Section 504 Referral For Evaluation Cover Page

Student Name: ______Birth Date: ______Student #: ______

School: ______Grade: ______Date of Referral: ______

Send the referral “packet” to the Parkway Special Services Department at the AdministrativeCenter and keep all original documentation in the student education record at the school. Staff from the Special Services Department and/or Parkway’s Health Services Department will contact school following receipt of the referral.

The following served as the basis for the SUSPECTED DISABILITY and determination to refer for a Section 504 evaluation (include all that are required, applicable, and/or needed):

Copy of “Section 504 Referral Review Letter” or “Joint Review Letter” [REQUIRED]

Evidence of mental or physical IMPAIRMENT (e.g., documentation of diagnosis from private professional, public school generated data/documentation/test scores) [REQUIRED]

Letters/emails from parents detailing their concerns and reason for 504 request

Documentation of any accommodations currently being provided to/needed by the student and/or “Interim” suspected disability plan (if formal plan developed) [REQUIRED]

Specialized Health Care Plan [REQUIRED, if one needed/developed]

Care Team documents (summary of team decisions/recommendations)

Information collection forms gathered for Care Team (e.g., Parent Contact Form, Teacher Information Form, Counselor Information Form)

List of current and/or previous supports/interventions and their effectiveness

Progress reports/report cards and/or copy of cumulative education record folder

Standardized assessment scores (Stanford, OLSAT, MAP, PLAN)

Parkway “common assessment”scores

Student work samples utilized by Care Team (areas of concern ONLY)

Copy of any assessments/ratings scales(i.e., Conner’s Rating Scale) previously completed by school staff

Private evaluation reports and/or copy of assessments/ratings scales (i.e., Conner’s Rating Scale) completed by school staff at request of private professionals

Other: ______

Comments/notes: ______

Person submitting referral:

______

SignatureTitlePhone #

Contact person at school, IF different from above:

______

SignatureTitlePhone #

6/18/10