Assessment Plan (22C)
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Purpose of Meeting* Purpose of Meeting* (If other, specify:)
 
To Parent or Guardian of ,   Date Date  
 
District - School Grade Birthdate  
 
Primary Language - English proficiency/CELDT Level  
 
has been referred and/or recommended for an assessment by the following individual(s):
 
       
 
 
 
 
  Parent (Signature)   Nurse (Signature)   Teacher (Signature)   Sp Ed Teacher (Signature)
 
The district proposes to assess your child to determine his/her eligibility for special education services or continued eligibility and present levels of academic performance and functional achievement. Your child will be assessed in all areas of suspected disability as needed. To meet your child’s individual education needs, this assessment will consist of an evaluation in only the areas checked by the local educational agency (LEA)/district.
 

 
  Evaluation Area   Examiner Title  

  Academic Achievement – These tests measure reading, spelling, arithmetic, oral and written language skills, and/or general knowledge.    

  Health – Health information and testing is gathered to determine how your child’s health affects school performance.    

  Intellectual Development – These tests measure how well your child thinks, remembers, and solves problems.    

  Language/Speech Communication Development – These tests measure your child’s ability to understand and use language and speak clearly and appropriately.    

  Motor Development – These tests measure how well your child coordinates body movements in small and large muscle activities. Perceptual skills may also be measured.    

  Social/Emotional – These scales will indicate how your child feels about him/herself, gets along with others, takes care of personal needs at home, school and in the community.    
 
  Adaptive/Behavior
        
     

  Post Secondary Transition – Age appropriate transition assessments related to training, education, employment and where appropriate independent living skills.    

  Other
        
   

  Alternative Means of Assessment
(Describe alternative methods of assessing the child, if applicable)
        
   
 
 

 
____ I consent to the assessment. I understand that the results will be kept confidential and that I will be invited to attend the IEP team meeting to discuss the results. I also understand that no special education services will be provided to my child without my written consent.
 
____ I do not consent to the proposed assessment described above.
 
____ I would like the following assessment information to be considered by the IEP team: _____________________________
 
 
Parent/Guardian Signature     Date    
 
   
 
 
Address:    
 
 
 
      Phone Number:    
 
   
 
 
Comments:    
 
 
     
 
 
 
Please return this form within 15 days of receipt to:    
 
NOTE: Prior Written Notice attached if this is an initial evaluation.
 
  Date received Date received