CusterSchool District 16-1
Referral to Special Education—There is reasonable cause to suspect that this child is or may be in need of special education services.
Student Name______M/F______
DOB______Age______Grade______School______
Mother/Guardian______Address______
Phone H)______W)______
Father/Guardian______Address______
Phone H)______W)______
Referring Person’s Signature & Title______
A. Record of Parent Contact(s) :
Dates and Method(s): (Phone, Written [email], Meeting, etc.):
Method(s): Phone /___/___Written /___/__Other /___/__
(date) (date)(date)
By Whom:
Outcome:______
Method(s): Phone /___/___Written /___/__Other /___/__
(date) (date)(date)
By Whom:
Outcome:______
Parent Input: concerns were noted by the parent in the following areas as per our conversation on______
HomeworkStudy SkillsCommunication Language ArtsMathematics
Health/MedicalDaily Living Skills Fine MotorGross MotorBehavior/Social
Other: ______
B. Reason for Referral (Primary Concern):
Please list SPECIFIC concerns prompting this referral. What makes this student difficult to teach? (Give 3 examples of attitude, behaviors, poor work, etc.)
______
______
______
How do this student’s academic skills compare to those of an average student in your classroom?
______
______
______
In what settings/situations does the problem occur most often?
______
______
______
In what settings/situations does the problem occur least often?
______
______
______
Describe the student’s strengths.
______
______
______
Medical Concerns
Has the child been diagnosed with a medical condition? ______
______
Is the child on medication? (If yes, please add any known information) ______
______
Family History Describe the family history/structure(who child lives with, guardianship, siblings, etc.) ______
Please check those items below that further describe your area(s) of concern:
READING COMPREHENSION
☐Identify Main Idea & Related Details☐Cause and Effect ☐Sequence of Events
☐Make Inferences☐Make Predictions☐Summarize
☐Describe Setting, Character, Plot, and Theme☐Visualizing/Mental Picture
☐Vocabulary/Meaning of Words or Phrases in Selection☐Construct Meaning from Text
BASIC READING SKILLS
☐Reading Readiness☐Blend Sounds to Make Words☐Consonant Sounds
☐Identify Letters of the Alphabet☐Identify Sounds in Words☐Vowel Sounds-Long/Short
☐Letter-Sound Correspondence☐Omission of Letter Sounds in Words ☐Decoding
☐Syllabication☐Addition of Letter Sounds in Words ☐Multisyllabic Word Reading
READING FLUENCY SKILLS
☐Accuracy☐Voice Inflection
☐Words Per Minute/Rate☐Sight Word Identification
MATH CALCULATION
☐Number Names and Count Sequence☐Subtraction Facts☐Division Operations
☐Identify Numbers ☐Regrouping in Addition-Carrying ☐Fractions-add/sub/mult/div
☐Counting Objects☐Regrouping in Subtract-borrowing☐Decimals-add/sub/mult/div
☐Addition Facts☐Multiplication Operations ☐Consumer Math Skills
MATH PROBELEM SOLVING
☐Measurement/Estimation of Time, Volume, and Objects☐Understanding Fractions
☐Applying Appropriate Concepts to Solve Problems☐Interpreting Data on Charts/Maps/Graphs
☐Word Problems with More Than One Math Function
WRITTEN EXPRESSION
☐Incorrect Pencil Grasp ☐Letter/Word Reversals ☐Grammar: subject-verb agreement
☐Legibility ☐Punctuation/Capitalization☐Abbreviations
☐Upper/Lower Case Letters☐Spelling
☐Sentence Structure-Writing Complete Thoughts
ORAL EXPRESSION
☐Expressive Vocabulary ☐Synonyms☐Syntax (sentence structure)
☐Reasoning/Problem Solving ☐Antonyms ☐Pragmatics (functional use)
☐Grammar☐Analogies
LISTENING COMPREHENSION
☐Auditory Attention Span ☐Receptive Vocabulary☐Understanding Directions
☐Auditory Discrimination ☐Sequences of Events☐Answers Questions Inappropriately
☐Auditory Memory ☐Needs Questions/Directions Repeated
COMMUNICATION
☐Articulation: may omit, substitute or distort certain speech sounds ☐Sentence Structure
☐Voice: may be hoarse, breathy or nasal, may talk to loud or soft☐Concepts/Vocabulary
☐Fluency: may stutter, repeat words, hesitate, or prolong words ☐Conversational Skills
☐Expressive Language ☐Receptive Language ☐Other (Specify)
BEHAVIOR/EMOTIONAL (Extreme or Excessive)
☐Independent Activity ☐Group Activity ☐Peer Relationships
☐Attention Span☐Overactive ☐Home Relationships
☐Passive/Shy ☐Verbally Aggressive☐Unresponsive
☐Withdrawn☐Disruptive ☐Physically Aggressive
☐Mood Swings ☐Motivation ☐Other (specify)
☐Non-Compliant ☐Teacher Relationships
MUST comment on areas checked. Please include settings, frequency and duration:
EARLY CHILDHOOD (Children 3-5 years old)
☐Gross Motor ☐Fine Motor ☐Expressive Language
☐Adaptive Behavior ☐Social/Behavior ☐Cognitive Skills
☐Receptive Language
Comments:
HEALTH
☐Hearing (Specify Concerns)
☐Vision (Specify Concerns)
☐Fine Motor (Specify Concerns
☐Gross Motor (Specify Concerns)
C.Interventions: An intervention is a data driven plan or process that is specific, measurable, reasonable, and implemented consistently for a minimum of 6 weeks.
Does the student receive Title 1 services? ____Yes ____No If yes, what subject? ______
Describe 2-3academic and/or behavioral interventions that have been implemented, and their outcomes:
1. Begin Date______End Date:______Person Responsible: ______
What you tried to do to resolve the problem:
How did it work (include data/test scores)?
2. Begin Date______End Date:______Person Responsible: ______
What you tried to do to resolve the problem:
How did it work (include data/test scores)?
CURRENT REVIEW OF EXISTING DATA (Completed by teacher/principal prior to submitting to Special Education)
Cumulative Performance Review:
MUST ATTACH copies of Campus information for the following ( if attached; provide explanation if not):
___ Current grades
___ Report cards from past 3 years
___ MAP test scores for past 3 -4 assessments
___ Attendance for present year and past year
___ Number of Office Discipline Referrals for present year
Is this student transferring from another district? Yes/No Has the student been previously evaluated? Yes/No
Vision Screening Date______Pass /Fail Hearing Screening Date______Pass /Fail Limited English Proficient Yes/No
Smarter Balance Results Math______Reading ______
Prior program involvement: Special Education______Title 1 for______Head Start______School Counseling______
Behavior Plan______504 Plan (If Yes indicate type)______Is the child an English Language Learner (ELL)______
Part C (preschool) Program______Preschool Screening______Retained in grade______
How many different schools has the student attended? ______
Is the student’s current teacher/teachers Highly Qualified? Yes ______No______Other______
Is there any other information about this student you wish to convey?_
Building Principal’s Signature______
Date Referral Completed and Sent to Special Ed Dept: ______
Please attach work samples & additional information that may be pertinent to this referral.
1 Revised 11- 17-2015