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:

Parent/Guardian Mailing Address:

(Street Address or PO Box)

City/Zip Code

Student’s Dominant Language: Sex:

School Code: Date of Birth: Ethnic Group:

Jurisdiction begin date:

SCREENING

01 Date of Hearing Screening: Result of Hearing Screening:

03 Date of Vision Screening: Result of Vision Screening:

05 Date of Health Screening: Result of Health Screening:

02 Date of Language Screening: Result of Language Screening:

04 Date of Motor Screening: Result of Motor Screening:

06 Date of Assistive Technology: Result of Assistive Technology:

07 Date of Educational Screening: Result of Education Screening:

08 Date of Social/Emotional/Behavior: Result of Soc./Emot/Beh.Screening:

09 Date of Sensory Processing: Result of Sensory Processing:

Transfer Student (Evaluation completed by another LEA):

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:

Coordinator Name:

Parental Waiver for Triennial Reevaluation: If the box is checked the permission request

date and the disseminated date must be the same.

Primary Exceptionality:

If primary Exeptionality is “unable to complete eval.”

*******Detail Code: (Required for Hearing Impairments, Speech or Language, and Unable to

Complete Evaluation)

Speech or Language:

Secondary Exceptionality:

Speech or Language:

Secondary Exceptionality:

Speech or Language:

Secondary Exceptionality:

Speech or Language:

Medical Diagnosis:**(Required for Orthopedic impairment, Other health impairment, and Traumatic Brain Injury)

Participants:

Date of Extension: Reason for 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.