Notice of Proposed Action and/or Referral for Special Education Evaluation

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        Date
 
To the parent/guardian of   DOB
 

   
  Last First      
 
Parent/Guardian/Surrogate Parent/Guardian/Surrogate Address Address
 
City City State State Zip Zip Phone Phone
  Home Work
 
Primary language of student   Home language  
 
 
  LEP status

This notice is to fully inform you regarding the school district's proposal to initiate or change the identification, evaluation, educational placement of your child, or the provision of a free appropriate public education to your child. This notice includes a description of the proposed action, an explanation of why the district proposes to take this action, a description of any other options the agency considered and the reasons why those options were rejected, and any other factors that are relevant (interventions and modifications attempted and results) in this proposal.

 

Description of Proposed Action:
 
 
 
 
  Evaluation type:   (if other, specify:) 
 
 
 
  Placement type:   (if other, specify:) 
 
  
 

Reason(s) for this proposed action: Reason(s) for this proposed action:
 
Other options considered and reasons why they were rejected: Other options considered and reasons why they were rejected:
 
Interventions and modifications attempted, concerns, and results: Interventions and modifications attempted, concerns, and results:
 
Description of evaluation procedures, test records or report(s) and any other factors (if any) relevant to this proposed action: Description of evaluation procedures, test records or report(s) and any other factors (if any) relevant to this proposed action:
 

Check area(s) of suspected disability (for evaluation only):
 
   
     
     
 
 
 
 

You have protections under state and federal procedural safeguard provisions. Please refer to the enclosed NOTICE OF PROCEDURAL SAFEGUARDS for an explanation of these rights. If you would like further information about your rights, the proposed action, and/or referral, please contact:

   

 
 
District Contact   Phone   Position