Martinsville City Public Schools
Special Education Evaluation Referral
Meeting Documentation Sheet
Please enter the dates when each action is completed. For initialreferrals, remember the principal/designee has 10 business days to hold a child study meeting once thereferralis received. For triennials, remember the IEP team must review existing evaluation data and determine the need for reevaluation at least once every three years. If the parent agrees, this review may be conducted without a meeting. If new evaluation data is desired, the case manager should take reasonable measures to secure parental permission. If the case manager is unable to secure permission after three documented attempts, he/she may proceed as if permission has been granted. Direct Referrals are available only to students who are not enrolled in public school and can be made by contacting Jeanne Westphalen at 403-5837.Attach additional sheets for further follow-up meetings as needed.
DATEACTION
______Referral received
______Parent contacted and invited to meeting
______Initial meeting
______Follow-up meeting (as needed)
______Follow-up meeting (as needed)
______Studentnot referred because the committee does not suspect the student has a disability under IDEA.
The committee has implemented successful general education interventions.
The committee is referring the student back to the IST/PST
The student has not received adequate instruction in Reading/Math. (May include missed opportunity for instruction)
Other ______
______Studentis referred for a full evaluation because the committee suspects the student has a disability under IDEA (check one and complete pages 7-8).
The committee has reviewed the data from the IST and is not recommending any additional general education interventions.
A variety of research-based strategies have been tried and have been unsuccessful.
There is documentation of an existing disability that is having an educational impact and requires specialized instruction.
The student has failed a speech screening.
The committee is referring this child directly without interventions because ______
Committee Members (sign first time, then check for additional meetings. Initial if fulfilling more than one role.)
Referring Source ______Initial Follow up Follow up
Principal or Designee______Initial Follow up Follow up
Teacher______Initial Follow up Follow up
Specialist______Initial Follow up Follow up
Other______Initial Follow up Follow up
The following information will be used to begin the child study process. A student should be referred to the Child Study Team if there is a strong reason to suspect that he/she has a disability under IDEA. Students who are having general academic or behavioral issues should first be referred to the Instructional Support Team for intervention. If these interventions are not successful, the IST/PST may then refer the student to the Child Study Team.
Student ______Grade _____DOB ______State Testing ID ______
Parent or Guardian______Referring Source: ______
Address______Phone ______Date of Request ______
Gender: ______Race: ______
- Reasons for referring student for an Evaluation:
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Martinsville City Public Schools
Special Education Evaluation Referral
Medical Concerns
Academic Achievement
Classroom discipline problem
Developmental Issues
Socialization problems
Communication (Speech) Issues
Due for a triennial Evaluation
Requesting Reevaluation
Other ______
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Martinsville City Public Schools
Special Education Evaluation Referral
Previous Referrals: Has this student had any previous referrals? If so, please list the dates and results:______
Discipline Records: Is the student a discipline problem?______
______
Attendance Record: Attends school regularlyMisses instruction due to frequent removals
Frequently leaves earlyHas missed more than 10 days in a year
`Frequently tardy in grades ______
Health Issues (Screenings and Parent Interview)
Complete screenings: Vision ______Hearing ______
If the student has glasses, does he or she wear them regularly? ______
Sleeping issues? Requires less sleep than averageTakes medication to help with sleep
Yes NoRequires more sleep than averageWakes frequently, snores, restless
Has the child had any serious illnesses or accidents? ______
______
Has the child been diagnosed with any specific medical/mental health conditions: ______
______
Does the child take any prescription or over-the-counter medications regularly? ______
______
Has the student had any recent emotional or physical trauma?______
______
Check this box if information is continued on the back
Choose One
Consent to Exchange Information form has been given to school nurse
Permission to Provide Physical Examination form has been completed and is attached
The student has NO medical/mental health diagnoses or areas of concern
Student Name: ______
CURRENT STUDENT PERFORMANCE REPORT:
SUBJECT / TEST/QUIZ AVERAGE / BENCHMARK SCORES / HOMEWORK COMPLETION? / CLASSWORK / SOLsEnglish
Math
Science
Social Studies
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Martinsville City Public Schools
Special Education Evaluation Referral
** How do the student's grades compare to others in the class? ______
______
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Martinsville City Public Schools
Special Education Evaluation Referral
Has the student been through the Instructional Support Process? Yes No
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Martinsville City Public Schools
Special Education Evaluation Referral
General Ed. Interventions attempted:
Instruction
Extra practice on lessons
Peer tutoring
Academic Intervention (SGL, small group, PM homework help)
Computer assisted instruction
Varied instructional modes (multi-sensory learning styles)
Materials
Copies of texts at home
Graphic organizers provided
Audiovisual aids
High-interest reading materials
Manipulatives
Calculator for math
Computer for word processing
Testing
Study guide for tests
Extra time for tests
Retake tests
Extra credit options
Grading
No spelling or handwriting penalty
Organization
Simplify, repeated instructions
Review directions
Guided notes
Agenda check
Preferential seating
Color coded materials
Assign a buddy to check agenda
Behavior Management
Positive reinforcement
Incentive program
Written behavior contract
Mentor assigned
Post and review rules
Immediate consequences delivered
Consistent enforcement of rules
Recorded behavioral changes
Progress reports sent to parents
Counseling
Frequent Parent Contact
Has an FBA been done? Y N
Does the student have a BIP? Y N
Is the BIP being followed? Y N
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Martinsville City Public Schools
Does the student receive any additional supports? TDTCounseling504 plan
Other ______
Please list any additional pertinent information below (or on back) as needed:
MEETING INVITATION
Student Name ______Date ______
This is to notify you that a team meeting has been scheduled for the above student. Your participation and attendance at this meeting are very important. This meeting must be scheduled at a mutually agreed upon time and place. This meeting has been scheduled because there are concerns about your child’s progress at school. The purpose of this meeting is to:
Develop strategies to help your child do better in school.
Determine the need for an evaluation (including a triennials or other reevaluation) for special education and related services(including speech/language).
Determine the needed evaluation components for an evaluation (including a triennials or other reevaluation)for special education and related services (including speech/language).
Follow-up on your child's progress since your child was found ineligible for special education services at a recent eligibility meeting.
This meeting has been scheduled for ______o’clock on ______at ______
If you have any questions or would like additional information or assistance to help you prepare for this meeting, please contact ______at ______
The following people are invited to attend and participate in this meeting:
Referring Source Principal or Designee
Teacher(s)Specialist(s)
Other individuals may be invited if additional information is required from an individual with specialized training or specific knowledge. A single team member may perform more than one role.
At least on member of the team is knowledgeable about alternative interventions and the procedures required to access programs and services available to assist with children’s educational needs.
------
Please detach and return:
Student name ______Date of meeting ______
I will attend the meeting as scheduled.
I cannot attend the meeting as scheduled, but do wish to attend. Please contact me to reschedule.
I understand the importance of attending this meeting, but do not wish to attend. You may hold this meeting in my absence. I will contact you to share any preferences or concerns that I have.
Parent Signature ______Date ______
The best way to contact me is by ______at ______
Teacher/Parent Input
(Make additional copies of this page as needed
Name of Student ______Date ______
The above named student is being referred for a special education evaluation. Please provide any information that might be helpful in designing interventions and making decisions.
Strengths:ParentTeacher
Weaknesses:
Can the student complete homework independently? Are necessary supports for homework completion available?
Child Study Intervention Strategies
(Make additional copies of this page as needed)
Student Name ______Initial Meeting Date: ______Follow-up Date ______
Interventions are not necessary because
Student has received adequate interventions through IST and has not made progress
Student has a documented existing condition and the committee suspects he/she has a disability.
Student has been referred by the speech pathologist due to failing a speech screening
Student is due for a reevaluation
______
Specific problem statement: (i.e., the student only knows 15 out 50 sight words) / Goal Statement: (i.e., the student will recognize 50/50 sight words) / Strategies to be used: / Person(s) who will implement the strategies: / Evaluation (including pre/post data)Prior Notice and Consent for Evaluation
Student Name ______SS# ______
I have received the VA Special Education Procedural Safeguard Notice: Your Family’s Special Education Rights, and understand the Martinsville City Schools proposal and my rights.I understand that parental consent is not required before reviewing existing data as part of an evaluation or administering a test or other evaluation that is administered to all children, unless parental consent is required before administration to all children. Parental consent for initial evaluation shall not be construed as consent for initial provision of special education and related services. (34 CFR 300.300)
Signature ______Date ______
I give permission for the Martinsville City Schools to proceed with the formal evaluation to consist of the checked components as well as formal and/or informal observation.The results of these evaluations will be used to determine:whether my child is or continues to be a child with a disability and/or my child's educational needs as indicated elsewhere on this referral
Educational – a written report describing current educational performance and identifying instructional strengths and weaknesses in academic skills. This may include language performance, processing skills, and/or psychomotor skills.
