SEN RESOURCING AND ASSESSMENT PANEL

Request Form for Statutory Assessment and Additional Funding

Schools and PVI settings - Foundation Stage 1and Funded Two year oldsonly

N.B Sections 1, 2 and 3 must be completed in full in order to process the request for Statutory Assessment.

Are you applying for Statutory Assessment? ☐ Yes ☐ No

Are you applying for additional funding? ☐ Yes ☐ No

  1. Basic Information

CHILD
Name & Address of School /Setting:
Surname: / Other names:
Home Address:
Gender: / Religion:
Date of Birth:
Age: / Home Language:
PARENTAL RESPONSIBILITY
Is the young person a looked after child? Yes/No (please circle)
What legal status do they have?
Who has parental responsibility, is it shared? If so who with e.g. Local Authority, other parent, grandparent(please mark N/A if no other parent involved)?
Surname (1): / Surname (2):
Other names (1): / Other names (2):
Home address (1): / Home address (2):
Telephone number (1): / Telephone number (2):
Relationship to child: / Relationship to child:
OTHER AGENCIES INVOLVED
Agency / Named Contact / Involvement / Report Attached / Date of Report / If report not within last 6 months please explain why
Start / Finish
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  1. Special Educational Need

SEN Descriptorwhich is the best fit judgement/s – Please number in order, 1 being the primary need (please note that you do not need to list all those below, only those relevant in order) and the relevant Band in terms of that particular need (1 to 6).
Cognition and Learning ☐ Action / Action Plus Band:☐
SpLD ☐ MLD ☐ SLD ☐ PMLD ☐
Communication and Interaction ☐ Action/Action Plus Band:☐
SLCN ☐ ASD☐
Physical and Sensory ☐ Action/Action Plus Band:☐
HI ☐ VI ☐ PD ☐ MSI ☐
Behaviour Emotional and Social ☐ Action/Action Plus Band:☐
BESD ☐
Other (please specify) ☐
Please tick all that apply:
Medical needs ☐
Uses Alternative Augmentative communication e.g. British Sign Language ☐Signalong☐PECS☐Switches☐other (please specify)☐
Autistic Spectrum Condition diagnosed ☐
Requires regular 1:1 (if 2:1 please state) manual handling ☐
Alternative methods of recording ☐
Risk assessment / H&S needs ☐
Proposed Banding ☐1 ☐2 ☐3 ☐4 ☐ 5 ☐6
  • Please refer to the banding descriptors and only tick ONE box – it needs to be best fitamongst all the needs of the child.
  • Please do send in a copy of the Banding Descriptors with your highlighted sections
  • Please state the reasons that the child falls into this proposed band:

  1. Progress towards the Early Learning Goals
    Please refer to Guidance Criteria and progression Guidance for Statutory Assessment

Please attach completed EYFS Developmental Summary Sheet

This can be found in the SEN – Applying for Statutory Assessment and Funding: Alternative summary sheets will NOT be considered.

☐Confirm this has been attached
CHECKLIST
Parents have signed their agreement to this request (unsigned requests will be returned for full completion). / ☐
All reports listed are enclosed. / ☐
All reports are dated and signed. / ☐
Sections 1, 2 and 3 are fully completed, including EYFS Developmental Summary Sheet and reports from professionals. / ☐
  1. Request for Statutory Assessment

Outline your evidence for why the child meets the criteria for request for Statutory Assessment:
(Please make reference to the banding descriptors, the Early Years Entitlement Document and the Guidance Criteria for Statutory Assessment. These documents can be found in the SEN – Applying for Statutory Assessment and Funding section: )

5. Request for Additional Funding

Is the child already under assessment for Statutory Assessment? ☐Yes ☐ No
Is this your first request for funding for this child?☐Yes ☐ No
Do you receive any other additional funding i.e. inclusion funding for Funded 2 year olds? ☐Yes ☐ No
Please provide details of how you are currently supporting this child to meet their needs:
Child’s Needs:
(Refer to statements in Early Years Entitlement Document) / Strategies and interventions/IPP targetsinclude IPP targets/behaviour support strategies. / Impact (progress) / Cost
Total:
Please explain why you are seeking additional funding:
  1. To fund the above additional resource already in place ☐
  2. To fund additional resource (as below) not yet in place ☐

Please describe in detail how you will you use the additional resources / funding (if different from the above):
Strategies and interventions / Anticipated impact / Time / Resource Needed

Total time required for additional support across one week (in hours):

(maximum of 15 hours)

  1. Has this been discussed with the child (as appropriate) and what is their view?
    ☐Yes ☐No
  1. Record of Parents/Carers’ view about this request
  1. Signatures – by signing this request form you are giving consent for the Consultant Community Paediatrician to provide a report for the assessment if required.

Manager/Headteacher:
Print:
Sign / Date:
Parent/Carer:
Print:
Sign / Date:
This form should be submitted to:
SEN Assessment Team
Swindon Borough Council
Wat Tyler House,
Beckhampton Street,
Swindon, SN1 2GH

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