Section I – Medical and Sensory Information
REEVALUATION SUMMARY REPORT
DEMOGRAPHIC INFORMATION
Student Name (Last, First, Middle Initial) / Birthdate (month, day, year)_____/_____/______/ Sex
q Male q Female
School System / School of Enrollment / Grade / Primary Language
Name of Parent/Guardian / Primary Language at Home
PROCEDURAL SAFEGUARDS
Month Day YearPrior Written Notice for Reevaluation ______
Date Parent/Guardian Signed Consent for Reevaluation ______
(If Comprehensive Evaluation is indicated by IEP team)
BACKGROUND INFORMATION
SECTION I – Medical and Sensory Information
1. q Yes q No q N/A Is there a change in the student’s medical/health status?
If yes, explain: ______
______
Student’s current medications: ______
______
Summary of previous medical evaluations: ______
______
2. Review of vision and hearing screenings:
Vision Screening
q Yes q No Vision was screened on ____/____/______ and was within normal limits.
q Yes q No Vision was screened on ____/____/______ and was failed with results of ______
______
______
Follow-up vision screening was made on ____/____/______ with results of ______
______
q Wears glasses/visual aids
Hearing Screening
q Yes q No Hearing was screened on ____/____/______ and was within normal limits.
q Yes q No Hearing was screened on ____/____/______ and was failed with results of ______
______
______
Follow-up hearing screening was made on ____/____/______ with results of ______
______
______
q Wears hearing/auditory aid(s)
ED – 3070 / Rev. 02/09 Reevaluation Summary Report – Sections I & II
Department of Education Medical/Sensory & IEP Records Reevaluation Review
Section II – IEP and Records Review
SECTION II – IEP and Records Review
1. Primary Disability: ______Eligibility Date _____/_____/______
Secondary Disability: ______Eligibility Date _____/_____/______
List Previous Disability Determinations / IEP Team Date(s) forDisability Determination / Evaluation/Reevaluation
Report in File
_____/_____/______/ q Yes q No
_____/_____/______/ q Yes q No
_____/_____/______/ q Yes q No
_____/_____/______/ q Yes q No
2. Last IEP Team / IEP Date: _____/_____/______
3. Related services: ______
4. Special education hours: ______
5. Programs listed in IEP:
q Inclusion q Occupational/Physical Therapy
q Direct Service q Consultation
q Direct Speech/Language Therapy q Other: ______
q Other: ______
Current program modifications include: ______
______
______
6. Attendance: (check one) q Adequate q Problematic
Grades retained: ______
Number of schools attended in 3-year reevaluation cycle: ______
7. Behavior: (check one) q Adequate q Problematic
q Yes q No Does the current evaluation adequately address any presenting behavioral issues?
q Yes q No Does the student’s behavior warrant further evaluation?
q Yes q No Behavior problems: (If Yes, describe behaviors below.)
______
______
______
______
______
______
Where are the targeted behaviors addressed?
q Yes q No IEP Goals/Objectives q Yes q No Separate Behavior Plan
(Describe past and current interventions below.)
______
______
______
______
______
Date ____/____/______
Reviewing Assessment Team Member Signature ______
ED – 3070 / Rev. 02/09 Reevaluation Summary Report – Sections I & II
Department of Education Medical/Sensory & IEP Records Reevaluation Review