Medical- Records Review– written notes from a licensed general practice physician and/or specialist indicating general and specific medical history along with any medical/health problems that may impede learning.
Medical – Physical Examination –a written report from a licensed physician indicating general medical condition as well as the discovery of any medical/health problems that may impede learning
Sociological – a written report supervised by a qualified visiting teacher (or designee) that will include background information as well as social/adaptive behavior and examine the possible impact of cultural, and/or economic factors.
Psychological – a written report from a qualified psychologist including an individual intelligence test. This may also include social/emotional and behavioral evaluations as well as measures of adaptive behavior.
Developmental – a written report describing how a young child (ages 2-6) functions in the major areas of development including cognition, motor skills, social/adaptive behavior, perception and communication.
Speech/Language – a written report indicating current functioning in the areas of articulation, voice, fluency, and expressive and receptive language.
Vision and Hearing Screening – an assessment of basic vision and hearing function.
Audiological – an assessment of hearing for students who fail the hearing screening multiple times.
Vision – an assessment of visual acuity for students with a possible significant visual impairment.
Observation:an observation of academic performance in the regular classroom by someone other than the child’s regular teacher. In the case of a child not attending school the child will be observed in the natural environment.
Other Evaluations (as listed): ______
Your informed consent is required before the District may proceed with an evaluation, except when the District is relying on existing data, classroom observations, or has taken reasonable measures to obtain your consent for a reevaluation and you have failed to respond. Your consent is voluntary and may be revoked at any time. Any revocation of consent will not be retroactive.
Your child’s assessment must be sufficiently comprehensive to identify all of his or her special education and related service needs, whether commonly linked to the disability category suspected or in which your child has been classified. The assessment will be at no cost to you.
Parent/Guardian Signature ______Date ______
I do not give permission for Martinsville City Schools to proceed with the formal assessment as described above for my child.
Parent/Guardian Signature ______Date ______
CONSENT TO EXCHANGE INFORMATION
To provide the best service for your child, various community agencies must share information from time to time. By signing this form, I am allowing the involved agencies to exchange certain information, enabling them to coordinate efforts that will maximize the benefits for my child.
I,______, am signing this form on behalf of my
(full printed name parent or guardian)
child______. Birth date: ______
(full printed name of child)
Address: ______
I want to have the following confidential information about my child to be shared:(check all that apply)
[ ] Medical Records (Summary including diagnoses and current medications)[ ] Other ______
[ ] Mental Health Records (Summary including diagnoses and current medications)[ ] Other ______
SETR1
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Martinsville City Public Schools
I give permission for the following agencies to share information about my child. (Attach additional sheets as needed.)
[] Children’s Medical Center[ ] Martinsville Pediatrics[ ] Piedmont Community Services[ ] National Counseling Group
[] Eden Pediatrics[ ]Brenner Children’s Hospital[] Family Preservation Services[ ] Martinsville Memorial Hospital
[] Child Development Center[] Compassionate Care[]Carillion Pediatrics
______
(Name of agency) (Contact Information)
______
(Name of agency) (Contact Information)
I want this information be exchanged for only eligibility determination for special education services and/or service coordination and planning.
SETR1
Last modified 12/16
Martinsville City Public Schools
This Consent will be effective until: ______
Signature(s):______
(Consenting person or persons)
Date: ______
Person Explaining Form: ______
(Name) (Title) (Phone Number)
FOR SCHOOL USE ONLY: If this consent is revoked, partially or in its entirety, please check the box at the bottom of this form and fill out and attach a revocation form.
This consent has been revoked, effective ______
Special Education Referral Checklist
Student Name: ______
DATEACTION
______Referral process initiated by Child Study Committee or IEP team
______Procedural Safeguards given to parent.
______Parental Consent obtained/ Prior Written Notice signed.
______Information collected and attached to referral
Medical permission form (if a physical is needed)
Consent to Exchange Information form (given to school nurse) for any child who:
- Takes medication on a regular basis
- Is seen by a medical specialist and/or mental health professional for an ongoing condition
- Is being considered for a disability category with a major medical component (i.e. Other Health Impaired, Visually Impaired, Hearing Impaired, Orthopedically Handicapped, Traumatic Brain Injury…)
- Has had an evaluation completed by an outside agency.
SETR1
Last modified 3/21/11