For Pac Use Only

FOR PAC USE ONLY

Coordinator / Race / Gender / Case # / State ID #

ST. LANDRY PARISH – PUPILAPPRAISALCENTER

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 Evaluation
REASON 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 2
Student’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 Resultsmust 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 ONMandatory EvaluationCHECKLIST
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 /

For Pac Use Only

FOR PAC USE ONLY

COMPLETE FOR RE-EVALUATION or WAIVER ONLY:

CURRENT SCREENING RESULTS(Attach all necessary dated forms and documentation)

SBLC Meeting Date

SBLC Participants’ Signatures Required

Position

Race

Gender