REEVALUATION FORMS
(DD turning 9, Change of Classification)
St. Landry Parish School Board
Revised: September 1, 2016
Checklist for Reevaluations
(DD Turning 9, Change of Classification)
Student:
School:
Section 1: Referral Information
Two-Page Screening Packet (Teacher)
Copy of Student’s Schedule (Teacher – Power School)
Students with Special Health Care Needs/Referral Checklist (Parent)
School Health History Form (Parent)
Authorization for Release of Confidential Information (Parent)
St. Landry Parish Health Screening Protocol (School Nurse)
Copy of Medication Order (when applicable) (Cum. Folder – Teacher)
Psycho-Social Checklist Form (Parent)
Section 2: Screening and Intervention Data
A. Academic Performance
Copy of Cum. Card (Grade progression and cumulative attendance) (Teacher)
State-wide/District-wide Test Scores (Student and Class Report) (Teacher)
Dyslexia Screening (Teacher – Cum. Folder)
Current Report Card (Sped Teacher)
Teacher Observation Data Form (Sped and/or Reg. Ed. Teacher)
Progress Reports (Sped Teacher – Current One)
Behavior Reports/Plans (contents of discipline folder including intervention data)
(Teacher – PBIS)
B. Attendance
Power School (Teacher)
C. Screenings and Interventions
Louisiana Assistive Technology Screening (Teacher)
Sensory Processing Screening (Teacher)
Sensory Processing Intervention Strategies (when sensory is a concern) (Teacher)
Speech/Language/Hearing Screening Protocol (Speech Pathologist)
School Vision Report (Teacher – Cum. Folder)
Hearing Screening Protocol (Teacher – Cum. Folder)
Hearing Screening Results (Teacher – Cum. Folder)
State Health Form (Teacher – Cum. Folder)
Adaptive Physical Education Screening/Reevaluation Form (P.E., Sped, or Reg. Ed.
Teacher)
Motor Reevaluation/Waiver (APE Teacher)
Social, Emotional, Behavior Skills Checklist (Teacher)
Progress Monitoring Data & Graph(s) (Sped Teacher and Related Service Providers)
Graph of class-wide progress (Reg. Ed. or Sped Teacher) DIBELS
Narrative of intervention strategies used (Sped Teacher)
Checklist for Strategies, Adjustments, and Modifications (Sped and/or Reg. Ed. Teacher)
Revised August 2016
FOR PAC USE ONLY
Coordinator / Race / Gender / Case # / State ID #ST. LANDRY PARISH – PUPIL APPRAISAL CENTER
CHILD IDENTIFICATION
Screening Packet - Page 1
STUDENT / / /First / Middle / Last
PHYSICAL ADDRESS
Street / Highway / City / State / Zip Code
MAILING ADDRESS
(if different)
Street / Highway / P. O. Box / City / State / Zip Code
DOB / AGE / RACE / GENDER
Years Months
PRIMARY LANGUAGE
HEAD OF HOUSEHOLD - FATHER MOTHER GRANDPARENT FOSTER OTHER
FATHER
First / Middle / Last
MOTHER
First / Middle / Maiden / Last
GUARDIAN
First / Middle / Last
Home Phone / Work Phone / Emergency Phone
and/or Cell Phone
SCHOOL / TEACHER / GRADE
Referred by / Position / Race / Gender
COMPLETE FOR RE-EVALUATION or WAIVER ONLY:
Exceptionality / Sped. Teacher / Case # / Date of Last EvaluationREASON FOR REFERRAL: / SPECIFY CONCERNS:
Initial Evaluation
Reevaluation / Mandatory Reevaluation
Results of Manifestation Determination
Declassification
Significant Change of Placement
New Concern
Gifted
Talented
Waiver
Preschool Screening
Court Decision / Due Process Hearing Decision
Other:
*Race: W-White B-Black H-Hispanic AI-American Indian A-Asian (St. Landry Parish – August 2016)
Screening Packet - Page 2Student’s Name
¨CURRENT SCREENING RESULTS (Attach all necessary dated forms and documentation)
Area / Date / Normal/Pass / At Risk/ Failed / No Concern / Date Corrected/Comments
Hearing
Vision
Sensory Processing
Health
Speech/Language
Motor
Assistive Technology
Soc./Emotional/ Behavior
Educational
¨REFERRAL RESULTS (Attach all necessary dated forms and documentation)
RTI Results must include: current scientifically research-based intervention(s) implemented with fidelity and evidenced by data sheets, computer-generated records, or other permanent products; monitoring documentation of the student’s progress relative to peers, at reasonable intervals; and graphed evidence that the student’s rate of progress relative to peers is not adequate. (LA Bulletin 1508, 2009)
Lack of Progress Considerations must include: current data-based documentation that the student’s lack of educational progress is not primarily due to: lack of appropriate, explicit and systematic instruction in reading which includes the essential components of reading instruction: phonics, phonemic awareness, fluency, comprehension, and vocabulary; (e.g., if more than 50% of the class falls below benchmark on universal screening, lack of appropriate instruction might be suspected); lack of appropriate instruction in math (e.g., if more than 50% of the class falls below benchmark on universal screening, lack of appropriate instruction might be suspected); limited English proficiency; environmental or economic disadvantage (e.g., if a majority of low income students in the class fall below benchmark on universal screening, environmental or economic disadvantage as a primary factor might be suspected); or cultural factors (e.g., for students from culturally and linguistically diverse backgrounds, there is evidence that the school and classroom teacher have been sensitive toward the students’ diverse learning needs). (LA Bulletin 1508, 2009)
¨ALL OTHER FORMS AND DOCUMENTATION LISTED ON Mandatory Evaluation CHECKLIST
¨GIFTED AND TALENTED SCREENING (Attach all necessary dated forms and documentation)
Gifted - include: Universal Screening, High Potential Checklist, Standardized Test Scores, etc.
Talented - must include: State Approved Screening Form and Parish Screening Instrument
Notification of SBLC Meeting sent on /
SBLC Meeting Date
/SBLC Participants’ Signatures Required
/ /Position
/ /Race
/ /Gender
// / / Principal / / / / /
/ / / SBLC Chairperson / / / / /
/ / / PAC Representative / / / / /
/ / / Parent / / / / /
/ / /
Teacher
/ / / / // / /
Teacher
/ / / / // / /
Student
/ / / / /Student’s Schedule
STUDENTS WITH SPECIAL HEALTH CARE NEEDS
SCREENING/REFERRAL CHECKLIST
Student: / DOB: / School:Person Completing Form: / Date:
DOES THE STUDENT: / YES / NO
1. Experience severe allergic reactions that require immediate medications, (i.e., Epi-Pen)?
2. Have a medical diagnosis of a chronic health problem (i.e., Diabetes, Tourette syndrome, rheumatic fever, ADD/ADHD, Epilepsy/seizures, Cystic Fibrosis, Asthma, Muscular Dystrophy, Liver Disease, digestive disorders, respiratory disorders, Hemophilia, Spina Bifida, emotional disorders, heart conditions, Cancer, Sickle Cell, Cerebral Palsy, or any other condition)?
3. Receive medical treatments during or outside the school day (i.e., oxygen, gastrostomy care/feedings, tracheostromy care, suctioning, injections)?
4. Experience frequent absences due to illness or frequent hospitalizations?
5. Receive ongoing medication at home or school for physical or emotional problems (i.e., ADD/ADHD, seizures, heart condition, allergy, Asthma, Cancer, Depression)?
6. Require adjustments of the school environment or schedule due to a health condition (i.e., seizure, limitations in physical activity, periodic breaks for endurance, part-time schedule, building modifications for access)?
7. Require environmental adjustments to classroom or school facilities (i.e., temperature control, refrigeration/medication storage, availability of hot/cold running water)?
8. Require major safety considerations (i.e., special precautions in lifting, positioning, special transportation, emergency plan, special safety equipment, special techniques for positioning, feeding procedures)?
9. Require a special diet (i.e., blended, soft, low salt, low fat, liquid supplement, Diabetic)?
10. Require assistance with activities of daily living (i.e., eating, toileting, walking)?
If the answer to any questions is yes, have parent/guardian fill out student health history and sign the Consent to Disclosure of Confidential Records. Refer to school Nurse.
Referred to: / Date: / Phone:(Name of School Nurse)
By: / Date: / Phone:
(Name) (Position)
St. Landry Parish School Board
Pupil Appraisal Center
SCHOOL HEALTH HISTORY
CASE# / SCHOOL / GRADEDATE:
Dear Parent(s) / Guardian(s),
We would like your child to gain the most from his/her school experience. In order for us to assist in accomplishing this, it is necessary to have a current health history. Please complete this form and return it to school.
PREGNANCY / BIRTHING HISTORY / YES / NO / EXPLAIN “YES” ANSWERS1. / Did mother have prenatal care during the
pregnancy?
2. / Did mother have any health problem(s) during the
pregnancy or during the delivery?
3. / During the pregnancy with this child, did the mother:
a. / SMOKE CIGARETTES / Amount:
b. / DRINK ALCOHOL / Amount:
c. / TAKE MEDICATION OTHER THAN VITAMINS? / Name medication(s):
4. / Where was your child born?
5. / Was your child born more than 3 weeks early or late?
6. / What was the birth weight? / lbs. / oz.
7. / Were there any concerns with your child at birth?
8. / Were there any concerns with your child in the
nursery?
9. / Did child or mother stay in hospital for medical
reasons longer than usual?
DEVELOPMENTAL MILESTONES / EARLIER / WHEN EXPECTED / LATER / AGE
(a) / Walk
(b) / Talk
(c) / Feed and Dress Self
(d) / Learn to Use the Toilet
HOSPITALIZATIONS AND ILLNESSES / YES / NO / EXPLAIN “YES” ANSWERS
1. / Has your child ever been hospitalized or had surgery?
