Graves County Schools

Guided Planning for Initial and Re-evaluation of Other Health Impairment

Do not use this form for Record Review

Student name ______Date of birth ______Age ______

Parent name and address ______

School ______Teacher ______Grade ______

Initial Evaluations must have all of the following data given to Counselor prior to a Referral:

______Before the RTI committee meets to refer there must be an Other Health Impairment medical diagnosis from a doctor indicating the student has limited Strength, Alertness, or Vitality from the condition that impacts education.

______RTI data: Persons responsible=RTI Committee, Regular Education Teacher(s), Counselor, Parent-if applicable

  • Form A: RTI Parent Letter
  • Form B: Student Intervention Documentation/Log & data analysis for each specific Behavior of Concern (BOC) & Academic area(s) that are impacted by the impairment:
  • Charts/graphs w/aim line & data points showing students Rate of Improvement for each specific BOC & Academic area(s)
  • Charts/graphs w/data showing student’s Rate of Improvement compared to peers ROI in behaviors & Academic area(s)
  • Form D: Fidelity Checklist
  • Form E: Student Progress Update(s)
  • Form K: Summary of Interventions & Data (Used to assist Counselor in completing Referral in the KY Evaluation)
  • Form N: Determination of Student Representative

_____ Universal Screening results including Charts/graphs (STAR, DIBELS, PBIS, etc.)

_____ KY Evaluation: Person Responsible=Counselor

  • Completed Referral

All Initial & Re-evals. must include this data based on the Eval. Planning Form. Give to Counselor, who will notify testing center when all received:

Date Evaluation Person responsible

______Vision screening (Current within a year) School nurse/SLP

______Hearing screening (Current within a year) School nurse/SLP

______Previous assessment (If applicable) Counselor/Sp.Ed. Staff

______Social and developmental history (Updated if Re-eval)Parent interview in ARC

______Language evaluation (If applicable) SLP

______Behavior Observations(2)Teacher/Assistant/Admin/Counselor

1-Academic area impactedAND 1-On task behavior

______Behavior Rating Scale (choose 2 scales)Teacher/Parent/Student

BASC-2 – one parent, one teacher, & one student

ADDES – one teacher

Conner’s 3 – one parent, one teacher, & one student

Vanderbilt – one parent, one teacher

______Individual Intelligence Test School Psychologist

______Individual Academic Achievement test(s) (Reading, Math, Written Exp.) Psychometrist

______*Learning Styles Inventory (If not already completed)Teacher/Parent/Student

______*Vocational Inventory (14 years and older) Teacher/Parent/Student

______*Transition Assessments(14 years and older) (Interviews, surveys, interest inventories) Teacher/Parent/Student

*May refer to ILP for this information.**Person Responsible: Initial Eval-Teacher=Reg. Ed Teacher; Re-eval-Teacher=Reg. Ed. Teacher &/or Spec. Ed Teacher