Referral Review of Existing Data by Team Members

INITIAL EVALUATION

Referral Review of Existing Data by Team Members

Student Name:

Date of Planning Meeting:

DOB: Grade:

Case Manager:

Gen Ed Teacher Input:

Date Eligible / IEP Due Date:

File Review by:

Primary Disability:

Parent Information:

Other Suspected Disability:

Review of Existing Data by Team Members

The following team members participated in the referral/review meeting:

NamePositionNamePosition

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Reason for Referral:

Current grades in classes, attendance data, behavior/discipline referral data, MAP (district) and Smarter Test (state) test data must be reviewed and utilized as a basis for determining needs for evaluation.

THE FOLLOWING MUST BE ATTACHED TO THE REFERRAL FORM OR GATHERED AT REVIEW MEETING:

Map Results: Attach most recent MAP test results

Smarter Balanced test results: (attach or list below):

ELA/Literacy Scores

Grade – Year / ELA Score / Level / Min. Score to Meet Std

Math Scores

Grade – Year / Math Score / Level / Min. Score to Meet Std

Academic Grades:

Attendance Record: (Current year and possibly prior year.)

Discipline Data:

Medical Concerns: (has the child been diagnosed with a medical condition, such as vision/hearing loss? Is the child on medication?)

Check any HEALTH concerns and specify concerns:

☐ADHD ☐Hearing ☐ Vision

☐Fine / Visual Motor ☐Gross Motor

*Medical Notes:

Parent Input: Attach additional documentation/notes from referral review meeting as needed.

Teacher Input: Attach additional documentation/notes from referral review meeting as needed.

Other Team Member Input (OT, PT, Speech, Counselor, Administrator, etc.):

Please check areas to be addressed in the evaluation based upon referral review / review of existing data:

READING COMPREHENSION

☐Identify Main Idea & Related Details☐Cause and Effect ☐Sequence of Events

☐Make Inferences☐Make Predictions ☐Summarize

☐Describe Setting, Character, Plot, and Theme ☐Visualizing/Mental Picture

☐Vocabulary/Meaning of Words or Phrases in Selection☐Construct Meaning from Text

BASIC READING SKILLS

☐Reading Readiness☐Blend Sounds to Make Words☐Consonant Sounds

☐Identify Letters of the Alphabet☐Identify Sounds in Words☐Vowel Sounds-Long/Short

☐Letter-Sound Correspondence☐Omission of Letter Sounds in Words ☐Decoding

☐Syllabication☐Addition of Letter Sounds in Words ☐Multisyllabic Word Reading

READING FLUENCY SKILLS

☐Accuracy☐Voice Inflection

☐Words Per Minute/Rate☐Sight Word Identification

MATH CALCULATION

☐Number Names and Count Sequence☐Subtraction Facts☐Division Operations

☐Identify Numbers ☐Regrouping in Addition-Carrying ☐Fractions-add/sub/mult/div

☐Counting Objects☐Regrouping in Subtract-borrowing☐Decimals- add/sub/mult/div

☐Addition Facts☐Multiplication Operations ☐Consumer Math Skills

MATH PROBELEM SOLVING

☐Measurement/Estimation of Time, Volume, and Objects ☐Understanding Fractions

☐Applying Appropriate Concepts to Solve Problems☐Interpreting Data on Charts/Maps/Graphs

☐Word Problems with More Than One Math Function

WRITTEN EXPRESSION

☐Incorrect Pencil Grasp ☐Letter/Word Reversals ☐Grammar: subject-verb agreement

☐Legibility ☐Punctuation/Capitalization☐Abbreviations

☐Upper/Lower Case Letters☐Spelling

☐Sentence Structure-Writing Complete Thoughts

ORAL EXPRESSION

☐Expressive Vocabulary ☐Synonyms☐Syntax (sentence structure)

☐Reasoning/Problem Solving ☐Antonyms ☐Pragmatics (functional use)

☐Grammar☐Analogies

LISTENING COMPREHENSION

☐Auditory Attention Span ☐Receptive Vocabulary☐Understanding Directions

☐Auditory Discrimination ☐Sequences of Events☐Answers Questions Inappropriately

☐Auditory Memory ☐Needs Questions/Directions Repeated

COMMUNICATION

☐Articulation: may omit, substitute or distort certain speech sounds ☐Sentence Structure

☐Voice: may be hoarse, breathy or nasal, may talk to loud or soft☐Concepts/Vocabulary

☐Fluency: may stutter, repeat words, hesitate, or prolong words ☐Conversational Skills

☐Expressive Language ☐Receptive Language

☐Other (Specify)Click or tap here to enter text.

