Martinsville City Public Schools

Special Education Evaluation Referral

Meeting Documentation Sheet

Please enter the dates when each action is completed. For initialreferrals, remember the principal/designee has 10 business days to hold a child study meeting once thereferralis received. For triennials, remember the IEP team must review existing evaluation data and determine the need for reevaluation at least once every three years. If the parent agrees, this review may be conducted without a meeting. If new evaluation data is desired, the case manager should take reasonable measures to secure parental permission. If the case manager is unable to secure permission after three documented attempts, he/she may proceed as if permission has been granted. Direct Referrals are available only to students who are not enrolled in public school and can be made by contacting Jeanne Westphalen at 403-5837.Attach additional sheets for further follow-up meetings as needed.

DATEACTION

______Referral received

______Parent contacted and invited to meeting

______Initial meeting

______Follow-up meeting (as needed)

______Follow-up meeting (as needed)

______Student not referred (check one)

The committee has implemented successful interventions.

The committee is referring the student back to the IST

The committee does not suspect that the child has a disability. (Attach PWN)

Other ______

______Student referred for a full evaluation (check one and complete pages 7-8).

The committee has reviewed the data from the IST and is not recommending any additional interventions.

The committee has implemented a variety of research-based strategies that have been unsuccessful.

There is documentation of an existing disability that is having an educational impact.

The student has failed a speech screening.

The committee is referring this child directly without interventions because ______

Committee Members (sign first time, then check for additional meetings)

______Initial Follow up Follow up

______Initial Follow up Follow up

______Initial Follow up Follow up

______Initial Follow up Follow up

______Initial Follow up Follow up

SPECIAL EDUCATION EVALUATION REFERRAL FORM

The following information will be used to begin the child study process. A student should be referred to the Child Study Team if there is a strong reason to suspect that he/she has a disability. Students who are having general academic or behavioral issues should first be referred to the Instructional Support Team for intervention. If these interventions are not successful, the IST may then refer the student to the Child Study Team.

Student ______Grade _____DOB ______State Testing ID ______

Parent or Guardian______Referring Source (Name and school): ______

Address______Phone ______Date of Request ______

Gender: ______Race: ______

  1. Reasons for referring student for an Evaluation:

Last modified 8/3/16 SECS1

Martinsville City Public Schools

Special Education Evaluation Referral

Medical Concerns

Academic Achievement

Classroom discipline problem

Developmental Issues

Socialization problems

Communication (Speech) Issues

Due for a triennial Evaluation

Requesting Reevaluation

Other ______

Last modified 8/3/16 SECS1

Martinsville City Public Schools

Special Education Evaluation Referral

Previous Referrals: Has this student had an previous referrals? If so, please list the dates and results: ______

______

Discipline Records: Is the student a discipline problem? Please list concerns and attach a copy of the student discipline record:

______

______

Attendance Record: Does the student regularly attend school? Please attach a copy of the current attendance record.

Grade(s) / School(s) Attended / Absences / Tardies+ >1 hr

Health Issues (Screenings and Parent Interview)

Complete screenings: Vision ______Hearing ______

If the student has glasses, does he or she wear them regularly? ______

How much sleep does the child get each night? ______

Has the child had any serious illnesses or accidents? ______

______

Does the child take any prescription or over-the-counter medications regularly? ______

______

Has the student had any recent emotional or physical trauma?______

______

Choose One

Consent to Exchange Information form has been given to school nurse

Permission to Provide Physical Examination form has been completed and is attached

The student has NO medical/mental health diagnoses or areas of concern

Student Name: ______

CURRENT STUDENT PERFORMANCE REPORT:

SUBJECT / TEST/QUIZ AVERAGE / BENCHMARK SCORES / HOMEWORK COMPLETION? / CLASSWORK / SOLs
English
Math
Science
Social Studies

Last modified 8/3/16 SECS1

Martinsville City Public Schools

Special Education Evaluation Referral

** How do the student's grades compare to others in the class? ______

______

Last modified 8/3/16 SECS1

Martinsville City Public Schools

Special Education Evaluation Referral

  1. Has the student been through the Instructional Support Process? Yes No

Last modified 8/3/16 SECS1

Martinsville City Public Schools

Special Education Evaluation Referral

  1. Interventions attempted:

Instruction

Extra practice on lessons

Peer tutoring

Academic Intervention (SGL, small group, PM homework help)

