ard form episd 2009 revised version 4

8/14/2019 ARD Form EPISD 2009 Revised Version 4

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Revised Jul2009

Date of Meeting:

ADMISSI ON, REVIEW, AND DISMI SSAL COMMI TTEE MEETING

ID No: Last Name: First Name: Middle Initial:

DOB: _____Age:__ Grade: Current Teacher:____________________ Ethnicity:

Home Address:_____________________________City:__________ST: Zip Code: __

Home School (Code/Name): / School Attending (Code/Name): /

Language: Primary: Secondary: Home:

Home Language Survey (HLS): Date: LEP:

Father’s Last Name: First Name:

Home Address:_____________________________City:__________ST: Zip Code: __

Phone (H): Phone (W): Phone (M):

Mother’s Last Name: First Name:

Address: City: ST: Zip Code:


Guardian Last Name: First Name:

Address: City: ST: Zip Code:


1. USE OF INTERPRETER OR OTHER ACTIONS

An interpreter was needed and used to assist in conducting the meeting for parent(s) with deafness or whose native languageis other than English. If YES, specify the language or other mode of communication.

Yes No

Signature of Interpreter: ____________________________________________________________________________

If the student’s parent is unable to speak English, the LEA will either:

Provide the parent with a written or audiotaped copy of the student’s IEP (ARD record) translated into Spanish if Spanish is theparent’s native language; or

If the parent’s native language is a language other than Spanish, make a good faith effort to provide the parent with a written oraudiotaped copy of the student’s IEP (ARD record) translated into the parent’s native language.

2. P ROCEDURAL SAFEGUARDS

Procedural safeguards were provided/explained to the parents on: <<print form>>

Date given: ________________ To (Name): ________________

Initial

Annual

Review



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3.EXISTING EVALUATION DATA AND IN FORMATION REVIEWED AND CONSIDERED

Initial Evaluation:

DateOR

Reevaluation:

Date

Addendum:

Date Description

Addendum:

Date Description

Addendum:

Date Description

Statewide Assessment Results:

Districtwide Assessment Results:

Strengths of the student:

Concerns of the parent(s) for enhancing the education of the student:

Age-appropriate transition and functional vocational evaluation information:

Progress on the previous year’s annual goals and benchmark/short-term objectives:



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4.DETERM INA TION OF THE NEED FOR ADDITIONAL EVALUATION (Based on ARD review of existing evaluation data)

If YES, complete REVIEW OF EXISTIN G EVALUATION DATA and PRIOR WRI TTEN NOTICE OF EVALUATION .

Based on the ARD committee’s review of existing evaluation data, the ARD committee determines:

Additional Evaluation(s)1. (for 3-year reevaluations complete entire REED form) Yes No Type: Due Date:

Type: Due Date:

THE RECOMMENDATION IS BASED ON THE FOLLOWING EXISTING EVALUATION DATA: [Multiple Select Option]

Evaluations and information provided by the parents of the student:

Current classroom-based, local or state assessments, and classroom-based observations

Observations by teachers and related service providers

COMMENTS:

Specify timeline for completion of the evaluation:

1 Provide NOTICE and obtain CONSENT FOR EVALUATION and/or CONSENT FOR DISCLOSURE OF CONFIDENTIAL

INFORMATION



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5.DETERMIN ATION OF ELIGIBILITY 2

Based on the evaluation data reviewed, the ARD committee determines that the student:

does NOT meet eligibility criteria to receive special education services.

meets criteria for the following disability/disabilities:

auditory impairment mental retardation speech/language impairment

autism multiple disabilities traumatic brain injury

deaf-blind non-categorical visual impairment

emotional disturbance other health impairment

specific learning disability orthopedic impairment

AND

by reason of the disability/disabilities has a need for special education and related services.

Yes No

If the ARD Committee determines that the student has a disability and needs special education, the ARD committee must conduct an analysis

of determinant factors before determining a student is eligible for special education services.

Analysis of determinant factors: the ARD committee finds that the determinant factor (reason) for the student’s low achievement is:

lack of explicit and systematic instruction in phonemic awareness.

Yes No

lack of explicit and systematic instruction in phonics.

Yes No

lack of explicit and systematic instruction in vocabulary development.

Yes No

lack of explicit and systematic instruction in reading fluency, including oral reading skills.

Yes No

lack of explicit and systematic instruction in reading comprehension strategies.

Yes No

lack of appropriate instruction in math.

Yes No

limited English proficiency.

Yes No

If the answer to any of the above determinant factor questions is YES, the student does not have a disability.

