Evaluation Coordinator S Tracking Chart
CONFIDENTIAL
EVALUATION COORDINATOR’S TRACKING CHART
AVOYELLES PARISH SCHOOL BOARD
PUPIL APPRAISAL
RE-EVALUATION
SOCIAL SECURITY NUMBER:
(Last Name) First Name (Middle Initial)
Parent/ Guardian of Residence:
(Last)(First)(MI)
Parent/Guardian Relationship: 01 Parent 02 Sibling(s) 03 Parent and Stepparent 04 Legal Guardian (Court Appointed) 05 Foster Parent (s) 06 Grandparent (s) 07 Surrogate Parent 08 Foster Parent Whi is Surrogate 09 Other Relative 10 Stepparent Only 99 Other
Parent/Guardian Mailing Address:
(Street Address or PO Box)
Bordelonville 71320 Bunkie 71322 Centerpoint 71323 Cottonport 71327 Deville 71328 Dupont 71329 Effie 71331 Hamburg Hessmer 71341 Long Bridge 71355 Mansura 71350 Marksville 71351 Moreauville 71355 Morrow 71356 Plaucheville 71362 Simmesport 71369 Vick 71331
City/Zip Code
Student’s Dominant Language: 01 English 02 French 03 German 04 Italian 05 Russian 06 Spanish 07 Chinese 08 Japanese 09 Korean 10 Vietnamese 11 Other European 12 Other Asian 13 Hebrew 14 Arabic 15 Total Communication 16 No System of Communication 99 Other M Male F Female
School Code: A02003 Cottonport Correctional A04002 Marksville Correctional 005003 BES 005004 BHS 005007 CES 005012 LES 005015 MES 005016 MHS 005018 AHS 005019 PES 005020 RES 005025 LASAS 0005700 APSB 501007 Marksville Catholic 501013 Sacred Heart 501014 St. Anthony 501023 St. Mary's 501034 St Josesph K06008 Little Bo Peep K06009 Brooks Development K06061 Cinderella K06001 Cinderella Head start K06002 Humpty Dumpty Head start K06004 Mother Hubbard Head Start K06006 Cardinal Cushing Head start K06008 Little Bo Peep Head start K06009 Brooks Child Devel. Head start K06010 Jack and Jill Head start H17001 New Beginnings Head start K06007 Mother Goose Head start VGO001 Nay's VHY001 ECDC VIH001 Toddle Town VCX001 Cribs to Crayon Bunkie KQ9001 Cribs to Crayon Cottonport KQ8001 Bayou Chateau KLI001 1, 2 Buckle My Shoe Date of Birth: Ethnic Group : 01 American Indian 02 Asian 03 Black 04 Hispanic 05 White
Jurisdiction begin date:
SCREENING
01 Date of Hearing Screening: Result of Hearing Screening: Normal At risk
03 Date of Vision Screening: Result of Vision Screening: Normal At risk
05 Date of Health Screening: Result of Health Screening : Normal At risk
02 Date of Language Screening: Result of Language Screening: Normal At risk
04 Date of Motor Screening: Result of Motor Screening: Normal At risk
06 Date of Assistive Technology: Result of Assistive Technology: Normal At risk
07 Date of Educational Screening: Result of Education Screening: Normal At risk Advanced
08 Date of Social/Emotional/Behavior: Result of Soc./Emot/Beh.Screening: Normal At risk Advanced
09 Date of Sensory Processing: Result of Sensory Processing: Normal At risk
Transfer Student (Evaluation completed by another LEA): 1 In state 2 Out of state
RE-EVALUATION
Permission Request/Start Date: (Date on which fully informed consent was requested)
Re-evaluation decline Date:
Report Disseminated Date: Reason for Re-evaluation: 1 Triennial Reevaluation 2 Significant change in placement proposed 5 Declassification-child no longer has disability 9 Gifted Talented Reevaluation New Concern
Coordinator Name: Gwen Descant Brenda Matkin Aimee Moreau Margaret Brasseaux Brooke Normand Kelsey Ducote Rachal Normand Lillie Armand
Parental Waiver for Triennial Reevaluation: If the box is checked the permission request
date and the disseminated date must be the same.
