Assessment Plan (22A)
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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  
 
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. *Tests conducted pursuant to these assessments may include, but are not limited to classroom observations, rating scales, one-on-one testing or some other types or combination of tests.
 

 
  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 - These scales indicate how your child takes care of personal needs at home, school and in the community.    

  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: _____________________________
 
 
Signature     Date    
 
   
 
 
____ If my child is or may become eligible for public benefits (Medi-Cal): I authorize the LEA/District to release student information for the limited purpose of billing Medi-Cal/Medicaid and to access Medi-Cal health insurance benefits for applicable services.  
 
Signature    
 
 
 
Parent/Guardian/Student has received written notification of protections available to parents when LEA requests to access Medi-Cal benefits  
     
 
Address     Phone Number:    
 
   
 
 
Comments:    
 
 
 
Please return this form within 15 days of receipt to:    
 
 
  Date received by District/LEA Date received by District/LEA
NOTE: Prior Written Notice attached if this is an initial evaluation.
 
 

 
  NOTE: The state forms committee removed the following item (7.2013), and it no longer prints:
 
  Adaptive behavior
(description from first table column)