Evaluation Plan (continued)
Name   Date

   Administered by: Administered by:  
 
Purpose: These tests measure how well a student remembers what has been seen and heard in the environment, how well the student can use the information, and how well he/she solves problems. (Tests yielding IQ scores cannot be administered to African American students). Tests may include, but are not limited to:
 
 
 
 
 
  Other: 

   Administered by: Administered by:  
 
Purpose: These tests measure the student's general adjustment to life and school. They indicate what individuals can do for themselves and how well they get along with others. Tests may include, but are not limited to:
 
 
 
 
 
  Other: 
   

   Administered by: Administered by:  
 
Purpose: Prevocational/vocational tests assist in the identification of a student's interest and aptitude which can be utilized to explore career options. Tests may include, but are not limited to:
 
 
  Other: 

   Administered by: Administered by:  
 
Purpose: Alternative assessment may provide different and/or additional information in a variety of areas. Tests may include, but are not limited to:
 
 
  Other: 

   Administered by: Administered by:  
 
Purpose: Alternative assessment may provide different and/or additional information in a variety of areas. Tests may include, but are not limited to:
 
 
  Other: 
   
 
If you have any questions about this Evaluation Plan, or would like more information regarding a test identified above, please contact:
   

 
 
Name   Position   Phone
 

PARENT ACKNOWLEDGEMENT
Are there any other areas of suspected disability that you would like to be evaluated? ___ No    ___ Yes
If yes, please specify
 

Do you have any independent assessments you would like to have considered? ___ No    ___ Yes
If yes, please specify and provide a copy of the assessment for your child's file which will be considered by the IEP team.
 

Please initial the appropriate responses and sign below:
(     ) I understand the proposed evaluation plan.
(     ) I give permission for the evaluation as indicated. OR (     ) I give my permission on for the following assessments:
 

(     ) I will make my child available for the evaluation.
(     ) If an evaluator feels additional test are needed, she/he may contact me to obtain verbal permission at   (     )
(     ) I have received a copy of the NOTICE OF PROCEDURAL SAFEGUARDS.


 
Parent/Guardian/Surrogate/Student Signature   Date