Based on the information above, it has been determined that this student is eligible for special education servicesunder the following disability categories:

Yes No

2 NOTE: A COPY OF THE EVALUATION REPORT AND THE DOCUMENTATION OF THE DETERMINATION OF ELIGIBILITY SHALL BE GIVEN TO THE PARENT.



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6.PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMAN CE

Present Levels of Academic Achievement:

Academic Areas Academic Achievement Levels

Readiness skills:

Reading:

Writing:

Math:

Science:

Social Studies:

Other:

Other:

Other:

Present Levels of Functional Performance (including information necessary to develop an Individual Healthcare Plan if needed):

Functional* Areas Functional Performan ce Levels

* Functional is generally used to refer to activities and skills that are not considered academic or related to a student’s academicachievement as measured on Statewide achievement tests. Functional needs must be addressed for all students (e.g. behavior,vision, hearing, health accessibility).

Describe how the student’s disability(ies) affect(s) the student’s involvement and progress in the general education curriculum:

Describe how the disability(ies) affect(s) the preschool student’s participation in appropriate activities:



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7.DETERMI NATION OF P ARTICIPATION I N STATE AND DI STRICTWIDE ASSESSMENTS

All students with disabilities must be included in all general State and districtwide assessment programs with appropriate accommodations andalternate assessments where necessary as determined by the ARD committee. For students with limited English proficiency, the ARDcommittee in conjunction with the Language Proficiency Assessment Committee (LPAC) must make these decisions (e.g., Texas EnglishLanguage Proficiency Assessment System (TELPAS) for students with limited English proficiency):



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TAKS-ALT RPTE □ TAKS □ TAKS with Accommodations □ TAKS-M □

TAKS-ALT

□ 10 th Grade

ELA □ TAKS □ TAKS with Accommodations □ TAKS-M □ TAKS-ALT

Mathematics □ TAKS □ TAKS with Accommodations □ TAKS-M □ TAKS-ALT

Science □ TAKS □ TAKS with Accommodations □ TAKS-M □

TAKS-ALT Social Studies □ TAKS □ TAKS with Accommodations □ TAKS-M □

TAKS-ALT RPTE □ TAKS □ TAKS with Accommodations □ TAKS-M □

TAKS-ALT

□ 11 th Grade (Exit Level)



Science □ TAKS □ TAKS with Accommodations □ TAKS-M □ TAKS-ALT

Social Studies □ TAKS □ TAKS with Accommodations □ TAKS-M □ TAKS-ALT

RPTE □ TAKS □ TAKS with Accommodations □ TAKS-M □ TAKS-ALT

□ 12 th Grade (Exit Level)



Science □ TAKS □ TAKS with Accommodations □ TAKS-M □ TAKS-ALT

Social Studies □ TAKS □ TAKS with Accommodations □ TAKS-M □ TAKS-ALT

RPTE □ TAKS □ TAKS with Accommodations □ TAKS-M □ TAKS-ALT

Districtwide Assessment (name, if any):______________________________ □ Student will take without accommodations

□ Student will take with allowable accommodations (describe):_____

_____

□ Alternate assessment

The student requires allowable accommodations in order to participate in State or districtwide assessment.

Yes No

If YES, list the State or districtwide assessment

measure(s) for which accommodations are necessary:

List the individualized appropriate accommodations (consistent with Stateguidelines) that are necessary to measure the academic achievement and

functional performance on such assessment:



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The student requires an alternate assessment on one or more State or districtwide assessment instruments consistent withState guidelines.

If YES, Yes No

Provide a statement of why the student cannot participate in the regular assessment with or without allowableaccommodations consistent with State guidelines.

Identify the alternate assessment(s) selected as appropriate for the student consistent with State guidelines and explain whythe assessment(s) is/are appropriate:

Designate the grade level and scores for indicating limited English proficiency:



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8.TRANSI TION SERVICES

The student is in attendance. If NO, describe the steps taken to ensure the student’s preferences and interests areconsidered.

Yes No

The student is involved in his/her transition to life outside the public school system as follows (including if the student does not attend the

meeting, other steps taken to ensure that the student’s preferences and interests are considered):

For the student under 18, the parent is involved in the student’s transition to life outside the public school system as follows:

For the student who is 18 or older, if the parent is invited to participate by the student or by the LEA, the parent is involved in the student’stransition to life outside the public school system as follows:

Review of existing evaluation data as related to transition needs:

Information provided by the parent(s) related to transition needs;

Evaluation(s) performed by the LEA related to transition needs;

Evaluation(s) performed by outside agencies related to transition needs;

Current classroom-based assessments and observations related to transition needs;

Teacher and/or related service provider information related to transition needs;

Attendance records based on this review of data related to transition needs; and

Other related to transition needs.

