SCHOOL BUILDING LEVEL COMMITTEE
WAIVER FORMS
St. Landry Parish School Board
Revised by:
August 8, 2013


Checklist for Waiver

Student:

School:

Section 1: Referral Information

Page 1 of Screening Packet

Section 2: Screening and Intervention Data

A. Academic Performance

Copy of Cum. Card (Grade progression and cumulative attendance)

State-wide/District-wide Test Scores (Student and Class Report)

Current Report Card

Behavior Reports/Plans (contents of discipline folder including intervention data)

Progress reports/progress monitoring data (Include statement from all service providers)

*Waivers SHOULD NOT be conducted if there are additional academic concerns or behavior concerns that warrant an FBA/BIP.


FOR PAC USE ONLY

Coordinator / Race / Gender / Case #

ST. LANDRY PARISH – PUPIL APPRAISAL CENTER

CHILD IDENTIFICATION

Screening Packet - Page 1

CHILD FIND
STUDENT / / /
First / Middle / Last
PHYSICAL ADDRESS
Street / Highway / City / State / Zip Code
MAILING ADDRESS
(if different)
Street / Highway / P. O. Box / City / State / Zip Code
DOB / AGE / RACE / GENDER
Years Months
SSN / PRIMARY LANGUAGE
HEAD OF HOUSEHOLD - FATHER MOTHER GRANDPARENT FOSTER OTHER
FATHER
First / Middle / Last
MOTHER
First / Middle / Maiden / Last
GUARDIAN
First / Middle / Last
Home Phone / Work Phone / Emergency Phone
and/or Cell Phone
SCHOOL / TEACHER / GRADE
Referred by / Position / Race / Gender

COMPLETE FOR RE-EVALUATION or WAIVER ONLY:

Exceptionality / Sped. Teacher / Case # / Date of Last Evaluation
REASON FOR REFERRAL: / SPECIFY CONCERNS:
Initial Evaluation
Reevaluation / Mandatory Reevaluation
Results of Manifestation Determination
Declassification
Significant Change of Placement
New Concern
Gifted
Talented
Waiver
Preschool Screening
Court Decision / Due Process Hearing Decision
Other:

*Race: W-White B-Black H-Hispanic AI-American Indian A-Asian

Attach Current Report Card


Attach Progress Reports/Progress Monitoring Data

Attach discipline folder contents, FBA, BIP, etc.

Student Name:
Case #

Motor Reevaluation / Waiver

To be completed for students currently receiving Adapted Physical Education

Level of Motor Deficit / Level of Service / Type of Instruction
Mild / Sessions per week / Individual
Moderate / Minutes per session / Small Group
Severe / Inclusion with regular P.E. Class
Are student’s objectives being achieved?
Most / Some / Few / None
Is there a continued need for participation in an Adapted Physical Education program?
Yes / No
Is there a need for further motor assessment?
Yes / No
COMMENTS:
Teacher’s Signature

Attach Statement from ALL Service Providers