INITIAL FORMS
St. Landry Parish School Board
Revised: September 1, 2016
Checklist for Initial Evaluations
Student:
School:
Section 1: Referral Information
Two-Page Screening Packet (Teacher)
Copy of Student’s Schedule (Teacher – Power School)
Students with Special Health Care Needs/Referral Checklist (Parent)
School Health History Form (Parent)
Authorization for Release of Confidential Information (Parent)
St. Landry Parish Health Screening Protocol (School Nurse)
Copy of Medication Order (when applicable) (Cum. folder – Teacher)
Psycho-Social Checklist (Parent)
Section 2: Screening and Intervention Data
A. Academic Performance
Copy of Cum. Card (Grade progression and cumulative attendance) (Teacher)
State-wide/District-wide Test Scores (Student and Class Report) (Teacher)
Dyslexia Screening (Teacher – Cum. Folder)
Current Report Card (Power School – Teacher)
DIBELS Card (Teacher – Cum. Folder)
Teacher Information Form (Teacher)
Progress Reports (Teacher – Current One)
Behavior Reports/Plans (contents of discipline folder including interventiondata)
(Teacher – PBIS)
B. Attendance
Power School (Teacher)
C. Screenings and Interventions
Louisiana Assistive Technology Screening (Teacher)
Sensory Processing Screening (Teacher)
Sensory Processing Intervention Strategies (when sensory is a concern)
(Teacher)
Communication Skills Checklist (Teacher)
Speech/Language/Hearing Screening Protocol (if necessary)
(Speech Pathologist)
School Vision Report (Teacher – Cum. Folder)
Hearing Screening Protocol (Teacher – Cum. Folder)
Hearing Results Form (Teacher – Cum. Folder)
State Health Form (Teacher – Cum. Folder)
Adaptive Physical Education Screening/Reevaluation Form (P.E./Reg. Teacher)
Social, Emotional, Behavior Skills Checklist (Teacher)
Orientation and Mobility Screening Checklist (when vision impairment suspected) (Teacher)
Review Response to Intervention TIERS Forms
Graph of student progress indicating intervention changes (Interventionist)
Graph of class-wide progress (Interventionist)
Narrative of intervention strategies used (Reg. Ed. and/or Sped. Teacher)
Checklist for Strategies, Adjustments, and Modifications (Teacher)
Revised September 2016
FOR PAC USE ONLY
Coordinator / Race / Gender / Case # / State ID #ST. LANDRY PARISH – PUPILAPPRAISALCENTER
CHILD IDENTIFICATION
Screening Packet - Page 1
STUDENTFirst / Middle / Last
PHYSICAL ADDRESS
Street / Highway / City / State / Zip Code
MAILING ADDRESS
(if different)
Street / Highway / P. O. Box / City / State / Zip Code
DOB / AGE / RACE / GENDER
Years Months
PRIMARY LANGUAGE
HEAD OF HOUSEHOLD - FATHER MOTHER GRANDPARENT FOSTER OTHER
FATHER
First / Middle / Last
MOTHER
First / Middle / Maiden / Last
GUARDIAN
First / Middle / Last
Home Phone / Work Phone / Emergency Phone
and/or Cell Phone
SCHOOL / TEACHER / GRADE
Referred by / Position / Race / Gender
COMPLETE FOR RE-EVALUATION or WAIVER ONLY:
Exceptionality / Sped. Teacher / Case # / Date of Last EvaluationREASON FOR REFERRAL: / SPECIFY CONCERNS:
Initial Evaluation
Reevaluation / Mandatory Reevaluation
Results of Manifestation Determination
Declassification
Significant Change of Placement
New Concern
Gifted
Talented
Waiver
Preschool Screening
Court Decision / Due Process Hearing Decision
Other:
*Race: W-White B-Black H-Hispanic AI-American Indian A-Asian (St. Landry Parish – August 2016)
Screening Packet - Page 2Student’s Name
CURRENT SCREENING RESULTS(Attach all necessary dated forms and documentation)
Area / Date / Normal/Pass / At Risk/ Failed / No Concern / Date Corrected/Comments
Hearing
Vision
Sensory Processing
Health
Speech/Language
Motor
Assistive Technology
Soc./Emotional/ Behavior
Educational
REFERRAL RESULTS (Attach all necessary dated forms and documentation)
RTI Resultsmust include: current scientifically research-based intervention(s) implemented with fidelity and evidenced by data sheets, computer-generated records, or other permanent products; monitoring documentation of the student’s progress relative to peers, at reasonable intervals; and graphed evidence that the student’s rate of progress relative to peers is not adequate. (LA Bulletin 1508, 2009)
Lack of Progress Considerations must include: current data-based documentation that the student’s lack of educational progress is not primarily due to: lack of appropriate, explicit and systematic instruction in reading which includes the essential components of reading instruction: phonics, phonemic awareness, fluency, comprehension, and vocabulary; (e.g., if more than 50% of the class falls below benchmark on universal screening, lack of appropriate instruction might be suspected); lack of appropriate instruction in math (e.g., if more than 50% of the class falls below benchmark on universal screening, lack of appropriate instruction might be suspected); limited English proficiency; environmental or economic disadvantage (e.g., if a majority of low income students in the class fall below benchmark on universal screening, environmental or economic disadvantage as a primary factor might be suspected); or cultural factors (e.g., for students from culturally and linguistically diverse backgrounds, there is evidence that the school and classroom teacher have been sensitive toward the students’ diverse learning needs). (LA Bulletin 1508, 2009)
ALL OTHER FORMS AND DOCUMENTATION LISTED ONMandatory EvaluationCHECKLIST
GIFTED AND TALENTED SCREENING(Attach all necessary dated forms and documentation)
Gifted - include: Universal Screening, High Potential Checklist, Standardized Test Scores, etc.