Based on the review of data related to transition needs, additional age-appropriate assessments including functionalvocational evaluation (focused on improving the academic and functional achievement of the student with a disability to

facilitate the student’s movement from school to post-school activities) are needed. If YES, describe and specify timelinefor completion: Yes No



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8a . Age of student: Age(s) during duration of ARD/IEP

For a student who will be under the age of 16 for the duration of the ARD/IEP, the ARD committee has determined thattransition services are appropriate at this time. If YES, complete all remaining parts of this TRANSITION SERVICES section. If NO , move to the ANNUAL GOALS section. [IS IT POSSIBLE TO HAVE THE REMAINING PART OF THISTRANSITION SECTION POPULATE ONLY IF THE “Yes” BOX IS CHECKED?]

Yes No

Beginning not later than the first IEP to be in effect when th e student turns 16, or younger if determined appropriate by the ARD committee, and updated annually thereafter, the ARD comm ittee must address transition services as part of the IEP.

Student’s strengths:

Student’s preferences:

Student’s interests:

DEVELOPMENT OF POSTSECONDARY TRAN SITION GOALS

Appropriate measurable postsecondary goals based upon age-appropriate transition assessments related to:

Training;

Education;

Employment; and

Independent Living Skills (where appropriate).

DEVELOPMENT OF A COORDI NATED SET OF ACTIVITIES

Transition services means a coordinated set of activities for a student with a disability that is designed to be within a results oriented process,that is focused on improving the academic and functional achievement of the student with a disability to facilitate the student’s movementfrom school to post-school activities, including postsecondary education, vocational education, integrated employment (including supportedemployment), continuing and adult education, adult services, independent living, or community participation; is based on the individualstudent’s needs, taking into account the student’s strengths, preferences, and interests; and includes (i) instruction; (ii) related services; (iii)community experiences; (iv) the development of employment and other post-school adult living objectives; and (v) if appropriate, acquisitionof daily living skills and provision of a functional vocational evaluation.

Describe the transition services including courses of study needed to assist the student in reaching the postsecondary goals:

Consideration of Employment Goals and Objectives in the Development of the IEP:

The ARD committee determined that it IS appropriate to integrate into the ARD/IEP employment goals and objectives. If YES, address in ANNUAL GOALS section.

Yes No

Consideration of Independent and Adult Living Goals and Objectives in the Development of the IEP:

The ARD committee determined that it IS appropriate to integrate into the ARD/IEP independent and/or adult living goalsand objectives. If YES, address in ANNUAL GOALS section.

Yes No



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Consideration of Student and Parental Involvement in the Student’s Transition:

Appropriate student involvement in the student’s transition to life outside the public school system should be integrated inthe ARD/IEP.

If YES, the ARD committee will integrate in the IEP as follows: Yes No

Annual Goals FBA BIP Supplementary Aids & Services

Special Education Related Services

Community Experiences:

Daily Living Skills:

For the student who is younger than 18, appropriate parental involvement in the student’s transition should be integratedin the ARD/IEP.

If YES, describe: Yes No

For the student who is 18 or older, if the parent is invited to participate by the adult student or LEA, appropriate parentalinvolvement in the student’s transition should be integrated in the ARD/IEP.


Consideration of Postsecondary Education Options in the Development of the IEP:

The ARD committee determined that it IS appropriate to integrate into the ARD/IEP services to facilitate postsecondaryeducation options.

If YES, the ARD committee will integrate in the IEP as follows: Yes No





Consideration of the Availability of Age-Appropriate Instructional Environments:

For the student who is 18 or older, the ARD committee considered the availability of age-appropriate instructionalenvironments and determined that it IS appropriate to integrate age-appropriate instructional environments into the

ARD/IEP. Yes No

If YES, the ARD committee will integrate in the IEP as follows:







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Consideration of the Need to Refer to an Outside Governmental Agency:

The ARD committee believes that appropriate circumstances exist for the student to be referred to a governmental agencyfor services to address transition to life outside of the public school system.


Participating Agency Failure to Fulfill Transition Services Responsibilities:Has a participating agency failed to provide transition services described in the IEP?

If YES, the following are alternative strategies to meet the transition objectives for the student set out in the IEP: Yes No

8b.TRANSFER OF RIGHTS AT AGE OF MAJORITY

Beginning not later than one year before the student reaches the age of 18:

The student has been informed of the student’s rights under the IDEA, if any, that will transfer to the student on reaching the age of 18.



