SST Referral to Special Education

Please complete this on-line and send as an attachment to the special education consultant and also put a copy in the file before it goes to the ISC -

  1. STUDENT INFORMATION

Student’s Name: / Student’s name
School District:
School:
Grade: / CowetaCounty
School Name – not just abbreviation
Grade of the student
Primary Language: / Primary language
Birth Date:
GTID: / Date student was born
Student ID #
  1. CASE HISTORY

Reason the child was referred for special education evaluation: / Describe concerns – academic, behavioral
Has the child attended (or is the child attending) a preschool or Head Start program?
_____YES_____NO / Please name the program or school:Name the preschool program – Babies Can’t Wait, Headstart, Kids-R-Kids, public school, etc.
Is this child age appropriate for grade level?
_____YES_____NO
/ If no, please check all of the following that apply:
  • Retained: (Specify Grade):_____
  • Started School Late:
  • Held Out of School by Parents:

Is the child’s hearing/vision within normal limits (attach documentation)?
_____YES_____NO / If no, attach documentation or explain.If not, state information from Dr.
Does the child have significant health concerns, major childhood illness/disease, or a diagnosed syndrome?
_____YES_____NO / If yes, please explain:Include any medical diagnosis – including those from MD’s, parental report, private psych’s, private OT’s, private PT’s
Does the child take medication on a regular basis?
_____YES_____NO / If yes, please explain:Discuss current medications
Does the child have motor /coordination/mobility needs?
_____YES_____NO / If yes, please explain:Discuss any issues with motor skills – fine or gross motor skills
Does the child have adaptive or medical needs (e.g., eye glasses, wheelchair, walker, hearing aids, leg braces, feeding tube, etc.)?
_____YES_____NO / If yes, please explain:Discuss use of eye glasses, hearing aids, etc.
Does the child have other significant issues not covered in the previous questions?
_____YES_____NO / If yes, please explain:Anything else that comes up – such as student is involved in outside counseling services
  1. SUMMARY OF INTERVENTIONS AND DATA PRIOR TO REFERRAL

The child’s disability requires immediate consideration of special education eligibility. / Please explain: This is only for SST expedited students
What academic or behavioral concerns did SST identify? / What was the referral issue or the area(s) on the plan e.g. reading fluency, articulation, difficulty remaining in seat, inappropriate interactions, etc.
Summarize the interventions and data that were collected. (attach more specific information) / Summarize:Briefly summarize interventions – e.g. Read Naturally program, Speedy Speech, reinforcers for behavior, small group counseling, etc. Include time (30 min. 3x/wk)
  1. SUMMARY OF PROGRESS MONITORING TOWARD ACHIEVING STANDARDS (attach actual data)

Area(s) of Difficulty including curriculum areas or behavioral concerns: / Be specific – academic – reading comprehension
Evidence Based Intervention(s)
Provided: / Interventions
Baseline Performance Data,
Date and performance: / Baseline data
Results of Intervention, date and performance: / Summary of progress monitoring data – put the time span of when data was collected and then summarize the results; Progress was or was not made;
  1. RESULTS OF ADDITIONAL STRATEGIES IMPLEMENTED AFTER PSYCHOEDUCATIONAL EVALUATION WAS COMPLETED AND DEFICIT AREAS MORE READILY DEFINED**

Area(s) of Difficulty including curriculum areas or behavioral concerns: / Be specific – academic – reading comprehension
Evidence Based Intervention(s)
Provided: / Interventions
Baseline Performance Data,
Date and performance: / Baseline data
Results of Intervention, date and performance: / Summary of progress monitoring data – put the time span of when data was collected and then summarize the results
  • After psychological testing, the committeemust implement new strategies based on the testing results and recommendations even if the student is being referred to Special Education. However, data collection on the old strategies must also continue unless they are deemed no longer appropriate based on the new information.
  • If thisstudent is being referred to Special Education, the SST filemust be forwarded to the ISC as indicated on the last page and according to posted timelines.
  • Indicate above the new strategies/interventions. After 4 weeks of data collection on the new strategies, forward the new data collected to the Special Education Consultant. Also forward the continuation of the old data. Mark the date of when this data andcontinuing data will be sent to the Special Education Consultant which is located on the last page of this form.
  1. RESULTS OF RELEVANT DISTRICT, STATE AND BENCHMARK ASSESSMENTS

Date / Name of Statewide, Local, and Benchmark Assessments; GAA / Results
Spring 2008 / CRCT / Score and if this meets or exceeds or does not meet
Fall 2008 / ITBS / Percentile scores
Sept 2008 / CogAT / Standard scores and/or percentile
Please forward this completed SST file to your In-School Coordinator
*In-School Coordinator - Please copy what is needed and determine if any additional information needs to be gathered.
Please forward this file within 3 days to the Special Education Office to the attention of Student Records Clerk
even if further data is being collected so that a meeting can be scheduled.
All files should include a psychological.
Please state Yes or No if the following are in the SST file: (If No, the ISC will gather the information to send to
the Special Education Consultant and provide a date by which it will be sent)
Analyzed Work Samples (for all eligibilities)
Statement of Status Checklist and/or SST Grade Level Comparisons Form (for all eligibilities)
Classroom Observations (for all eligibilities)
______/ Date by which ISC will send additional information to Consultant

______Date by which SST coordinator will send additional/new intervention data to Consultant as well

as continuation of existing data

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