Primary Exceptionality:01 Autism 02 Visual Impairment-Blindness 03 Hearing Impairment-Deafness 04 Deaf-Blindness 05 Emotional Disturbance 07 Developmental Delay 08 Hearing Impairment-Hard of Hearing 11 Specific Learning Disability 12 Mental Disability (MD) (Mild) 13 Mental Disability (MD (Moderate) 14 Mental Disability (MD) Severe) 15 Mental Disability (MD) (Profound) 16 Multiple Disabilities 18 Orthopedic Impairment 19 Other Health Impairment 20 Visual Impairment-Partially Seeing 22 Educationaly Hanicapped/Slow Learning (EH/SL) 24 No Exceptionality 25 Traumatic Brain Injury 27 Gifted 28 Speech/Language Impairment 32 Talented 99 Unable to complete evaluation
If primary Exeptionality is “unable to complete eval.” 01 Death 02 Moved 03 Parent Rescinded Permission 04 Dropped Out
*******Detail Code: (Required for Hearing Impairments, Speech or Language, and Unable to
Complete Evaluation)
Speech or Language: Articulation Fluency Language Voice Articulation Fluency Language Voice Articulation Fluency Language Voice
Secondary Exceptionality: 01 Autism 02 Visual Impairment-Blindness 03 Hearing Impairment-Deafness 04 Deaf-Blindness 05 Emotional Disturbance 07 Developmental Delay 08 Hearing Impairment-Hard of Hearing 11 Specific Learning Disability 12 Mental Disability (MD) (Mild) 13 Mental Disability (MD (Moderate) 14 Mental Disability (MD) Severe) 15 Mental Disability (MD) (Profound) 16 Multiple Disabilities 18 Orthopedic Impairment 19 Other Health Impairment 20 Visual Impairment-Partially Seeing 22 Educationaly Hanicapped/Slow Learning (EH/SL) 24 No Exceptionality 25 Traumatic Brain Injury 27 Gifted 28 Speech/Language Impairment 32 Talented 99 Unable to complete evaluation
Speech or Language: Articulation Fluency Language Voice Articulation Fluency Language Voice Articulation Fluency Language Voice
Secondary Exceptionality: 01 Autism 02 Visual Impairment-Blindness 03 Hearing Impairment-Deafness 04 Deaf-Blindness 05 Emotional Disturbance 07 Developmental Delay 08 Hearing Impairment-Hard of Hearing 11 Specific Learning Disability 12 Mental Disability (MD) (Mild) 13 Mental Disability (MD (Moderate) 14 Mental Disability (MD) Severe) 15 Mental Disability (MD) (Profound) 16 Multiple Disabilities 18 Orthopedic Impairment 19 Other Health Impairment 20 Visual Impairment-Partially Seeing 22 Educationaly Hanicapped/Slow Learning (EH/SL) 24 No Exceptionality 25 Traumatic Brain Injury 27 Gifted 28 Speech/Language Impairment 32 Talented 99 Unable to complete evaluation
Speech or Language: Articulation Fluency Language Voice Articulation Fluency Language Voice Articulation Fluency Language Voice
Secondary Exceptionality: 01 Autism 02 Visual Impairment-Blindness 03 Hearing Impairment-Deafness 04 Deaf-Blindness 05 Emotional Disturbance 07 Developmental Delay 08 Hearing Impairment-Hard of Hearing 11 Specific Learning Disability 12 Mental Disability (MD) (Mild) 13 Mental Disability (MD (Moderate) 14 Mental Disability (MD) Severe) 15 Mental Disability (MD) (Profound) 16 Multiple Disabilities 18 Orthopedic Impairment 19 Other Health Impairment 20 Visual Impairment-Partially Seeing 22 Educationaly Hanicapped/Slow Learning (EH/SL) 24 No Exceptionality 25 Traumatic Brain Injury 27 Gifted 28 Speech/Language Impairment 32 Talented 99 Unable to complete evaluation