BEHAVIOR/EMOTIONAL (Extreme or Excessive)

☐Independent Activity ☐Group Activity ☐Peer Relationships

☐Attention Span ☐Overactive ☐Home Relationships

☐Passive/Shy ☐Verbally Aggressive ☐Unresponsive

☐Withdrawn☐Disruptive ☐Physically Aggressive

☐Mood Swings ☐Motivation ☐Other (specify)

☐Non-Compliant ☐Teacher Relationships

EARLY CHILDHOOD (Children 3-5 years old)

☐Gross Motor ☐Fine Motor ☐Expressive Language

☐Adaptive Behavior ☐Social/Behavior ☐Cognitive Skills

☐Receptive Language

Comments:

List any HEALTH concerns:

☐Hearing (Specify Concerns)

☐Vision (Specify Concerns)

☐Fine Motor (Specify Concerns

☐Gross Motor (Specify Concerns)

CATEGORICAL AREAS OF SUSPECTED DISABILITY (INCLUDE ON PARENTAL CONSENT):

If SLD, check the following areas that will be addressed:

☐Reading comprehension

☐Basic reading skills

☐Reading fluency skills

☐Math calculation

☐Math problem solving

☐Written expression

☐Oral expression

☐ Listening comprehension

The following areas of evaluation are needed (INCLUDE ON PARENTAL CONSENT): (Note: Skill-based assessment data in the suspected areas of disabilitywill be gathered as part of the evaluations administered below):

☐Academic Achievement ☐Articulation☐Audiological

☐Ability☐Language ☐Ophthalmological

☐Observation ☐Fluency ☐Chronic/Acute Health (Diagnosis)

☐Adaptive Behavior (to include social) ☐Voice ☐Current Medical Data/Records

☐Behavior ☐Fine Motor ☐Autism Specific Instrument

☐Transition ☐Gross Motor ☐Orientation/Mobility

☐Developmental (Cognitive, Adaptive, Motor, Communication, Personal/Social)

☐Braille

List other areas to be evaluated: (Might include areas such as: ☐vision screen, ☐hearing screen, ☐sensory motor,

☐visual motor, ☐personality, ☐social/emotional, ☐functional behavior assessment, etc...)

Existing Evaluation Data: If existing evaluations are to be used, document the following:

Evaluation Area: Test Administered: Date:

*COMPLETE THE PARENTAL CONSENT FOR EVALUATION BASED UPON EVALUATION AREAS CHECKED ABOVE.

**REJECT TESTING NOT CHECKED ABOVE FOR QUESTION #2 ON PPWN CONSENT FOR EVALAUTION

PRONG 1-STANDARDIZED TESTING EVALUATION PLAN

PRONG 1

Area to be Assessed

/ Test to be Given / Evaluator / List additional team members involved in evaluation (GEN Ed teacher, parent, etc):
☐Ability (required) / SCHOOL PSYCH
☐Achievement (required)
☐ Behavior
☐Social / SCHOOL PSYCH
☐Functional Behavioral
Assessment/ Behavior
Plan
☐Autism
Health:
☐Audiological
☐Ophthalmological
☐Health Diagnosis
☐Medical Records
☐Adaptive Behavior / SCHOOL PSYCH
☐Transition: Complete if student is age 14 or older / PENNY
Communication
☐Artic. ☐Language
☐Fluency ☐Voice / SPEECH PATH
☐Fine Motor
☐Gross Motor / OT/PT
☐Developmental
(Cognitive, Adaptive, Motor, Communication, Personal/Social) / BDI-II
☐Other:
☐Braille
☐Orientation /mobility

PRONG 2: Skill-Based Assessment Plan:

Complete this form as specifically and accurately as possible. Information from this form will be transferred to the evaluation report.

TestsEvaluators

OBSERVATIONS:
Behavior
SLD
ACHIEVEMENT:

**Do not forget parent/teacher interviews as appropriate

FOR SLD EVALUATIONS

Check All that Apply: / Additional Skill-Based SLD Tests: / Evaluator:
☐Oral Expression
☐Listening Comprehension
☐Written Comprehension
☐Basic Reading Skills
☐Reading Fluency
☐Reading Comprehension
☐Math Calculator
☐Math Problem Solving

PRIOR NOTICE CONSENT SENT TO PARENTS: Click or tap to enter a date.(date)

CONSENT RECEIVED Click or tap to enter a date. (date)

PARENTAL RIGHTS and PROCEDRUAL SAFEGUARDS sent to Parents: (date) Click or tap to enter a date.

PLAN SENT TO EVALUATORS LISTED ABOVE and Cheryl:Click or tap to enter a date.date)

Send copies of this form to all evaluators listed above and Cheryl as soon as permission is obtained.

Notes:

For Psych and Diana:

Upcoming conflicts to consider in scheduling (field trips, etc.):

Evaluation Quick Reference Guide:

CIRCLE ALL AREAS OF SUSPECTED DISABILITY ON THE EVALUATION QUICK REFERENCE GUIDE TO ENSURE COMPREHENSIVE EVALUATIONS

REMINDERS:
Transition evaluations will need to be conducted and services included in the IEP prior to age 16, or at a younger age as determined by the IEP team.
Evaluations must be based upon the child’s needs as determined by the IEP team. The purpose of conducting evaluations is to generate information in order to make decisions about eligibility, educational strategies and placement options.
The team should take into account any exceptionality of the individual in the choice of assessment procedures.
When a child has a previous diagnosis, such as autism, ADHD, TBI, etc., best practice would be to pull forward that previous diagnosis on the Parental Prior Written Notice/Consent for Evaluation.

