Page 1 of 3
Re-evaluation Referral Checklist
Student’s name ______School ______DOB ______
This form must be completed by the case manager and included on top of the referral packet.
Submit referral packet to Julie Schexnayder at Werz: Special Education Office
Step 1. School Use:The following items are required to be submitted with the packet and MUST be completed in GOIEP. Please initial next to each to item indicating the item has been completed in in GOIEP and include with the referral packet.
Case-Manager:
Completes and includes the following items with this checklist:
_____ Re-Determination Report (DOR) from GOIEP
_____ Parent Consent for Evaluation for Special Education form
_____ Hearing/Vision Screening form with passing results
_____ Parent Questionnaire – do not delay submission if unable to receive
_____ Grade Level Comparison Form
_____ Student Data Review Form – new form this year – on website under referral forms
_____ Medical form – include a copy if student has a medical condition
Initial to indicate that the following items have been completed:
_____ Re-Determination Report is finalized in GOIEP
_____ Started Re-Eligibility Report once redetermination is finalized
Indicate by checkingthe areas that mayrequire evaluation based on the concerns indicated in the redetermination:
Speech/language / Attention ConcernsIQ and Processing / Sensory Concerns - specify:
Academic Achievement / Motor Concerns - specify: fine or gross motor
Social Skills / Adaptive Concerns
Emotional/Behavior Concerns / Other – Specify:
Medical Concerns - Diagnosis: Yes or No
_____ Submit a copy of this form (page 1 only) and the referral packet items that includes the Redetermination form, Signed Parent Consent form, Hearing/Vision form, Parent Questionnaire, and Grade Level Comparison form, and Student Data Review form.
______
Name of person submitting packetDate Submitted
Step 2. Central Office Use Only:
Date Received by CO: ______ELIGIBILITY MEETING DUE DATE: ______
_____ Enter reevaluation referral to the referral log
_____ Submit this form and referral packet to psych services for testing
_____ Submit a copy of this form to the SLP if speech/language testing is needed
_____ Submit a copy of this form and the grade level checklist and student data review form to sped specialist
Re-evaluation Referral Checklist – Part 2
Step 3: School Use:Case Manager (CM) completes the following in the DRAFT Eligibility Report in GOIEP. Psychologist will enter evaluation assessments in the appropriate domains in the student data section and return the referral file to the case manager once completed.
Case History Section:
_____ Complete questions 1.1 through 1.12 using the redetermination, parent questionnaire, vision
and hearing form, medical information, etc.
_____ Attach electronic copy of vision/hearing form in question 1.4 and 1.5.
_____ Click Validate to make sure all sections have been completed.
Progress Monitoring Section:
_____ Complete question 2.1 – answer is no
_____ Complete question 2.2 – Enter progress monitoring data based on IEP goals.
_____ Click Validate to make sure all sections have been completed.
Student Data Section: Case manager ensures every domain is completed with school data as well as the data entered by the psychologist. Case manager collects and enters the following:
_____ Student Data Review form –CM has entered the data in each domain as indicated on the form.
_____ Grade Level Comparison Checklist – CM has entered pg 1 data in the academic domain and pg 2 in
other appropriate domains
_____ Parent Questionnaire –CM has entered updated parent questionnaire in relevant domains.
_____ Analyzed classroom work samples for each area of concern – CM has entered data in
work samples domain. Work samples should correlate to areas of concerns.
_____ Classroom observation for each area of concern – Completed observation and entered data in
observation domain
_____ Medical diagnosis and/or concerns -CM has transferred data to medical domain and will
bring the original completed OHI form to the meeting.
_____ Other Health Impaired Medical Form and signed HIPAA Form included in file
_____ Benchmarks, GRASP Data, etc – CM has entered data in the academic achievement domain.
_____ Any other pertinent information has been entered into the eligibility report under the appropriate
domain (i.e. Speech evaluation, OT evaluation, Physician reports, etc.)
_____ Validate Case History and Progress Monitoring sections to be sure information has been entered
accurately. Update, correct, or add any missing information
_____ Psycho-educational Report – Psychologist has entered data into the appropriate domain categories. If
student is SDD reevaluation they will have a psych report completed. The psych report should be
attached in GOIEP under documents tab.
Decision Making Section:
_____ Case manager completes question 5.1. and 5.2
Eligibilities to Consider:
Eligibilities will automatically populate based on domains in the student data section that have data in the weaknesses box.
Exclusionary Factors:
_____ Case manager has answered exclusionary factors for each eligibility category listed
Step 4: School Use: Hold Eligibility Meeting
______Contact Special Education Specialist for your school to set up reevaluation eligibility meeting.
______Contact parents to schedule meeting date.
______Generate and send to parents formal Notice of Eligibility/IEP Meeting from GOIEP
______Send all eligibility team members meeting date, time and location (include SLPs, OTs, etc if
needed)
______Print draft copies for the eligibility meeting
______Hold eligibility meeting and make final eligibility decisions
If Eligible:
______Hold IEP meetingto update the IEP
If NOT Eligible:
______Student returns to regular education refer to RTI team for appropriate Tier placement.
______Finalize eligibility report in GOIEP (for SLD, hard copy of the report must be signed) – Work with Sped Specialist to determine who will finalize the eligibility report.
______Submit completed reevaluation file to central office. Continue to next step 5.
Step 5: School Use: SUBMIT COMPLETED referral file to CO
______Change in Status Form is completed and submitted with referral file to Julie Schexnayder and
Vickie Shepherd at Werz, CO or Renea Walton for preschool.Form may be submitted via email or in
the courier.
______Reevaluation Referral file with completed paperwork is submitted to Julie Schexnayder at Werz CO
with change in status form.
Coweta County Special Education Department
Revised: August 2014