Revised Jul2009 ARD Please duplicate this page as needed

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9.ANNUAL GOAL Accepted by ARD

Last Name First DOB SS/ ID Number Grade School Code

Implementer(s): General Education Teacher Special Education Teacher Speech Language Pathologist

Paraprofessional Itinerant Special Education Related Service Provider:___________________

The IEP must include a statement of measurable annual goals, including academic and functional goals, designed to (1) meet thestudent’s needs that result from the student’s disability to enable the student to be involved in and make progress in the generaleducation curriculum; and (2) meet each of the student’s other educational needs that result from the child’s disability.

Measurable Annual Goal: Academic Functional Transition

Progress Report for Period Ending on:Date

Date

Date Date Date

Date

Describe how the student’s progress toward meeting t he annual goal will be measured: (Please check the appropriatboxes.) Formative and

Summative Tests Benchmark Tests Curriculum-Based

Tests Teacher Made Tests Checklists

Portfolios Work Samples Anecdotal Notes Data Sampling Other:___________

Describe when periodic reports on the progress the student is making tow ard meeting the annual goal w ill beprovided to the parents: Every 6 weeks, concurrent with report cards Every 9 weeks, concurrent with reports cards Other (must be at least every 9 weeks):__________________________________________

No. Benchmarks or Short-Term Objectives (only required forstudents taking an alternate assessment aligned toalternate achievement standards):

Progress Report for Period Ending on:

Date

Date Date Date Date Da



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10. CONSIDERATION OF SPECIAL FACTORS

BEHAVIOR CONSIDERATIONS

The student’s behavior impedes his/her learning or the learning of others.

Yes No If YES, consider the use of positive behavioral interventions and supports, and other strategies to address the behaviorincluding as part of SUPPLEMENTARY AIDS AND SERVICES, SPECIAL EDUCATION AND RELATED SERVICES,FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA) and/or BEHAVIOR INTERVENTION PLAN (BIP).

Describe how the committee will address behavior strategies as part of the ARD/IEP:

COMMUNICATION CONSIDERATIONS

The communication needs of the student are as follows:

10 a. ASSISTIVE TECHNOLOGY CONSIDER ATIONS

The student has AT needs that are addressed through SUPPLEMENTARY AIDS AND SERVICES, SPECIAL EDUCATION AND RELATED SERVICES.

Yes No

If YES, explain:

FOR IDENTIFICATION OF A STUDENT AS LIMI TED ENGLISH PR OFICIENT

For entry into a bilingual or English as a Second Language (ESL) program, the ARD committee in conjunction with the LPAC must review allpertinent information including the results of the appropriate assessment(s) used to indicate if the student is a student with limited Englishproficiency.

Describe the information reviewed, including State and districtwide assessments:

Based on the information reviewed, the ARD committee in conjunction with the LPAC agrees the student needs to enter abilingual education or ESL program.

Yes NoSpecify:

10b. FOR STUDENTS WITH LIMI TED ENGLISH PR OFICIENCY

The language needs of the student, as such needs relate to the student’s IEP, are as follows:

FOR EXIT OF A STUDENT FROM A BI LINGUAL EDUCATION OR ENGLI SH AS A SECOND LANGUAGE PROGR AM

At the end of the school year in which a student with a disability received special language services from a bilingual education or English as asecond language program, the ARD committee in conjunction with the LPAC may exit a student from the bilingual education or English as aSecond Language program based on the review and determination below.

The ARD committee in conjunction with the LPAC must review the result of the appropriate assessment instrument(s) determined by the ARDcommittee in conjunction with the LPAC to indicate English proficiency.



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Describe the assessment results:

Exit may occur upon a determination of YES to both determination statements.

The student has met the performance standard requirement for exit. Describe:

Yes No

The student will be able to participate equally in an all-English, instructional program that does not provide special languageservices from the bilingual education or English as a Second Language program.

Yes No

10c. FOR STUDENTS WHO ARE DEAF OR HARD OF HEARI NG

The ARD committee provided to the parent(s) the State-adopted brochure that contains written information about programs offeredby Texas School for the Deaf (TSD).

The language and communication needs of the student are as follows:

The student has the following opportunities for direct communications with peers and professional personnel in the student's language andcommunication mode:

The full range of needs, including opportunities for direct instruction in the student's language and communication mode, are as follows:

The academic level of the student is addressed as part of PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONALPERFORMANCE in the student’s IEP/ARD.