☐(500) Deaf-Blindness

Ophthalmological or Optometric
Audiological
Ability
Academic Achievement
Language
Adaptive behavior
Braille assessment (the team shall consider based upon age-appropriateness)
Orientation and mobility
If the team decides there are other areas of suspected disability, other evaluations must be given, such as if appropriate, speech, motor, hearing, etc.

NOTE: Skill based assessment information is to be gathered for each skill area affected by the disability. / ☐(505) Emotional Disturbance

Ability
Academic achievement
Observations

Behavior – (Standardized Rating Scale must be completed individually, at a minimum, by two teachers and home or community, and if appropriate, the student).
If the team decides there are other areas of suspected disability, other evaluations must be given, such as adaptive behavior (to include social skills), speech or language.

NOTE: Skill based assessment information is to be gathered for each skill area affected by the disability.
☐(510) Cognitive Disability

Ability
Academic achievement
Adaptive behavior
If the team decides there are other areas of suspected disability, other evaluations must be given, such as motor, speech or language.

NOTE: Skill based assessment information is to be gathered for each skill area affected by the disability. / ☐(515) Hearing Loss

Audiological
Ability
Academic achievement
Language
If the team decides there are other areas of suspected disability, other evaluations must be given, such as adaptive behavior or speech.

NOTE: Skill based assessment information is to be gathered for each skill area affected by the disability.
☐(525) Specific Learning Disability
Eligibility using the discrepancy model will be determined through a comprehensive individual evaluation process which will include:

Ability
Academic achievement
Observation
If the team decides there are other areas of suspected disability, other evaluations must be given, such as adaptive behavior, speech or language. Eligibility using RtI will be determined through a comprehensive individual evaluation process which will include:

Academic achievement (1.5 standard deviations from the mean);
Evaluation of student growth relative to benchmark utilizing CBM data taking into account both level and rate of learning; and
Direct observation to assess student performance in the classroom;
If the team decides there are other areas of suspected disability, other evaluations must be given, such as adaptive behavior, speech or language.

NOTE: Skilled based assessment information is to be gathered for each skill area affected by the disability.
☐(535) Orthopedic Impairment

Ability
Academic achievement
Gross and/or fine motor
Adaptive Behavior
Current medical data from a qualified medical examiner.
Documentation including observation of classroom performance and evaluation of how orthopedic impairments adversely affect education performance in the general education classroom or learning environment.
If the team decides there are other areas of suspected disability, other evaluation must be given, such as speech or language.

NOTE: Skill based assessment information is to be gathered for each skill area affected by the disability. / ☐(545) Deafness

Audiological
Ability
Academic achievement
Language
If the team decides there are other areas of suspected disability, other evaluations must be given, such as adaptive behavior, or speech.

NOTE: Skill based assessment information is to be gathered for each skill area affected by the disability.
☐(550) Speech/Language Impairment

Articulation: a standardized articulation test and observation
Fluency: as determined by the speech/language pathologist
Voice: as determined by the speech/language pathologist, medical evaluation may be necessary
Language: standardized language assessments, checklists, language samples
If the team decides there are other areas of suspected disability, other evaluations must be given, such as adaptive behavior.

NOTE: Skill based assessment information is to be gathered for each skill area affected by the disability.
☐(540) Vision Loss

Ophthalmological or Optometric
Ability
Academic achievement
Adaptive Behavior
Braille assessment (the team shall consider based upon age-appropriateness).
If the team decides there are other areas of suspected disability, other evaluations must be given, such as speech, language, or orientation and mobility.

NOTE: Skill based assessment information is to be gathered for each skill area affected by the disability.
☐(555) Other Health Impaired

Ability

Academic achievement
Documentation of a chronic or acute health problem If ADHD (Attention Deficit Hyperactivity Disorder) is the impairment, behavioral evaluations must be administered. To support educational impact a Standardized Rating Scale must be completed individually, at a minimum, by two teachers, a parent/guardian and if appropriate, the student).
If the team decides there are other areas of suspected disability, other evaluations must be given, such as adaptive behavior, speech or language.
NOTE: Skill based assessment information is to be gathered for each skill area affected by the disability.

/ ☐(565) Traumatic Brain Injury

Ability
Medical records of documentation of brain injury
Academic achievement
Adaptive Behavior to include social skills
If the team decides there are other areas of suspected disability, other evaluations must be given, such as speech, language, gross motor, fine motor or attention

NOTE: Skill based assessment information is to be gathered for each skill area affected by the disability.
☐(570) Developmental Delay

Standardized developmental assessment which evaluates skills in all development areas:
Cognitive,
Physical/Motor (gross and fine)
Communication
Social/Emotional
Adaptive
If the team decides there are other areas of suspected disability, other evaluations must be given, such as speech.

Revised 1/22/2018