Bloomington Public Schools

1350 West 106th Street

Bloomington, MN 55431-4126

REFERRAL FOR SPECIAL EDUCATION CONSIDERATION

Name of Student: Date of Birth: Grade: School: Parent Contact(s): Date By Relationship to student: Date By Relationship to student:

Referral completed by: ____________

Parent contacted about Special Education Referral: Date Date Referral received by Team Facilitator

ACADEMIC PERFORMANCE

Was the student's academic related problems apparent before this year?


By

No Yes. Describe

Please rate the student's performance in the following areas:

Mild Mod. Severe

Superior Average Problem Problem Problem

Reading

Written Language/Spelling

Math

Science

Social Studies

COGNITIVE/PROCESSING FUNCTIONS

Please rate the student's performance in the following areas:

Mild Mod. Severe

Superior Average Problem Problem Problem

Understanding of spatial directions (left/right, up/down)

Reverses or Rotates words, numbers

Short term memory

Long term memory

Expresses ideas orally

Expresses ideas in written form

Follows verbal directions (classroom routines)

Responds to verbal directions (no visual cues)

Understands meaning from tone of voice or intonation

Obtains information during large group instruction

Yes No

Speaks in mazes. Goes round and round; doesn't get to the point
Has difficulty finding the right word when speaking.
Uses nonspecific language, (uses a great deal of pauses, fillers i.e. -er, um, ah, kinda)
Seems to know what she/he wants to say but can't say it.
Expresses thoughts in a sequential manner with a beginning, middle and end.
Perseverates on a word, phrase, topic

FUNCTIONAL SKILLS

Please rate the student's performance in the following areas:

Mild Mod. Severe

Superior Average Problem Problem Problem

Find way around building

Manage stairs in school and on bus

Complete self-help and dressing manipulations at level of peers

Open doors and locker independently

BL #12a 9/04 This form is available in several languages, Braille, or other format. Contact the individual sending this form.

FUNCTIONAL SKILLS

Mild Mod. Severe

Superior Average Problem Problem Problem

Keep up with peers during passing time or transitions

Be on time for school and classes

Follow a schedule independently

Complete assignments in a timely manner

Maintain organized materials, desk, locker

Pay attention/stay on task

Complete and turn in homework

Participate in class discussion

Use of class time

Ask and answer oral questions

Ask for help when needed

EMOTIONAL/BEHAVIORAL STATUS

What are the student's emotional, social, or behavioral strengths?

Please rate the student in the following areas:

Mild Mod. Severe

Superior Average Problem Problem Problem

Ability to tolerate frustration or failure

Ability to play with same age peers

Ability to interact appropriately with peers

Ability to read social cues

Ability to gain positive attention

Ability to develop and maintain friendships

Ability to interact appropriately with adults

Ability to seek positive attention

Demonstrates positive self-esteem

Please rate the student's behavior of concern:

Mild / Mod. / Severe / Where Behavior When Behavior / Frequency
Problem / Problem / Problem / NA / Occurs Occurs / (hourly, daily, etc)
Overly perfectionistic
Pervasive unhappiness or sadness
Shy or withdrawn (daydreams)
Anxious (seems tense, nervous)
Physically Aggressive
Impulsive (shows poor judgment)
Destructive to Property
Threatens others
Mood swings
Hyperactive
Fire setting
Stealing

What are the two behaviors of highest concern?

#1.

#2.

Please indicate presence of the following behaviors:

Mild / Mod. / Severe
Problem / Problem / Problem / NA / Fails to initiate and/or maintain conversations with peers and adults
Talks excessively about topics that hold little interest to others

EMOTIONAL/BEHAVIORAL STATUS

Mild
Problem / Mod. Problem / Severe
Problem / NA
Has peculiar voice characteristics (high pitched, monotone, excessively loud, etc...)
Repeats words or phrases over and over
Prefers solitary or isolated activities
Shows little or no interest in other children
Avoids or limits eye contact
Displays perseverative or obsessive interest in specific objects, patterns, topics, etc. Has difficulty with changes in routine
Displays rigid patterns of behavior or ritualistic behavior
Please describe: Displays unusual body movements (rocking, hand flapping, finger flicking,
spinning, etc.)
Overreacts to touch/tactile, noise, tastes, smells and/or visual stimuli
(including clothing)

LANGUAGE/COMMUNICATION

Please rate the student in the following areas: Articulation

Mild Mod. Severe No

Problem Problem Problem Problem Please describe sound errors:

Expressive Language

Mild Mod. Severe

Superior Average Problem Problem Problem

Uses proper grammar

Uses age-appropriate vocabulary

Retrieves words quickly

Verbally responds to questions quickly

Asks questions appropriately

Answers questions appropriately

Expresses and organize ideas

Retells stories and a sequence of events

Receptive Language

Mild Mod. Severe

Superior Average Problem Problem Problem

Follows oral directions/discussions

Understands oral information

Remembers auditory information

Discriminates between similar sounding words

Other

Yes / No
Reluctant to speak
Dysfluent (stutters)
Unusual voice quality, pitch, or volume

MOTOR SKILLS

Fine Motor

Please rate the student in the following areas:

Mild Mod. Severe

Superior Average Problem Problem Problem Ability to:

Cut and assemble art work at level of peers

Color within lines with good pressure

Use dominant hand

Write at a speed consistent with peers

Write legibly within indicated space

MOTOR SKILLS

Mild Mod. Severe

Superior Average Problem Problem Problem Ability to:

Copy from blackboard/overhead

Copy from desktop

Write with good pressure

Use correct pencil grasp

Write letters and numbers without reversals (after grade 2)

Use keyboard and/or mouse at same rate as peers

Sensory Motor

Please rate the student in the following areas:

Mild Mod. Severe

Superior Average Problem Problem Problem

Remains seated during an activity without excessive movement
Energy level comparable to peers
Adapts to a new motor task

Attach a handwriting or work sample if appropriate.

Gross Motor (Completed by the Physical Education Teacher)

Please rate the student in the following areas:

Mild Mod. Severe

Superior Average Problem Problem Problem

Strength

Speed

Endurance

Coordination/accuracy

Participation

Ability to follow directions

ASSISTIVE TECHNOLOGY

An Assistive Technology/Device is any item, piece of equipment, or product system that is used to increase, maintain, or

improve functioning of individuals.

Does the student currently use any Assistive Technology devices in any environment? Yes No

If yes, check all that apply.

pencil grips

slant boards

seating/posture adaptations

alternate pencils, pens, crayons, etc.

adapted paper

paper stabilizers (clip boards, dicey)

adapted scissors

highlighters

TRANSITION (for Secondary Students Only)


rubber stamps

calculators

keyboarding

carbon note taking tablets

zipper pulls

organizers: notebook, desk, locker

study carrel

other

Has a vocational assessment been completed?

Yes. When

No

Where

S.W.I.M. PROCESS

Date

Areas to consider

Decision Evaluate

Return to General Education for continued support

Refer to 504

Cognitive / Language/Communication
Academics / Fine Motor
Functional Skills / Gross Motor
Emotional/Behavioral Status / Sensory
Autism / Assistive Technology
OHD / Transition

Evaluation Case Manager:

Date Parent contacted (Within 5 days of S.W.I.M. meeting):

Team Facilitator Signature: