Evaluation Plan for Special Education Services
(This form can generate more than one printed page)
 
Date Date   Date of Referral Date of Referral
  Date Received by District Date Received by District
  IEP Due Date IEP Due Date
 

 
Your child has been referred for:* Your child has been referred for:*     (Specify if other purpose:)
 
Student   Date of Birth
 
   
  Last First  
 
School   Grade
 
   
 
Primary Language -   ELL  Yes No   Language Assessment Date Language Assessment Date
 

 
Reason for evaluation: (area of concern) Referred by:
 
The district recommends evaluating your child for the following reason:
 
To determine the eligibility of your child for special education services and your child's educational needs as a result of a referral dated: ______________
 
To reevaluate the eligibility and educational needs of your child as part of a three year reevaluation.
 
Other:  
 
The district considered the following alternatives to an evaluation and rejected each one for the reason listed:
 
The district has reviewed existing evaluation data including:
 
Student file. Information provided by parent.   List any formal evaluation provided 
 
Current classroom-based, local AND/or state assessments and Observation by teacher and other professionals
 

 
Based on its review of the information above, the district recommends an evaluation of your child by qualified district staff in the areas checked below. It is necessary that we obtain your consent to this plan before we proceed. We would also like you to provide us with any information regarding your child that may be relevant. Please note it in the box below.*
 
LANGUAGE/SPEECH/COMMUNICATION DEVELOPMENT
  These observations and tests measure the ability to understand, relate to and use language and speech clearly and appropriately.
ACADEMIC/PRE-ACADEMIC ACHIEVEMENT
  These observations and tests measure and may include basic reading and comprehension, written expression, math calculation and reasoning, oral expression and/or listening comprehension.
MOTOR/PSYCHO-MOTOR DEVELOPMENT
  These observations and tests measure the ability to coordinate body movements in both small and large muscle activities.These tests may also measure visual perceptual skills.
INTELLECTUAL DEVELOPMENT
  These observations and tests measure the ability to utilize information to problem solve in both familiar and new situations. Verbal and non-verbal tests may be used, as appropriate. These tests include the basic psychological processes of auditory, attention, visual and sensory motor.
SOCIAL/EMOTIONAL/BEHAVIORAL STATUS
  These observations and tests measure the ability to build and maintain satisfactory relationships and demonstrate appropriate behavior across environments.
HEALTH/DEVELOPMENT
  These observations and tests measure vision, hearing, health, developmental history and medical history, as well as a review of medical records.
SELF-HELP/ORIENTATION AND MOBILITY/ASSISTIVE TECHNOLOGY
  These observations and tests measure daily living skills and adaptive functioning across settings.
CAREER/VOCATIONAL ABILITIES (As appropriate.)
  These observations and tests measure interest and abilities relative to levels of skill development, work readiness, and/or occupational preparation.
ALTERNATIVE ASSESSMENT(S)
  (Including means to assess for language impairment or learning disability when standard tests are considered invalid.)
  Describe: 
OTHER
  Describe: 
 

 
*ADDITIONAL STUDENT INFORMATION PARENT WOULD LIKE CONSIDERED
Describe:
 

 
The results of the evaluation will be shared with you at a meeting of the Individualized Education Program (IEP) team following completion of the evaluation and you will be given a copy of the evaluation report(s). All information and evaluation results will be kept confidential. No initiation of special education services, or changes in special education services, will be made without your written consent. No single procedure may be used as the sole criterion for determining appropriate educational program. A pupil shall not be eligible if the determinate factor is lack of appropriate instruction in reading and/or mathematics, or limited English proficiency. Attached you will find a copy of rights for parents whose children are in, or being considered for, special education programs. This document includes a listing of sources for information on special education law and an explanation of your mediation and hearing rights in case of a disagreement with the district regarding special education. If you would like to receive future Special Education Notices by e-mail, please list your email address.
 

 
PARENTAL CONSENT FOR EVALUATION
 
_______ Yes, I understand the proposed evaluation and give my permission to conduct the evaluation as described.I understand my consent is voluntary and may be revoked. A document describing my procedural rights accompanied this statement. I agree to make my child available for the evaluation.
 
_______ No, I do not give my permission for this evaluation.
 
Parent/Guardian signature:   Date:  
 
 
 
Address:
 
Phone:
 

 
PLEASE SIGN AND RETURN THE EVALUATION PLAN TO: Name:
  Address:
  Phone: