FORMS 6A &
6B – SIGNATURE AND
PARENT CONSENT
1. IEP Meeting Participants: Have all
meeting participants sign and date that they were in
attendance. Make sure to include titles of each participant.
2. Consent: Have the parent(s)/guardian/surrogate/adult student initial, if they agree in- whole or in-part
to
the IEP. If
they
agree only in-part, document the areas they are not
in agreement with. Steps to resolve the disagreement should be documented on Form 7.
3. Not Eligible: If team determines child is not
eligible for special education,
check the appropriate box.
4. If the parent(s)/guardian/surrogate/adult
student
declines the initiation of
special education and related services, check the box.
5. No Longer Eligible: If team determines child is no longer eligible for
special education, check the appropriate box.
6. As a means of
improving services and results for your child did the school
facilitate parent involvement? When in the “Future IEP” be sure to uncheck the box prior to the IEP meeting. During the IEP meeting,
check the appropriate box.
This is a required CASEMIS data field. One of the boxes must
be checked. Note: you need to ask
this question annually, and the parent needs to check the box.
No response does not mean “we forgot
to
ask”. If the
parent(s)/guardian/surrogate/adult student checks “no”, then the team
needs to agree on a plan to address the issue in the coming year.
7. Parent(s)/guardian/surrogate/adult
student received a copy of the assessment
report if
applicable. Check this box if the parent(s)/guardian/surrogate/adult
student received a
copy of the assessment
report.
8. Parent(s)/guardian/surrogate/adult student received a copy of
the
IEP.
9. Signature: Have parent(s)/guardian/surrogate/adult student sign and date.
10. Public Benefits:
If
parent agrees to authorize district access to health insurance benefits provided by Medi-Cal, check the appropriate “Yes” or “No” box and have parent/guardian
sign.
Also indicate using the check box whether the parent(s)/guardian/surrogate/adult student
have
been given their written notification of protections to access Medi-Cal.
11. Students Enrolled in Private Schools by Their
Parents: If
the
student is enrolled in
private school by
his/her parent(s)/guardian/surrogate/adult student, check the box and develop a Services Plan, if appropriate.
Note: Form 6A is used by the District/LEA/SELPA with Medi-Cal signatures.
Form 6B is used by the District/LEA/SELPA without Medi-Cal signatures.
Educational Benefit
Reminder
-
Did all
IEP
Meeting participants sign and date, if
required?
- Do the parent(s)/guardian/surrogate/adult
student consent to all
components of
the
IEP?
- If not, are areas of agreement
and/or disagreement clearly specified?
- Are the next steps identified for reaching resolution, if appropriate?
- Are all required notifications marked for compliance?
[Excerpted
from the State SELPA IEP Manual, July, 2013]