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CONSIDERATION OF SPECIAL FACTORS

10d. FOR STUDENTS WHO ARE BLIND OR VISUALLY IMP AIRED

The ARD committee provided to the parent(s) the State-adopted brochure that contains written information about programs offeredby Texas School for the Blind and Visually Impaired (TSBVI).

Based on an evaluation of the student’s FULL AND INDIVIDUAL EVALUATION, the student is functionally blind. If YES,

each person assisting in the development of the IEP must receive information describing the benefits of Braille instruction. Yes No

Instruction in Braille or the use of Braille for the student is appropriate. If YES, the student will be provided with reading andwriting instruction in Braille and the use of Braille that is sufficient to enable the student to communicate with the same levelof proficiency as other students of comparable ability who are at the same grade, as follows: Yes No

For a student who is functionally blind, describe the appropriate learning media based on the FUNCTIONAL VISION EVALUATION and LEARNING MEDIA ASSESSMENT:

Provide a detailed description of the arrangements made to provide the student with the following:

Orientation and mobility training

Instruction in Braille

Instruction for large print

Other training to compensate for serious visual loss

Access to special media and special tools,appliances, aids, or devices commonly used byindividuals with serious visual impairments

Describe the plans and arrangements made for contacts with and continuing services to the student beyond regular school hours (if needed)to ensure the student learns the skills and receives the training specified above:

The student was provided with a detailed explanation of the various service resources available in the community and throughout the State,as follows:

Describe the training the student will receive in the expanded core curriculum (as required for the student to succeed in classroom settingsand derive lasting, practical benefits from the education in the LEA) as follows:

Compensatory skills

Communicative skills

Orientation and mobility

Social adjustment/interaction

Vocational or career counseling

Career education

Independent living skills

Recreation and leisure skills



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Use of assistive technology

Sensory efficiency skills

Self-determination



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CONSIDERATION OF SPECIAL FACTORS

10e. FOR A STUDENT WITH AUTISM OR OTHER PERVASI VE DEVELOPMENTAL DISORDER

Based on peer-reviewed research-based educational programming practices, to the extent practicable, the ARD committee determines whether thefollowing strategies are needed.

SOCIAL SKILLS SUPPORTS AND STRATEGIES

The ARD committee has considered the use of social skills supports and strategies based on social skills assessment/ curriculum and

provided across settings, and determined that the student DOES need services as part of his/her IEP. Describe:

The ARD committee will address this need in the IEP as follows: Annual Goals FBA BIP

Supplementary Aids and Services Special Education Related Services

The ARD committee has considered the use of social skills supports and strategies based on social skills assessment/ curriculum andprovided across settings and determined that the student DOES NOT need services as part of his/her IEP. The basis for this determinationis:

POSITIVE BEHAVIOR SUPPORT STRATEGIES

The ARD committee has considered the use of positive behavior support strategies based on relevant information and determined that thestudent DOES need services as part of his/her IEP. Describe:

he ARD committee will address this need in the IEP as follows: Annual Goals FBA BIP


The ARD committee has considered the use of positive behavior support strategies based on relevant information and determined that thestudent DOES NOT need services as part of his/her IEP. The basis for this determination is:

IN-HOME AND COMMUNITY-BASED TRAINING

The ARD committee has considered in-home and community-based training or viable alternatives that assist the student with acquisition ofsocial/behavioral skills and determined that the student DOES need services as part of his/her IEP. Describe:



The ARD committee has considered in-home and community-based training or viable alternatives that assist the student with acquisition ofsocial/behavioral skills and determined that the student DOES NOT need services as part of his/her IEP. The basis for this determination is:




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STAFF-TO-STUDENT RATIO

The ARD committee has considered the suitable staff-to-student ratio appropriate to identified activities and as needed to achievesocial/behavioral progress based on the student’s developmental and learning level that encourages work towards individual independenceand determined that the student DOES need specified staff-to-student ratio as part of his/her IEP. Describe:



The ARD committee has considered the suitable staff-to-student ratio appropriate to identified activities and as needed to achievesocial/behavioral progress based on the student’s developmental and learning level that encourages work towards individual independenceand determined that the student DOES NOT need specified staff-to-student ratio as part of his/her IEP. The basis for this determinationis:

MINIMAL UNSTRUCTURED TIME

The ARD committee has considered the use of daily schedules reflecting minimal unstructured time and active engagement in learningactivities and determined that the student DOES need services as part of his/her IEP.Describe:



