP team participants. A copy of the Procedural Safeguards must be given to the parents with this form. The form specifies the necessity of the re-evaluation for determining continued eligibility of the student to receive special education services. After the form is signed, if evaluation is necessary, it is given to the school psychologist, or the person assigned to conduct the evaluation. Guidelines for Completing
Form. Notice to Parents and Students Regarding Age of Majority Rights Form SpEd 9. This form is discussed with a student who has reached 18 years of age, informing the student that he/she is now considered an adult and can "approve his or her own education placement." The notice is to be signed by the student, parent, and school representative. Guidelines for Completing
Form. Private School Services Plan Forms SpEd 10. To be completed if the student receiving special education services is placed in a private school. Guidelines for Completing Form.
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