Form 1/Appendix B

FORM 1/APPENDIX B

FORM 1/APPENDIX B

REQUEST FOR CONSIDERATION OF INITIATION
OF STATUTORY ASSESSMENT
under Section 321 of the Education Act 1996
EVIDENCE SUBMITTED BY THE HEADTEACHER OF THE CHILD’S SCHOOL
WHICH MAY BE USED AS EDUCATIONAL ADVICE UNDER
THE EDUCATION (SPECIAL EDUCATIONAL NEEDS)
(ENGLAND) (CONSOLIDATION) REGULATIONS 2001
Regulation 7 (1)(b)

THIS INFORMATION MAY BE INCORPORATED INTO A PROPOSED

STATEMENT TO WHICH IT WILL BE ATTACHED AND SENT TO PARENTS
Please complete ALL sections.
Do not leave any section blank; enter NA or Not Known where appropriate.
Complete in black ink/ ballpoint or type responses

1 Amended on 03/10/18

FORM 1/APPENDIX B

Child

Surname:

Other Name(s):

Home Address:

Postcode:

Date of Birth: Age: Sex:

Religion:Home Language: Ethnic Origin:

Major Need:(please refer to EMS codes)

Parent(s)/Person(s) Responsible:

Name: Relationship to Child:

Address (if different from above):

Postcode:Tel. No.

School:

Present School:

Date of entry:

School contact:Tel. No.

Year Group in which child is placed:Chronological age Year Group:

(if different)

Number in class:Attendance ratio:

Previous school(s) attended with dates:
Dates
Dates
Dates
LEA only:
Request received: / Case Officer:
Panel date: / Entered on EMS:
Decision: / Letter sent:

PUPIL’S CURRENT LEVEL OF PERFORMANCE AT

/ Date:
1Summary of reason for request for statutory assessment
2Are you attaching any written information (eg a letter from the parent or notes of a consultation meeting with the parent) which indicates their permission to this request and which provides any evidence from the parent/person responsible? / YES / NO
If NO, summarise views of parent/person responsible here:

4National Curriculum core subjects levels according to latest teacher assessment

Current Key Stage:

Subjects

/ Latest SAT levels
(End of KS …… )
Date: / Current NC Teacher
Assessment
Date: / Targets for end of current Key Stage

English

Reading

Writing

Spelling (KS1 only)

Speaking & listening

Mathematics

Science

For those pupils who are expected to progress within a level please record progress within

the QCA differential levels (P scale, 1A/B/C and 2A/B/C) in the boxes below

QCA Scale

/ Last Key Stage / Current Level / Target for end of current Key Stage

Language & Literacy

Reading
Writing
Speaking

Listening

Mathematics

Number
Using/applying
Shape/space

Personal/Social

Standardised attainment tests for reading, spelling, comprehension, mathematics(Please include a recent assessment when pupil’s needs focus on literacy.)

Date / Test given / Chronological Age / Result
5Performance in foundation subjects:
Subject / National Curriculum Level
(from teacher assessment)
What are the pupil’s strengths and weaknesses and how do these affect the pupil in school? Specify areas where the pupils experiences success.
(a)As seen by staff
(b)As seen by pupil
6List any specific aspects of the pupil's needs and difficulties as observed and which are causing concern and give evidence as to the frequency and severity of the difficulties under the following headings:
(i) Communication and Interaction (including speech and language)
(ii) Cognition and Learning
(iii) Behaviour, Emotional and Social
(iv) Sensory and/or physical
(v) In relation to the information you have given please state (with reasons) how the pupils needs meet the LEA SEN criteria for statutory assessment.
7Current school provision for this pupil provided from the school’s delegated funding
(Level 1 and Level 2)
Type of provision currently
received by this pupil / Number of
hours per week / Who is providing this?
In class support
Withdrawal individual or in a pair
Small group teaching (number in group)
Other (please specify)
If the above arrangements are not able to meet the needs at school action plus stage please give reasons why.
How would any additional support provided through a statement be used?
8Tick support services, outside agencies currently involved with name where possible and attach any relevant reports or advice provided.
Outside Agency/
Support Service / 
if involved / Name if known: / 

Advice/report attached

STEPS members: / EP
BPS
LLS
REMA
EWO
SOCIAL WORKER
Lead agency
PSSS
Outreach team
School Doctor/Nurse
Speech & Language Therapist
Physiotherapist
Occupational Therapist
Child and Family Consultation (CAMHS)
representative
Private Tutor
Traveller Service
Other (please specify)
9Schools Action and Schools Action Plus Assessments Arrangements and Intervention.
You must attach copies of all action plans the school has carried out as these form a substantial part of the evidence for the panel.
The last 2 years of IEP’s required. Reception age screening not needed for junior/secondary referral
Please list attachments below:
End of foundation stage profile / YES / NO
Schools Action plans attached / YES / NO / Number of plans:
Schools Action Plus plans attached * / YES / NO / Number of plans:
*A child will normally have been at this stage for at least 2 terms with termly reviews of the Action Plans)
This form should be sent with attachments to the
relevant Case Officer at your Local Education Office
Please keep a copy for your records
Signed:
Designation:
Date:

1 Amended on 03/10/18