Request for Assistance/Referral for Evaluation of Section 504/Chapter 15 Eligibility
** School Initiated Referral
Date:Individual making request:
Student Name: Date of Birth:
Parent/Guardian:Age:
Address:Grade:
School:
Home Phone:
This referral will go to the Section 504/Chapter 15 Building Designee who will present it to the Section 504/Chapter 15 Committee for review. The Committee will review the referral/request along with the student’s educational records to determine what, if any, additional data needs to be collected, and the type of evaluation to be completed
Please indicate on this form any behaviors you may have noticed within your class, or concerns you have about this student. The nature of the evaluation and the appropriateness/effectiveness of the assistance ultimately provided is dependent upon your thoroughness, specific comments and your ability to present your concerns in observable, measurable terms.
Check those which apply:
The student presents with:_____a skill deficit (can’t do!)
_____a performance deficit (doesn’t do!)
_____opposition (refuses to do!)
_____no learning issues
Behavioral Concerns:
Academic Performance
____decline in quality of work_____inconsistent performance day to day
____decline in grades earned
____incomplete work
____work not handed in
_____failing grades due to:
_____lack of effort/motivation/interest
_____incomplete assignments
_____poor test scores
_____lack of preparation/participation
Math
____lacking basic math skills_____difficulty with fractions
____lack of fluency with basic facts_____difficulty with decimals
____cannot add or subtract multi-digits_____difficulty with word problems
____cannot multiply_____difficulty with basic algebra concepts
____cannot divide_____difficulty with language of math
____difficulty with procedures_____difficulty with application of concepts
_____difficulty with multistep problems
Reading/Writing
____weak basic reading skills____difficulty with spelling
____lacks use of phonological knowledge____unable to write complete
____limited sight vocabulary sentences
____difficulty with comprehension____difficulty with
____lacks use of strategies punctuation
____weak in background knowledge____cannot organize a
____does not use context clues paragraph
____limited reading vocabulary____cannot express thoughts
____reading rate below grade level in writing
____lacks fluency
____lacks automaticity in word recognition
Comments Specific to Academic Performance:
Classroom Conduct
____disruptive in class____defiance; breaking rules
____inattentive____frequently needs discipline
____lack of motivation____cheating
____lack of concentration____fighting
____sleeping in class____throwing objects
____impaired memory____defiance of authority
____negative attitude____verbally abusive
____in-school absenteeism(skipping class____obscene language or gestures
____school attendance____sudden outbursts or temper
____tardiness to class____vandalism
____disturbs others____physical aggression
____poor peer interactions
Observations:
____frequent visits to the nurse____apparent weight loss or gain
____frequent visits to the restroom____mood swings
____nervousness, anxiety____pale or flushed complexion
____seems depressed____bruises, burns, cuts, scrapes
____difficulty seeing the board____talks freely of alcohol or drug use
____difficulty copying
Other Behaviors:
____erratic behaviors day to day ____withdrawal, a loner
____change in friends and/or peer group____other students express concern
____sudden unexplained popularity____daydreaming
____seeks constant adult attention____blames others
____seeks constant peer attention/approval ____compulsive achievement
____seeks adult advice w/o specific problem
____time disorientation____preoccupation with school success
____apparent changes in personal values____perfectionism
____limited affect____difficulty accepting mistakes
____defensiveness____rigid obedience
Comments Specific to Conduct, Behavior, Observations; Anecdotal Records:
Interventions Attempted:
Instruction
____small group instruction
____breakdown large assignments
____individualized classroom instruction
____modified or shortened assignments
____individualized directions
____individualized worksheets
____taped lessons
____peer tutor
____other:
Behavior ManagementReinforcers
____clarification of rules____praise
____teach desired behaviors____daily or weekly effort report
____eliminate distractions____reinforce correct responses
____provide routine schedule____positive notes sent home
____structured classroom____contracts
____give more choices____principal
____time-out____other:
____detention
____use of logical consequences
____refer to principal
____preferential seating
Additional Relevant Information:
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For Building Use Only
Action Plan:
______
______
Section 504/Chapter 15 Building Designee
1
Request for Assistance/Referral for Evaluation of Section 504/Chapter 15 Eligibility- 7/2011
**School Initiated Referral
(15-B)