Talented - must include: State Approved Screening Form and Parish Screening Instrument
Notification of SBLC Meeting sent on /
SBLC Meeting Date
SBLC Participants’ Signatures Required
/Position
/Race
/Gender
PrincipalSBLC Chairperson
PAC Representative
Parent
Teacher
Teacher
Student
Student’s Schedule
STUDENTS WITH SPECIAL HEALTH CARE NEEDS
SCREENING/REFERRAL CHECKLIST
Student: / DOB: / School:Person Completing Form: / Date:
DOES THE STUDENT: / YES / NO
1. Experience severe allergic reactions that require immediate medications, (i.e., Epi-Pen)?
2. Have a medical diagnosis of a chronic health problem (i.e., Diabetes, Tourette syndrome, rheumatic fever, ADD/ADHD, Epilepsy/seizures, Cystic Fibrosis, Asthma, Muscular Dystrophy, Liver Disease, digestive disorders, respiratory disorders, Hemophilia, Spina Bifida, emotional disorders, heart conditions, Cancer, Sickle Cell, Cerebral Palsy, or any other condition)?
3. Receive medical treatments during or outside the school day (i.e., oxygen, gastrostomy care/feedings, tracheostromy care, suctioning, injections)?
4. Experience frequent absences due to illness or frequent hospitalizations?
5. Receive ongoing medication at home or school for physical or emotional problems (i.e., ADD/ADHD, seizures, heart condition, allergy, Asthma, Cancer, Depression)?
6. Require adjustments of the school environment or schedule due to a health condition (i.e., seizure, limitations in physical activity, periodic breaks for endurance, part-time schedule, building modifications for access)?
7. Require environmental adjustments to classroom or school facilities (i.e., temperature control, refrigeration/medication storage, availability of hot/cold running water)?
8. Require major safety considerations (i.e., special precautions in lifting, positioning, special transportation, emergency plan, special safety equipment, special techniques for positioning, feeding procedures)?
9. Require a special diet (i.e., blended, soft, low salt, low fat, liquid supplement, Diabetic)?
10. Require assistance with activities of daily living (i.e., eating, toileting, walking)?
If the answer to any questions is yes, have parent/guardian fill out student health history and sign the Consent to Disclosure of Confidential Records. Refer to school Nurse.
Referred to: / Date: / Phone:(Name of School Nurse)
By: / Date: / Phone:
(Name) (Position)
St. Landry Parish School Board
Pupil Appraisal Center
SCHOOL HEALTH HISTORY
CASE# / SCHOOL / GRADEDATE:
Dear Parent(s) / Guardian(s),
We would like your child to gain the most from his/her school experience. In order for us to assist in accomplishing this, it is necessary to have a current health history. Please complete this form and return it to school.
PREGNANCY / BIRTHING HISTORY / YES / NO / EXPLAIN “YES” ANSWERS1. / Did mother have prenatal care during the
pregnancy?
2. / Did mother have any health problem(s) during the
pregnancy or during the delivery?
3. / During the pregnancy with this child, did the mother:
a. / SMOKE CIGARETTES / Amount:
b. / DRINK ALCOHOL / Amount:
c. / TAKE MEDICATION OTHER THAN VITAMINS? / Name medication(s):
4. / Where was your child born?
5. / Was your child born more than 3 weeks early or late?
6. / What was the birth weight? / lbs. / oz.
7. / Were there any concerns with your child at birth?
8. / Were there any concerns with your child in the
nursery?
9. / Did child or mother stay in hospital for medical
reasons longer than usual?
