Assessment Plan (2006 version)
 
Purpose of Meeting* Purpose of Meeting* (If other, specify:)
 
To Parent or Guardian of ,   Birthdate  
 
  Date Date Pick a date  
 
School   Grade
 
District of Residence -   District of Service -
 
English Learner Yes No   Student Language -
 

 
Based on the recommendations of the school district’s evaluation team and your input, the District proposes the following assessment to address the areas of suspected disability.The assessment will be conducted by qualified staff, and when appropriate, interpreters of the individual’s primary language may be used. You may receive a copy of the assessment findings, upon request, prior to the Individualized Education Program Team following completion of the assessment. The results of this assessment may be a recommendation for special education services or maintenance or change of the current special education service(s). A student will not be placed in special education without the consent of the parent or guardian. All information and assessment results will be kept confidential. No single procedure may be used as the sole criterion for determining appropriate educational program.
 

       
Professional    
 
Academic Achievement  
 
 
  Purpose: These tests measure current reading, spelling, arithmetic, and oral/written language skills.Tests may include, but are not limited to: Wide Range Achievement Test, Peabody Individual Achievement Test, Woodcock-Johnson Psycho-Educational Battery: Part Two; Wechsler Individual Achievement Tests.  
 
  Others:   
 
Social/Adaptive  
 
 
  Purpose: These instruments will indicate how an individual copes with situations, gets along with other people, and takes care of herself/himself. Scales may include, but are not limited to: Interview; Adaptive Behavior Scale; Vineland; Alpern-Boll; Behavior Evaluation Scales; Self-Esteem Inventories; and Projective Tests.  
 
  Others:   
 
Motor Development  
 
 
  Purpose: Instruments in this area measure how well an individual coordinates body movements in small and large muscle activities. They also may measure visual perceptual skills. Tests may include, but are not limited to: Bender Gestalt; Beery-Buktenica Visual; Bruininks-Oseretsky Test of Motor Proficiency.  
 
  Others:   
 
Communication Development  
 
 
  Purpose: These tests measure the individual’s ability to understand, relate to and use language and speech clearly and appropriately. Tests may include, but are not limited to: Peabody Picture Vocabulary Test; Clinical Evaluation of Language Fundamentals; Test of Language Development, observation, language sample, and articulation scales.  
 
  Others:   
 
Cognitive Development  
 
 
  Purpose: These tests measure how well an individual remembers what has been seen and heard, how well the student can use that information, and how the student solves problems. Tests may include, but are not limited to: Wechsler Test of Intelligence; Stanford-Binet; Leiter; Kaufman ABC.  
 
  Others:   
 
Other (i.e., Hearing, Vision, Health, Vocational, Orientation/Mobility, Observation, Interview)  
 
 
   
 
Alternative Means:   
 

 
The professional(s) who may conduct the individual assessment are designated by number as noted below
 
  1-Resource Specialist 2-Audiologist 3-Special Education Teacher 4-Adapted PE Specialist  
 
 
  5-Psychologist 6-Nurse 7-Language, Speech, and Hearing Specialist 8-Other  
 
If you have any questions about the above Assessment Plan, please call:
 
Name Title Phone
 

 
THIS FORM MUST BE SIGNED BEFORE ASSESSMENT CAN BEGIN
 
____ I give informed consent for my child, ____________________________________, to be assessed according to the Assessment Plan above. I understand: 1) that the results will be confidential, and that I will be invited to discuss them at an Individualized Education Program Team meeting, and 2) that no special educational assessment or service will be provided without my written permission unless ordered by due process hearing officer.
 
____ I deny consent to conduct the assessment described above.
 
____ I have received a copy of the Procedural Safeguards.
 
____ Please contact me. Home Phone: ____________________________________
Work Phone: _________________________________
 
Please sign this form and return to: 
 
 
Parent/Guardian Signature     Date