2. / Has your child ever had a serious accident (broken
bones, head injuries, falls, burns, poisoning, etc.)?
3. / Has your child ever had a serious illness?
4. / Are your child’s immunizations up-to-date?
SOCIAL DEVELOPMENT / YES / NO / EXPLAIN “YES” ANSWERS
1. / Have there been any major changes in your child’s
life in the last six months?
2. / Are there any problems in the home that may affect
your child’s learning?
3. / Is there anything more about your child’s health that
you think is important for us to know?
Revised September 2016
ST. LANDRY PARISH PUPIL APPRAISAL CENTER
127 BLAIR STREET
OPELOUSAS, LA 70570
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
TO BE COMPLETED BY PARENT/LEGAL GUARDIAN
PART 1: CONTACT INFORMATION COORDINATOR: ______Student’s/Child’s Legal Name / Date of Birth / Social Security #
Case #
Parent/Legal Guardian ______Telephone # ______
Mailing Address ______
City/State/ZipCode ______
PART 2: RECORD REQUEST
Complete Box A OR B below. Both boxes may not be completed on the same form.
A. Specify the records to be released for the treatment date(s)
listed below in Part 3:
1 Medical records 1 Test Results
1 Individual Education Plan (IEP) 1 Phone Consult
1 Academic Achievement Assessment 1 Other______
1 Eligibility report
1 Cumulative Record ______
1 Related Services Report
1 Speech Evaluation
1 Prescription of Therapy and Medical Services from Physician
1 Medication Name(s) and Prescribed Dosage(s) / B. If initialed below, I specifically authorize release of the following:
Psychotherapy notes and records indicating
psychological or psychiatric impairment(s)
______
Initials of parent/legal guardian
PART 3: AUTHORIZATION
This does not authorize the release of the following: drug and alcohol use counseling and treatment and HIV/AIDS and sexually transmitted disease and treatment.
I AUTHORIZE:
Name: St. Landry Parish School Board (School System)
1 TO OBTAIN information FROM AND/OR 1 TO RELEASE information TO
Name: ______(Hospital, physician, Service Agency, health provider)
Address: ______
For treatment date(s): ______
The information is to be released for the purpose(s) of:
1 Evaluation to determine eligibility or continued 1 Designing an individual educational program
eligibility for special education services 1 Determining appropriate placement for treatment needs
1 Providing occupational therapy treatment 1 ______
1 Providing physical therapy treatment
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the same medical records department receiving this authorization form. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event or condition: ______. If I fail to specify an expiration date, event or condition, this authorization will expire nine (9) months from the date of authorization. An authorization is voluntary. I will not be required to sign an authorization as a condition of receiving treatment services or payment, enrollment, or eligibility for health care services. Information used or disclosed by this authorization may be re-disclosed by the recipient and will no longer be protected under the Health Insurance Portability & Accountability Act of 1996.
______
Signature of Student or Legal Representative Date (Relationship to student)
(Parent/Legal Guardian must sign if student < 18)
______
Signature of Witness Date
Vision: / Passed
Failed
No Concern
ST. LANDRY PARISH
HEALTH SCREENING PROTOCOL
1. / Identifying Information:Student’s Name / D.O.B. / Age
School / Date of Assessment
2. / Reason for the Assessment:
3. / Assessment Method(s) / Tools:
Information for the Assessment obtained by: (Check all that apply)
Physical Assessment / Observation(s)
Health/Developmental History by Parent / Parent Interview
Student Interview / Teacher Interview
Review of Medical Record(s) / Physician Consultation
Other:
4. / Strength(s) (Related to Health):
Good Health: / Appears Well-Nourished / Interacts Socially
Able to Communicate Need(s) by:
Good Personal Hygiene / Good Family Support / Ability to Follow Instruction(s)
Independent in Activities of Daily Living / Feeding / Bathing / Dressing
Toileting / Other Strength(s)
5. / Summary of Health Status:
Medical Diagnosis:
Life-Threatening Condition(s):
Prescriptions / Authorization(s) for: / Special Diet / Medication(s) @: / School / Home
Health Procedure(s): @ / School / Tube Feeding / Catheterization / Suctioning
Glucose Monitoring / Other
6. / Assessment Data:
Screening Result(s): / Hgt / Wgt / BP / Immunizations Up-to-date
7. / Nursing Diagnosis (Health Concern): from the IHP
Goal(s) (Student) :
Intervention(s):
8. / Impact on Education
Health concern(s) impact / (name) ability in the area(s) of:
Self-Help / Emotional/Social / Cognitive/Adaptive
Communication / Motor / Sensory
9. / Statement of Need :
Based on this assessment, this student / (name)
does require health services in order to benefit from his/her educational program.
Health services include (Circle all that apply) : / Medication(s) / Health Maintenance Procedure(s)
Activity of Daily Living / Health Counseling / Other
10. / Recommendations :
Yes, related health services are recommended to meet the goals and interventions listed above.
No, related health services are not required at this time.
Additional information is required to complete the health assessment.
Signature of Nurse / Date
Copy of Medication Order