The ARD committee has considered the use of daily schedules reflecting minimal unstructured time and active engagement in learningactivities and determined that the student DOES NOT need services as part of his/her IEP.The basis for this determination is:

COMMUNICATION INTERVENTIONS

The ARD committee has considered the use of communication interventions, including language forms and functions that enhance effectivecommunication across settings and determined that the student DOES need services as part of his/her IEP. Describe:



The ARD committee has considered the use of communication interventions, including language forms and functions that enhance effectivecommunication across settings and determined that the student DOES NOT need services as part of his/her IEP. The basis for thisdetermination is:




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EXTENDED EDUCATIONAL PROGRAMMING

The ARD committee has considered extended educational programming and determined that the student DOES need extended educationalprogramming as part of his/her IEP. Describe:


Supplementary Aids and Services Special Education Related Services ESY

The ARD committee has considered extended educational programming and determined that the student DOES NOT need extendededucational programming as part of his/her IEP. The basis for this determination is:

TEACHING STRATEGIES

The ARD committee has considered teaching strategies based on peer reviewed research-based practices for students with autism spectrumdisorders (ASD) and determined that the student DOES need teaching strategies specified in his/her IEP. Describe:



The ARD committee has considered teaching strategies based on peer reviewed research-based practices for students with ASD anddetermined that the student DOES NOT need teaching strategies specified in his/her IEP. The basis for this determination is:

FUTURES PLANNING

Beginning at any age, the ARD committee has considered futures planning (for integrated living, work, community, and educationalenvironments) that considers skills necessary to function in current and post-secondary environments, and determined that the studentDOES need services as part of his/her IEP. Describe:


Supplementary Aids and Services Special Education Transition Services Related Services

The ARD committee has considered futures planning (for integrated living, work, community, and educational environments) that considersskills necessary to function in current and post-secondary environments, and determined that the student DOES NOT need services as partof his/her IEP. The basis for this determination is:

PARENT/FAMILY TRAINING

The ARD committee has considered parent/family training and support provided by qualified personnel with experience in ASD anddetermined that services ARE needed as part of the student’s IEP. Describe:




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he ARD committee will address this need in the IEP as follows: Annual Goals FBA BIP


The ARD committee has considered parent/family training and support provided by qualified personnel with experience in ASD anddetermined that services ARE NOT needed as part of the student’s IEP. The basis

for this determination is:

PROFESSIONAL EDUCATOR AND STAFF SUPPORT

The ARD committee has considered professional educator/staff support and determined that services ARE needed and should be specifiedin the student’s IEP. Describe:

The ARD committee will address this need in the Supports for School Personnel as part of SUPPLEMENTARY AI DS AND SERVICES,SPECIAL EDUCATION AND RELATED SERVICES (If applicable).

The ARD committee has considered professional educator/staff support and determined that services ARE NOT needed as part of the

student’s IEP. The basis for this determination is:



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10f. FUNCTIONAL B EHAVIORAL ASSESSMENT

The Functional Behavioral Assessment (FBA) is for the purpose of helping to understand the function of a student’s behavior and aid in thedevelopment of positive behavioral interventions and supports, and other strategies to address behavior.

REVIEW OF EXISTING DATA

Review and describe the following:

Information provided by the parent;

Circumstances in the student’s life;

Evaluation(s) performed by the LEA;

Evaluation(s) performed by outside agencies;

Current classroom-based assessments and observations;

Teacher and/or related service provider information;

Discipline records;

Attendance records;

Behavior Intervention Plan; and

Other.




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ANTECEDENTS

Describe the events that typically precede problem behaviors in the school setting.

Request/redirective from teachers/staff:

Redirected from inappropriate activity:

Non-compliance:

Provocation by peers:

Engaged in academic activity:

Off task:

Student in an unstructured setting (hallways, cafeteria):

No observed precipitating events:

Other:




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BEHAVIOR

List behavior(s) by listing behaviors (in precise terms) that interfere with learning.

CONSEQUENCES

HYPOTHESIS

Explain the function of the behavior.

Antecedent Behavior Co

When this occurs: The student does: To get/avoid:

INTERVENTION HISTORY

Describe the effectiveness of positive behavioral interventions and supports, and other strategies.

Provide the following information about the behaviors.

Behavior Frequency Duration Latency Intensity

Describe the events that typically follow the problem behaviors in the school setting.




