Referral Checklist Evidentiary Hearing

FORM A (Hearing)

REFERRAL CHECKLIST – EVIDENTIARY HEARING

Date of Evidentiary Hearing: Select OneAugustSeptemberOctoberNovemberDecemberJanuaryFebruaryMarchAprilMay ,Select One2012201320142015

Note: An Evidentiary Charge Letter from the Bibb County Hearing Center is not required of students transferring to Bibb County from another county/state with discipline pending.

Student: Grade: DOB: Gender: Male Female

Home School: ID#: FTE#:

General Education Student: Program for Exceptional Children (PEC): Exceptionality: Hours:

------

If student is PEC or 504:

Zone Coordinator, Program for Exceptional Children notified 504 School Coordinator notified

Date of Manifestation Determination: Time:

For All Student:

·  Date of Suspension: Number of Days:

·  Date Parent Contacted: Incident recorded on student discipline record:

Meeting scheduled by Counselor with parent/student for Success Plan overview: (General Education students) (*PEC-below)

Date: Time:

Charge letter and brochure with explanation of hearing and appeal process provided to parent/student

Explanation of Alternative Program provided to parent/student

Course verification form reviewed

Prior Alternative School Placement YES NO

Administratively Placed in Grades: SelectPreKKK1st2nd3rd4th5th6th7th8th9th10th11th12th SelectPreKKK1st2nd3rd4th5th6th7th8th9th10th11th12th SelectPreKKK1st2nd3rd4th5th6th7th8th9th10th11th12th Previous Grade(s) Retained: SelectPreKKK1st2nd3rd4th5th6th7th8th9th10th11th12th SelectPreKKK1st2nd3rd4th5th6th7th8th9th10th11th12th SelectPreKKK1st2nd3rd4th5th6th7th8th9th10th11th12th SelectPreKKK1st2nd3rd4th5th6th7th8th9th10th11th12th

Psychological Testing Information Select OneNot ApplicableNot Applicable- Current PEC StudentCurrent PEC Student-Retesting in ProgressTesting In Progress, Continue Process If Assigned

------

*School support staff will provide information at the manifestation determination meeting in regard to Bibb County BOE Alternative Program and Evidentiary Hearing Process/Appeal to PEC/504 parent/student after the offense has been determined NOT to be a manifestation of the student’s disability. PEC/504 students in this category would then be brought to an evidentiary hearing and information below should be included in their packet along with results of the manifestation meeting as well as a copy of their current IEP/504 Plan:

------

Included in Packet for Hearing:

1

·  Evidentiary Hearing Charge Letter

(Please do not date)

·  All BIP/RTI/Section 504 Plan Documentation/IEP

Required if referred for persistent misconduct and struggling academically.

·  Administrative Transition Plan for Success

·  Student’s Acknowledgement of reading the Guidelines for Success

·  Student Profile Sheet

·  Home Schools Withdrawal Form

·  Attendance Records

·  Discipline Records

·  CURRENT Progress Report/Report Card/Transcript

1

______Date______

Administrator’s Signature Completing This Packet

______Date______

Zone Associate Superintendent’s Signature

______Date______

Principal’s Signature

1

FORM B (HEARING)

Bibb County School District

Purpose and Cause Summary – Alternative Placement

Select One2012-20132013-20142014-2015 School Year

Student Name: Grade Level:SelectPreKKK1st2nd3rd4th5th6th7th8th9th10th11th12th Home School:

Parent/Guardian Name:

Home Phone: Parent/Guardian Work Phone: Cell Phone:

Special Education Student: YES NO

List reason(s) for Hearing referral:

(Purpose and Cause Summary – including deficiencies)

Principal Signature Date

Graduation Coach/Counselor Date

Parent/Guardian Signature Date

Student Signature Date:

STUDENT PROFILE AND SCHEDULE

Student Name / SelectPreKKindergarden1st2nd3rd4th5th6th7th8th9th10th11th12th
Last / First / Current Grade
Lives with
First and Last Name / Primary Phone Number / Alternate Contact Method
Date of Birth: / Gender: Male Female / Date entered SelectPrek1st2nd3rd4th5th6th7th8th9th10th11th12th grade: / mo. / yr.
Free/reduced lunch? / Yes No / Current IEP? / Yes No / Current 504 Plan? / Yes No
Reason for Referral (check only one): Academics Attendance Behavior Medical New to District
District Student ID Number / Last Day of attendance at District / Building Name

Academic Information

Total Credits Earned / as of / # Credits Needed for Dist. Diploma

Student Course Schedule

Semester 1 / Semester 2
Course Titles / Credit Amt / Withdrawal Grade / EOCT
Needed / Course Titles / Credit Amt / Withdrawal Grade / EOCT
Needed

Proficiency Exams: CRCT

Score / Mo/Yr Taken / Score / Mo/Yr Taken / Score / Mo/Yr Taken
Language Arts/English / Writing / Science
Reading/Comprehension / Math / Cit/SS

Other

Please include any other comments or information we should know (e.g., current projected graduation date, additional credits being earned through correspondence or night school including both course titles and credit amounts, etc.)

District Authorization

Completion of this box confirms the student referral into the Alternative program and should be completed only by an authorized representative of the district.

Referrer Name: / Counselor Name:
Email/Phone:: / Email/Phone:

1