Speech or Language: Articulation Fluency Language Voice Articulation Fluency Language Voice Articulation Fluency Language Voice
Medical Diagnosis:**(Required for Orthopedic impairment, Other health impairment, and Traumatic Brain Injury)
01 Amputation 02 Arthogryposis 03 Asthma 04 Cancer 05 Cerebral Palsy 06 Congenital Heart Defect 07 Diabetes 08 Down Syndrome 09 Epilepsy 10 Hydrocephalus 11 Leukemia 12 Multiple Sclerosis 13 Muscular Dystrophy 14 Osteogenesis Imperfecta 15 Sickle Cell Anemia 16 Spina Bifida 17 Other Spinal Disability 18 Usher's Syndrome 19 ADD 20 ADHD 21 External Physical Force to Brain 22 Severe Allergies 23 Narcolepsy 24 Bi-Polar 25 Post-Traumatic Stress Syn. 26 Asperger Syndrome 99 Other 01 Amputation 02 Arthogryposis 03 Asthma 04 Cancer 05 Cerebral Palsy 06 Congenital Heart Defect 07 Diabetes 08 Down Syndrome 09 Epilepsy 10 Hydrocephalus 11 Leukemia 12 Multiple Sclerosis 13 Muscular Dystrophy 14 Osteogenesis Imperfecta 15 Sickle Cell Anemia 16 Spina Bifida 17 Other Spinal Disability 18 Usher's Syndrome 19 ADD 20 ADHD 21 External Physical Force to Brain 22 Severe Allergies 23 Narcolepsy 24 Bi-Polar 25 Post-Traumatic Stress Syn. 26 Asperger Syndrome 99 Other 01 Amputation 02 Arthogryposis 03 Asthma 04 Cancer 05 Cerebral Palsy 06 Congenital Heart Defect 07 Diabetes 08 Down Syndrome 09 Epilepsy 10 Hydrocephalus 11 Leukemia 12 Multiple Sclerosis 13 Muscular Dystrophy 14 Osteogenesis Imperfecta 15 Sickle Cell Anemia 16 Spina Bifida 17 Other Spinal Disability 18 Usher's Syndrome 19 ADD 20 ADHD 21 External Physical Force to Brain 22 Severe Allergies 23 Narcolepsy 24 Bi-Polar 25 Post-Traumatic Stress Syn. 26 Asperger Syndrome 99 Other
Participants: 01 Audiologist 02 Educ. Diagnostician 03 Educ. Consultant 04 Psychiatrist 05 Optometrist/Ophtalmologist 06 Pedicatrician 07 Orthopedist 08 Other Medical Specialist 09 Certified School Psychologist 10 Qualified School Social Worker 11 Speech/Language Pathologist 12 Teacher (Current) 13 School Counselor 14 School Nurse 15 Physical Therapist 16 Occupational Therapist 17 Adapted P.E. Teacher 18 Parent 19 Neurologist 99 Other 01 Audiologist 02 Educ. Diagnostician 03 Educ. Consultant 04 Psychiatrist 05 Optometrist/Ophtalmologist 06 Pedicatrician 07 Orthopedist 08 Other Medical Specialist 09 Certified School Psychologist 10 Qualified School Social Worker 11 Speech/Language Pathologist 12 Teacher (Current) 13 School Counselor 14 School Nurse 15 Physical Therapist 16 Occupational Therapist 17 Adapted P.E. Teacher 18 Parent 19 Neurologist 99 Other 01 Audiologist 02 Educ. Diagnostician 03 Educ. Consultant 04 Psychiatrist 05 Optometrist/Ophtalmologist 06 Pedicatrician 07 Orthopedist 08 Other Medical Specialist 09 Certified School Psychologist 10 Qualified School Social Worker 11 Speech/Language Pathologist 12 Teacher (Current) 13 School Counselor 14 School Nurse 15 Physical Therapist 16 Occupational Therapist 17 Adapted P.E. Teacher 18 Parent 19 Neurologist 99 Other 01 Audiologist 02 Educ. Diagnostician 03 Educ. Consultant 04 Psychiatrist 05 Optometrist/Ophtalmologist 06 Pedicatrician 07 Orthopedist 08 Other Medical Specialist 09 Certified School Psychologist 10 Qualified School Social Worker 11 