Mid-Central Ed Coop Referral Form

Revised 2010

Mid-Central Ed Coop Referral Form

Information when considering a referral for special education

Name of Student ______Birth-date ______Age ______

Referring Person & Title ______

“To ensure that underachievement in a child suspected of having a learning disability is not due to a lack of appropriate instruction in reading or math, the group must consider, as part of the evaluation described in this article, data that demonstrates that prior to, or as a part of, the referral process, the child was provided appropriate instruction in the regular education setting, delivered by qualified personnel, and data-based documentation of repeated assessments of achievement at reasonable intervals, reflecting formal assessment of student progress during instruction, which was provided to the parents.” ARSD 24:05:24.01:19

Is the student’s current teacher/teachers Highly Qualified?: Yes ______No______

Notes______

Medical Concerns (ex. Has the child been diagnosed with a medical condition? Is the child on medication?):______

Attendance record:

1st Quarter______2nd Quarter______

3rd Quarter______4th Quarter:______

Enrollment gaps (How many schools has the child attended?): ______

(Has he/she ever been retained?):______

(Has he/she ever been referred for special education?):______

Other Comments/Concerns:

______

Current Grades (Last 9 weeks):

Class Grade

______

______
______

______

Administrator Signature Date Evaluate? Yes No

Please provide data-based documentation of repeated assessments of achievement at reasonable intervals, reflecting formal assessment of student progress during instruction, which was provided to the child’s parents. Provide information on particular instructional strategies and programs used in general education, with the student, in the areas of concern.

READING

Ø Phonemic Awareness skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Phonic Skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Vocabulary Skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Reading Fluency, including oral reading skills (ex. reading rate, words read per minute):

o Data: Interventions & ______

______

o Progress reported to parents (dates):______

______

Ø Reading Comprehension (ex. main idea, inferences, cause and effect, sequencing, vocabulary):

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

WRITTEN LANGUAGE

Ø Spelling skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Grammar skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Punctuation and Capitalization skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Writing Preparation, Production, and Revision skills (ex. topic selection, writing plan, note-taking, revision) :

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Choosing and Developing a Topic:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

MATHEMATICS

Ø Calculation skills (ex. math facts, fractions, decimals):

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Problem Solving skills (ex. math word problems):

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Functional Math skills (ex. measurement, weights, telling time):

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

LISTENING COMPREHENSION

Ø Auditory Discrimination skills (ex. student is given two words and he/she needs to state whether they sound the same):

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Following Oral Directions:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Listening to and Comprehending a Story Orally:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Listening Vocabulary skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

ORAL EXPRESSION

Ø Expressive Language:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Receptive Language:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Vocabulary skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Grammar skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Pragmatic Language (functional use of language) skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Sentence Structure (Syntax):

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Verbal Reasoning (Problem Solving) skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

BEHAVIOR:

Ø Attention/Concentration (ex. does not follow lessons, daydreams, easily distracted by minor movement or noises)

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Hyperactive (ex. out of seat, constant movement at desk, constant verbal behavior, can’t remain in line)

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Withdrawn ( ex. tired, generally unhappy, rarely asks for assess even when work is difficult, does not attempt work, cries without provocation, avoids calling attention to themselves)

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Aggressive Behavior (ex. hits, verbally attacks, steals, explosive when angry, argues with teaches, destructive to self and property, strikes back)

Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Disruptive (ex. demands attention of any sort form teachers and peers, does not follow class rules, interrupts lessons, tells bizarre stories)

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Uncooperative (ex. blames others for own mistakes, will not follow routine, defiant, argues, must have last word)

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Social Behavior (ex. comments one likes him/her, has no or very few friends, does not like to go out to recess, does not initiate play or talk to peers, is avoided by peers, does not function well in class discussion, exhibits inappropriate behavior in the classroom)

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

SPEECH and LANGUAGE

Ø Articulation ( ex. Substitutes one sound for another, leaves sounds out of words)

o Interventions & Data: ______

o Progress reported to parents (dates): ______

Ø Fluency (ex. Repeats words or phrases when speaking, gets “stuck” when saying words, holds sounds out longer than needed)

o Interventions & Data: ______

o Progress reported to parents (dates): ______

Ø Voice (ex. Has a harsh or raspy voice quality, talks with a “strained” voice):

o Interventions & Data: ______

o Progress reported to parents (dates): ______

Ø Expressive Language:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Receptive Language:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Vocabulary skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Grammar skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Pragmatic Language (functional use of language) skills:

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______

Ø Sentence Structure (Syntax):

o Interventions & Data:______

______

o Progress reported to parents (dates):______

______