Computer assisted instruction

Varied instructional modes (multi-sensory learning styles)

Materials

Copies of texts at home

Graphic organizers provided

Audiovisual aids

High-interest reading materials

Manipulatives

Calculator for math

Computer for word processing

Testing

Study guide for tests

Extra time for tests

Retake tests

Extra credit options

Grading

No spelling or handwriting penalty

Organization

Simplify, repeated instructions

Review directions

Guided notes

Agenda check

Preferential seating

Color coded materials

Assign a buddy to check agenda

Behavior Management

Positive reinforcement

Incentive program

Written behavior contract

Mentor assigned

Post and review rules

Immediate consequences delivered

Consistent enforcement of rules

Recorded behavioral changes

Progress reports sent to parents

Counseling

Frequent Parent Contact

Other: ______

______

Last modified 8/3/16 SECS1

Martinsville City Public Schools

Please list any additional pertinent information below (or on back) as needed:

INVITATION TO SPECIAL EDUCATION REFERRAL MEETING

Student Name ______Date ______

This is to notify you that a team meeting has been scheduled for the above student. Your participation and attendance at this meeting are very important. This meeting must be scheduled at a mutually agreed upon time and place. This meeting has been scheduled because there are concerns about your child’s progress at school. The purpose of this meeting is to:

Develop strategies to help your child do better in school.

Determine the need for an evaluation (including a triennials or other reevaluation) for special education and related services(including speech/language).

Determine the needed evaluation components for an (including a triennials or other reevaluation)for special education and related services (including speech/language).

Follow-up on your child's progress and develop recommendations since your child was found ineligible for special education services at a recent eligibility meeting.

This meeting has been scheduled for ______o’clock on ______at ______

If you have any questions or would like additional information or assistance to help you prepare for this meeting, please contact ______at ______

The following people are invited to attend and participate in this meeting:

______

______

______

------

Please detach and return:

Student name ______Date of meeting ______

I will attend the meeting as scheduled.

I cannot attend the meeting as scheduled, but do wish to attend. Please contact me to reschedule.

I understand the importance of attending this meeting, but do not wish to attend. You may hold this meeting in my absence. I will contact you to share any preferences or concerns that I have.

Parent Signature ______Date ______

The best way to contact me is by ______at ______

Teacher/Parent Input

(Make additional copies of this page as needed

Teacher Input

Parent Input

Name of Student ______Date ______

The above named student is being referred for a special education evaluation. Please provide any information that might be helpful in designing interventions and making decisions.

Strengths:

Weaknesses:

Can the student complete homework independently? Are necessary supports for homework completion available?

Completed by ______Relationship to Student ______

Child Study Intervention Strategies

(Make additional copies of this page as needed)

Student Name ______Initial Meeting Date: ______Follow-up Date ______

Interventions are not necessary because

Student has received adequate interventions through IST and has not made progress

Student has a documented existing condition and the committee suspects he/she has a disability.

Student has been referred by the speech pathologist due to failing a speech screening

Student is due for a reevaluation

______

Specific problem statement: (i.e., the student only knows 15 out 50 sight words) / Goal Statement: (i.e., the student will recognize 50/50 sight words) / Strategies to be used: / Person(s) who will implement the strategies: / Evaluation (including pre/post data)

Prior Notice and Consent for Initial Evaluation

Student Name ______SS# ______

I have received the VA Special Education Procedural Safeguard Notice: Your Family’s Special Education Rights, Revised August 2009, and understand the Martinsville City Schools proposal and my rights.

Signature ______Date ______

I give permission for the Martinsville City Schools to proceed with the formal evaluation to consist of the checked components as well as formal and/or informal observation. The Child Study/IEPTeam has deemed these components necessary to determine if my child is eligible for special education and related services.

Educational – a written report describing current educational performance and identifying instructional strengths and weaknesses in academic skills. This may include language performance, processing skills, and/or psychomotor skills.

