Pre-Referral Checklist

The following must be completed with dates provided and information collected before a Special Education Referral packet will be provided:

Student’s Name

Record Date or Circle Yes or No to answer questions.

Date student referred to Tier 3 (This date is on the RTI form J1, J2 & J3 Entry to Tier 3) Verify that the child is at Tier 3.
Yes or No / At least 2 tier 3 meetings have been held documenting two different interventions. Minutes and Intervention Plan attached.
Yes or No
Yes or No / Is Attendance an issue?
If YES, was School Social Worker involved in RTI meetings?
Date Student Passed Vision (Must be within the last 9 months.)
Date Student Passed Hearing (Must be within the last 9 months.)
Date if medical records have been requested Use Physician’s Report( Form ZZ)
Date medical records were received by the Student Support Team for children with known medical issues. NA for most kids. Use Physician’s Report (Form-ZZ)
Yes or No / Special Education Coordinator has been involved at the Tier 3 meeting where the referral for a Special Education Comprehensive Evaluation is anticipated. Special Education Coordinator will verify help document for exclusionary factors that may be present (lack of instruction, atypical attendance, English proficiency, culture, environmental disadvantage).
Yes or No / SST screening evaluations have been requested and reviewed at a Tier 3 meeting.
Yes or No / Work samples have been collected and analyzed to document problems
Date Social History (Form QQ) was completed.
Yes or No / RTI Grade Level Data Sheet completed
Yes or No / RTI Data attached – You must have a minimal of 8 data points in the areas of concern. (At least 8 in Reading Fluency, 8 in Reading Comp, 8 in Mathematics, or 8 in Behavioral Observations, not counting your universal screening or adding the points up across domains.). Eligibility cannot be determined without RTI data.
Yes or No / Student has a current private psychological dated ______.

Pre-referral reviewed by principal verifying two different interventions have been implemented for a

period of 12-16 weeks with baseline data and progress monitoring data for area(s) of concern. Principal’s Signature______Date______

Date School Psychologist was contacted to review information ______

School Psychologist reviewed information on ______

Recommendations of Review

______Insufficient information given to review. Provide the following information and resubmit to SP.

_____ Review Team suggests the following modification/interventions be tried

______Proceed with referral, referral packet given to ______

Form HHH