DEVELOPMENTAL MILESTONES / EARLIER / WHEN EXPECTED / LATER / AGE
(a) / Walk
(b) / Talk
(c) / Feed and Dress Self
(d) / Learn to Use the Toilet
HOSPITALIZATIONS AND ILLNESSES / YES / NO / EXPLAIN “YES” ANSWERS
1. / Has your child ever been hospitalized or had surgery?
2. / Has your child ever had a serious accident (broken
bones, head injuries, falls, burns, poisoning, etc.)?
3. / Has your child ever had a serious illness?
4. / Are your child’s immunizations up-to-date?
SOCIAL DEVELOPMENT / YES / NO / EXPLAIN “YES” ANSWERS
1. / Have there been any major changes in your child’s
life in the last six months?
2. / Are there any problems in the home that may affect
your child’s learning?
3. / Is there anything more about your child’s health that
you think is important for us to know?
Revised September 2016
ST. LANDRY PARISH PUPIL APPRAISAL CENTER
127 BLAIR STREET
OPELOUSAS, LA 70570
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
TO BE COMPLETED BY PARENT/LEGAL GUARDIAN
PART 1: CONTACT INFORMATION COORDINATOR: ______Student’s/Child’s Legal Name / Date of Birth / Social Security #
Case #
Parent/Legal Guardian ______Telephone # ______
Mailing Address ______
City/State/ZipCode ______
PART 2: RECORD REQUEST
Complete Box A OR B below. Both boxes may not be completed on the same form.
A. Specify the records to be released for the treatment date(s)
listed below in Part 3:
Medical records Test Results
Individual Education Plan (IEP) Phone Consult
Academic Achievement Assessment Other______
Eligibility report
Cumulative Record ______
Related Services Report
Speech Evaluation
Prescription of Therapy and Medical Services from Physician
Medication Name(s) and Prescribed Dosage(s) / B. If initialed below, I specifically authorize release of the following:
Psychotherapy notes and records indicating
psychological or psychiatric impairment(s)
______
Initials of parent/legal guardian
PART 3: AUTHORIZATION
This does not authorize the release of the following: drug and alcohol use counseling and treatment and HIV/AIDS and sexually transmitted disease and treatment.
I AUTHORIZE:
Name: St. Landry Parish School Board(School System)
TO OBTAIN information FROM AND/OR TO RELEASE information TO
Name: ______(Hospital, physician, Service Agency, health provider)
Address: ______
For treatment date(s): ______
The information is to be released for the purpose(s) of:
Evaluation to determine eligibility or continued Designing an individual educational program
eligibility for special education services Determining appropriate placement for treatment needs
Providing occupational therapy treatment ______
Providing physical therapy treatment
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the same medical records department receiving this authorization form. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event or condition: ______. If I fail to specify an expiration date, event or condition, this authorization will expire nine (9) months from the date of authorization. An authorization is voluntary. I will not be required to sign an authorization as a condition of receiving treatment services or payment, enrollment, or eligibility for health care services. Information used or disclosed by this authorization may be re-disclosed by the recipient and will no longer be protected under the Health Insurance Portability & Accountability Act of 1996.
______
Signature of Student or Legal Representative Date (Relationship to student)
(Parent/Legal Guardian must sign if student < 18)
______
Signature of Witness Date
Vision: / Passed
Failed
No Concern
ST. LANDRY PARISH
HEALTH SCREENING PROTOCOL
1. / Identifying Information:Student’s Name / D.O.B. / Age
School / Date of Assessment
2. / Reason for the Assessment:
3. / Assessment Method(s) / Tools:
Information for the Assessment obtained by: (Check all that apply)
Physical Assessment / Observation(s)
Health/Developmental History by Parent / Parent Interview
Student Interview / Teacher Interview
Review of Medical Record(s) / Physician Consultation
Other:
4. / Strength(s)(Related to Health):
Good Health: / Appears Well-Nourished / Interacts Socially
Able to Communicate Need(s) by:
Good Personal Hygiene / Good Family Support / Ability to Follow Instruction(s)
Independent in Activities of Daily Living / Feeding / Bathing / Dressing
Toileting / Other Strength(s)
5. / Summary of Health Status:
Medical Diagnosis:
Life-Threatening Condition(s):
Prescriptions / Authorization(s) for: / Special Diet / Medication(s) @: / School / Home
Health Procedure(s): @ / School / Tube Feeding / Catheterization / Suctioning
Glucose Monitoring / Other
6. / Assessment Data:
Screening Result(s): / Hgt / Wgt / BP / Immunizations Up-to-date
7. / Nursing Diagnosis (Health Concern): from the IHP
Goal(s) (Student) :
Intervention(s):
8. / Impact on Education
Health concern(s) impact / (name) ability in the area(s) of:
Self-Help / Emotional/Social / Cognitive/Adaptive
Communication / Motor / Sensory
9. / Statement of Need :
Based on this assessment, this student / (name)
does require health services in order to benefit from his/her educational program.