Speech/Language Pathologist 12 Teacher (Current) 13 School Counselor 14 School Nurse 15 Physical Therapist 16 Occupational Therapist 17 Adapted P.E. Teacher 18 Parent 19 Neurologist 99 Other 01 Audiologist 02 Educ. Diagnostician 03 Educ. Consultant 04 Psychiatrist 05 Optometrist/Ophtalmologist 06 Pedicatrician 07 Orthopedist 08 Other Medical Specialist 09 Certified School Psychologist 10 Qualified School Social Worker 11 Speech/Language Pathologist 12 Teacher (Current) 13 School Counselor 14 School Nurse 15 Physical Therapist 16 Occupational Therapist 17 Adapted P.E. Teacher 18 Parent 19 Neurologist 99 Other 01 Audiologist 02 Educ. Diagnostician 03 Educ. Consultant 04 Psychiatrist 05 Optometrist/Ophtalmologist 06 Pedicatrician 07 Orthopedist 08 Other Medical Specialist 09 Certified School Psychologist 10 Qualified School Social Worker 11 Speech/Language Pathologist 12 Teacher (Current) 13 School Counselor 14 School Nurse 15 Physical Therapist 16 Occupational Therapist 17 Adapted P.E. Teacher 18 Parent 19 Neurologist 99 Other 01 Audiologist 02 Educ. Diagnostician 03 Educ. Consultant 04 Psychiatrist 05 Optometrist/Ophtalmologist 06 Pedicatrician 07 Orthopedist 08 Other Medical Specialist 09 Certified School Psychologist 10 Qualified School Social Worker 11 Speech/Language Pathologist 12 Teacher (Current) 13 School Counselor 14 School Nurse 15 Physical Therapist 16 Occupational Therapist 17 Adapted P.E. Teacher 18 Parent 19 Neurologist 99 Other 01 Audiologist 02 Educ. Diagnostician 03 Educ. Consultant 04 Psychiatrist 05 Optometrist/Ophtalmologist 06 Pedicatrician 07 Orthopedist 08 Other Medical Specialist 09 Certified School Psychologist 10 Qualified School Social Worker 11 Speech/Language Pathologist 12 Teacher (Current) 13 School Counselor 14 School Nurse 15 Physical Therapist 16 Occupational Therapist 17 Adapted P.E. Teacher 18 Parent 19 Neurologist 99 Other 01 Audiologist 02 Educ. Diagnostician 03 Educ. Consultant 04 Psychiatrist 05 Optometrist/Ophtalmologist 06 Pedicatrician 07 Orthopedist 08 Other Medical Specialist 09 Certified School Psychologist 10 Qualified School Social Worker 11 Speech/Language Pathologist 12 Teacher (Current) 13 School Counselor 14 School Nurse 15 Physical Therapist 16 Occupational Therapist 17 Adapted P.E. Teacher 18 Parent 19 Neurologist 99 Other 01 Audiologist 02 Educ. Diagnostician 03 Educ. Consultant 04 Psychiatrist 05 Optometrist/Ophtalmologist 06 Pedicatrician 07 Orthopedist 08 Other Medical Specialist 09 Certified School Psychologist 10 Qualified School Social Worker 11 Speech/Language Pathologist 12 Teacher (Current) 13 School Counselor 14 School Nurse 15 Physical Therapist 16 Occupational Therapist 17 Adapted P.E. Teacher 18 Parent 19 Neurologist 99 Other
Date of Extension: Reason for Extension: End-of-school year Parentally Approved Extension
Number of days for extension (1 – 30):
If Reason # 7 Date Approved for Extension:
Teacher/Therapist providing services:
Comments:
Submit Copy to: School Supervisor of Special Education
Email to:
If the Parental Waiver for Triennial Reevaluation is checked, all fields except the Permission Start Date, the Report Disseminated Date, and the Reevaluation Reason must match the information from the previous Evaluation.