Medical- Records Review– written notes from a licensed general practice physician and/or specialist indicating general and specific medical history along with any medical/health problems that may impede learning.

Medical – Physical Examination –a written report from a licensed physician indicating general medical condition as well as the discovery of any medical/health problems that may impede learning

Sociological – a written report supervised by a qualified visiting teacher (or designee) that will include background information as well as social/adaptive behavior and examine the possible impact of cultural, and/or economic factors.

Psychological – a written report from a qualified psychologist including an individual intelligence test. This may also include social/emotional and behavioral evaluations as well as measures of adaptive behavior.

Developmental – a written report describing how a young child (ages 2-6) functions in the major areas of development including cognition, motor skills, social/adaptive behavior, perception and communication.

Speech/Language – a written report indicating current functioning in the areas of articulation, voice, fluency, and expressive and receptive language.

Vision and Hearing Screening – an assessment of basic vision and hearing function.

Audiological – an assessment of hearing for students who fail the hearing screening multiple times.

Vision – an assessment of visual acuity for students with a possible significant visual impairment.

Other Evaluations (as listed): ______

Your informed consent is required before the District may proceed with an evaluation, except when the District is relying on existing data, classroom observations, or has taken reasonable measures to obtain your consent for a reevaluation and you have failed to respond. Your consent is voluntary and may be revoked at any time. Any revocation of consent will not be retroactive.

Your child’s assessment must be sufficiently comprehensive to identify all of his or her special education and related service needs, whether commonly linked to the disability category suspected or in which your child has been classified. The assessment will be at no cost to you.

Parent/Guardian Signature ______Date ______

I do not give permission for Martinsville City Schools to proceed with the formal assessment as described above for my child.

Parent/Guardian Signature ______Date ______

CONSENT TO EXCHANGE INFORMATION

To provide the best service for your child, various community agencies must share information from time to time. By signing this form, I am allowing the involved agencies to exchange certain information, enabling them to coordinate efforts that will maximize the benefits for my child.

I,______, am signing this form on behalf of my

(full printed name parent or guardian)

child______. Birth date: ______

(full printed name of child)

Address: ______

I want to have the following confidential information about my child to be shared:(check all that apply)

[ ] Medical Records (Summary including diagnoses and current medications)[ ] Other ______

[ ] Mental Health Records (Summary including diagnoses and current medications)[ ] Other ______

SETR1

Last modified 03/16

Martinsville City Public Schools

I give permission for the following agencies to share information about my child. (Attach additional sheets as needed.)

[] Children’s Medical Center[ ] Martinsville Pediatrics[ ] Piedmont Community Services[ ] National Counseling Group

[] Eden Pediatrics[ ]Brenner Children’s Hospital[] Family Preservation Services[ ] Martinsville Memorial Hospital

______

(Name of agency) (Contact Information)

______

(Name of agency) (Contact Information)

I want this information be exchanged for only eligibility determination for special education services and/or service coordination and planning.

SETR1

Last modified 03/16

Martinsville City Public Schools

This Consent will be effective until: ______

Signature(s):______

(Consenting person or persons)

Date: ______

Person Explaining Form: ______

(Name) (Title) (Phone Number)

FOR SCHOOL USE ONLY: If this consent is revoked, partially or in its entirety, please check the box at the bottom of this form and fill out and attach a revocation form.

This consent has been revoked, effective ______

Special Education Referral Checklist

Student Name: ______

DATEACTION

______Referral process initiated by Child Study Committee or IEP team

______Procedural Safeguards given to parent.

______Parental Consent obtained/ Prior Written Notice signed.

______Information collected and attached to referral

Attendance printout

Copy of Transcript/Report Card

SOL scores

Student Schedule (for students in middle or high school)

Discipline report

Medical permission form (if a physical is needed)

Consent to Exchange Information form (given to school nurse) for any child who:

  • Takes medication on a regular basis
  • Is seen by a medical specialist and/or mental health professional for an ongoing condition
  • Is being considered for a disability category with a major medical component (i.e. Other Health Impaired, Visually Impaired, Hearing Impaired, Orthopedically Handicapped, Traumatic Brain Injury…)
  • Has had an evaluation completed by an outside agency.

SETR1

Last modified 3/21/11