Health services include (Circle all that apply) : / Medication(s) / Health Maintenance Procedure(s)
Activity of Daily Living / Health Counseling / Other
10. / Recommendations :
Yes, related health services are recommended to meet the goals and interventions listed above.
No, related health services are not required at this time.
Additional information is required to complete the health assessment.
Signature of Nurse / Date
Copy of Medication Order
(If applicable)
Student:
Case #:
Date:
Psycho-Social Checklist
The following is a checklist of psycho-social stressors that may impact a student’s academic and social functioning. Please check all that apply.
1. Severe illness of parent or family member (cancer, HIV, heart attack, psychiatric illness, etc.)2. Death of a parent or caretaker
3. Divorce or break-up of parent’s primary relationship
4. Student has received a threat of violence.
5. Witness to community violence
6. Severe illness of a student (leukemia, cancer, heart problems, etc)
7. Experienced child abuse (physical, emotional, or sexual)
8. Witness to domestic violence in home
9. Placed in foster care
10. Moved from one foster home to another
11. Experienced natural disaster (hurricane, tornado, etc)
12. Changed schools one or more times during a school year
13. Financial problems in the home (parent lost job, etc)
14. Alcohol or drug abuse in family
15. Substance abuse problems (older students)
16. Pregnancy (older students)
17. One or more psychiatric hospitalizations
18. Has attempted suicide or has expressed suicidal thoughts
19. Sexual identity issues
20. Homelessness
21. Parent or caretaker incarcerated
22. Juvenile offender
23. Health problems (asthma, diabetes, sickle cell, etc.)
24. Other (please specify):
Parent Signature: / Date:
LOUISIANA ASSISTIVE TECHNOLOGY SCREENING
CHECKLIST FOR USE IN EDUCATIONAL PROGRAMMING
Adapted for St. Landry Parish School System
Student’s Name: / DOB: / Screening Date:Person Completing Form: / School:
This Checklist documents physical, fine/gross motor, communication, sensory, academic, recreation and leisure, vocational, and self-help areas in which assistive technology may be considered to enable a student with a disability to access the general education curriculum. It serves as an organizer for considering those skills and activities in which assistive technology would benefit a student’s functioning in an academic setting.
Directions: Check yes or no for the following statements. If the task does not apply to the age level of the student, then put NA in the comment column.
Physical Functioning/Motor Abilities
Task / Yes / No / Comment1. The student can sit upright while completing tasks at his/her desk (i.e., not slouched, can hold head upright).
2. The student maintains an appropriate posture while seated and actively engaged in a motor task (i.e., keyboarding, cutting).
3. The student participates in playing and running activities without atypical postures.
4. The student sits on the floor without assuming asymmetrical postures.
5. The student has the motor skills necessary to get to/from school and/or get around within the school.
6. The student participates in physical activities (structured or independent) and navigates within the classroom without tripping and stumbling.
7. The student climbs and descends stairs independently.
8. The student is able to open doors independently.
9. The student maintains balance while performing an activity (e.g. getting up from the floor)
10. The student carries objects while walking independently (e.g. books and papers).
Comments:
Fine Motor Skills
Task / Yes / No / Comment1. The student cuts and/or handles scissors independently.
2. The student uses writing utensils (i.e., markers,paintbrush, pencil, crayons) independently.
3. The student copies materials from a book.
4. The student turns pages in a book.
5. The student ties shoes, buttons, snaps, and/or uses zippers independently
6. The student operates door handles, water faucets and uses manipulatives.
7. The student uses a standard keyboard to access a computer.
8. The student draws, forms letters, stays on the line, and/or traces accurately with writing utensils
Comments:
Communication Functioning
Task / Yes / No / Comment1. The student speaks to communicate.
2. The student uses a mode other than speech to communicate. (Check the communication mode.)
Picture communication
Electronic Device
Sign Language
Gestures
3. The student’s mode of communication (speech or other as stated in #2) is understood by others.
4. The student’s mode of communication is effective in his environment.
5. The student responds to speech and noises in the environment.
Comments:
Vision/Hearing
Task / Yes / No / Comment1. The student is able to see printed materials presented in the classroom.
2. The student is able to see toys/objects in the classroom environment.
3. The student is able to transfer information from a book, chart, and/or chalkboard to paper.
4. The student has some usable vision.
5. The student has some usable hearing.
6. The student is able to hear speech/noise out of his/her field of vision.
7. The student responds best to speech when the stimulus is within six feet of the speaker.
8. The student speaks in an unusually loud voice.
Comments:
Academic Functioning