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STUDENT’S BEHAVIOR IMPEDES HIS/HER LEARNING OR THAT OF OTHERS

Based on the results of the FUNCTIONAL BEHAVIORAL ASSESSMENT, the student’s behavior impedes his or herlearning or that of others. If YES, the ARD committee will address the use of positive behavioral interventions andsupports and other strategies in the IEP through:

Yes No

Annual Goals Supplementary Aids & Services

Continue current BIP Revise current BIP Develop BIP

Special Education Related Services Other:

ADDITIONAL DATA DETERMINATION

Based on consideration of existing data, the ARD committee determines that additional evaluation data are needed. If YES,describe and specify timeline for completion:

Yes No



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10 g. BEHAVIOR INTERVENTION PLAN

Describe precisely (list in rank order) the behavior(s) that is/are interfering with the student’s learning and/or the learning of others:

Describe precisely (operationalize) the desired (replacement) behavior(s):

Projected date for beginning of services: Date for ending of services:

Antecedent Strategies

Describe the appropriate strategies to be implemented.

Location

Adapt instruction:

Adapt curriculum:

Adapt classroom organization:

Pace:

Directions:

Procedures:

Expectations:

Task:

Student response:

Change presentation:

Internal conditions:

Other:

Behavior Strategies

Describe the appropriate strategies to be implemented including methods to teach replacement

behaviors.

Direct instruction/teach skills:

Practice:

Modeling:

Alternative communication:

Other:

Consequence Strategies

Describe the appropriate strategies to be implemented including positive consequences.

Increasing desired behaviors:

Reducing undesirable behaviors:



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11. LEAST RESTRICTIVE ENVIRON MENT

The ARD committee must ensure that to the maximum extent appropriate students with disabilities are educated with students who are notdisabled.

Efforts to Modify and Supplement the Student’s Participationin the General Education Setting

Check if Provided

Options ProvidedRate Results

Meaningful BenefitMinimum Benefit

No Benefit

Effect on ClassRate Options Provided

PositiveNone

Negative

Academic Nonacademic

General education classroomcore instructional interventions (Tier I)

Targeted group interventions (Tier II)

Intensive, individual interventions other than specialeducation (Tier III)

English as a Second Language (ESL)/bilingual education

Title I programs

Tutorial/remedial/compensatory services

Intensive program of instruction

Accelerated program of instruction

Personal graduation plan

Dyslexia services

Supplementary aids and services provided in the generaleducation classroom

Program modifications

Special education speech therapy

Special education resource room

Were these efforts to modify and supplement the student’s participation in the general education setting sufficientrather than token? Explain:

Yes No

Will the student receive an educational benefit from participation in the general education setting (includingnonacademic benefit)? Explain:

Yes No

Special Education Setting Check if Provided

Options ProvidedRate Results

Meaningful BenefitMinimum Benefit

No Benefit

Academic Nonac

Self-contained mild, regular campus

Self-contained moderate, regular campus

Self-contained severe, regular campus

Vocational adjustment class/program

Separate campus

Homebound

Hospital class

Nonpublic day school

Residential care and treatment facility



Revised Jul2009 ARD

8-2

Describe the student’s overall educational ex perience in the general education setting, balancing the benefits of gener al andspecial education for the individual student:

The committee recommends that this student receive ALL instruction and services in the general education setting with supplementaryaids and services. If selected, skip the next two sections and go to SUPPLEMENTARY AIDS AND SERVICES, SPECIALEDUCATION AND RELATED SERVICES in the student’s IEP/ARD.

OR

The committee recommends that this student receive part or all instruction in a special education setting. If selected, complete thefollowing sections of the student’s IEP/ARD:

• Consideration of Potential Harmful Effects;• Opportunity to Participate; and• SUPPLEM ENTARY AIDS AND SERVI CES, SPECIAL EDUCATION AND RELATED SERVICES

Consideration of Potential Harm ful Effects

If the student is removed from the general education classroom/campus, the following are potential harmful effects on the student and on thequality of services which the student needs such as:

Effects on the student: Effects on the quality of services:

Lack of opportunity for appropriate role models Diminished access to full range of curriculum

Stigmatization Decreased access to instructional opportunities

Lack of opportunity for social interactionsWide differences in development levels causing socialisolation

Decreased self-esteem

Opportunity to Participate in Nonacademic Activities

If the student is removed from the general education classroom/campus, will the student have the opportunity to participatewith students without disabilities in all nonacademic, extracurricular and other activities? If NO , describe the nonacademicand/or extracurricular activities in which the student will not have an opportunity to participate:

Yes No

meals regular transportation

recess periods health services

general education counseling services recreational activities

athletics special interest groups/clubs sponsored by the LEA

general education routines (homeroom assignments, lockers, study hall, class changes, social activities, etc.)

If any of the above items are marked, explain why this student is unable to participate:



Revised Jul2009 ARD

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12. SUPPLEMENTARY AIDS AND SERVICES, SPECIAL EDUCATION AND RELATED SERVICES(to be provided to the student or on behalf of the student based on peer-reviewed research to the extent practicable)

a.SUPPLEMENTARY AIDS AND SERVICESThe term "supplementary aids and services" means aids, services, and other supports that are provided in regular educationclasses, other education-related settings, and in extracurricular and nonacademic settings, to enable children with disabilities to beeducated with nondisabled children to the maximum extent appropriate.

LOCATION FREQUENCY AND DURATION

Course

Curriculum

Area

Non-

Academic

Area

FREQUENCY DURATION COMMENTS

#

SESSIONS PERIOD

AIDS, SERVICES, AND OTHER SUPPOR TS PROVIDED TO THESTUDENT(describe):

AIDS, SERVICES, AND OTHER SUPPOR TS PROVID ED TOSCHOOL PERSONNEL ONBEHALF OF THE STUDENT(describe):



Revised Jul2009 ARD

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SUPPLEMENTARY AIDS AND SERVICES, SPECIAL EDUCATION AND RELATED SERVICES(to be provided to the student or on behalf of the student based on peer-reviewed research to the extent practicable)

b. PROGRAM MODIFCIATIONS (IF ANY) FOR PARTICIPATION IN EXTRACURRICULAR AND OTHER NONACADEMIC ACTIVITIES

Projected date for beginning of services: Date for ending of services:

PROGR AM MODIFI CATIONS NEEDED TO ENABLE THE STUDENTTO PARTICIPATE IN EXTRACURRICU LAR AND OTHER

NONACADEMIC ACTIVITIES

SUPPORTS FOR SCHOOL PERSON NEL NEEDED TO ENABLE THESTUDENT TO PARTICIPATE IN EXTRACUR RICULAR A ND OTHER

NONACADEMIC ACTIVITIES

None needed None needed

Needed as follows: Needed as follows:

Duration, frequency, location: Duration, frequency, location:

ACCELERATED INSTRUCTION AND INTENSIVE PROGRAM OF INSTRUCTION

For a student in kindergarten, first or second grade, did the student perform satisfactorily on an early readingassessment? If NO , describe the manner in which the student will participate in an accelerated reading instructionprogram:

Yes No

The student performed satisfactorily on the most recent Statewide assessment. If NO , describe the intensive program of instruction or accelerated instruction, including reading instruction, to be provided to the student to attain a standard of annual growth on the basis of the student’s IEP/ARD:

Yes No

AND

For Grades 3, 5 and 8, if the student did not perform satisfactorily on the most recent Statewide assessment after the third attempt,the student will be:

promoted. retained.

For the student taking secondary level courses, the student performed satisfactorily on all End-of-Course exams. If NO ,describe the intensive program of instruction provided to the student:

Yes No



Revised Jul2009 ARD

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c. SCHEDULE OF GENERAL AND SPECIAL EDUCATION SERVICES INCLUDING PROGRAM MODIFCATIONSTo advance appropriately toward attaining the annual goals; To be involved in and make progress in the general education curriculum;To be afforded an equal opportunity to participate in extracurricular and other nonacademic activities; To be educated and participatewith other children with disabilities and nondisabled children in extracurricular and other nonacademic activities.

SCHEDULE OF SERVICES (A) Projected Date for the beginning of services: _________ PEIMS CODE:___________

Special education, related services, and supplementary services will be based on peer-reviewed research to the extent practicable. YearSemester

Texas Essential Knowledge and Skills(TEKS) With Alternate

TEKS Curriculum(see criteria for

TAKS-ALT)

DESCRIBE:

GeneralEducation

Time

SpecialEducation

Time

Progress/GradeDetermined By:

Area With* or withoutSupplementary

Aids andServices (*see

form)

With ProgramModifications

(see criteria forTAKS-M)DESCRIBE:

G E N

E D

S P

E D

J O I N T

English Language Arts

Reading

Math

Social Studies

Science / Health

Physical Education

Fine Arts

Elective / Other:

Speech/Language Services Location Direct Service Duration and FrequencyMin / Per

Indirect Service Duration and FrequencyMin / Per

STATEMENT OF INSTRUCTIONAL SUPPORT SERVICES

PROJECTED DATE FOR BEGINNING OFSERVICES:_________

LOCATION OFSERVICES

DIRECT SERVICES INDI RECT SERVICES COMMENT

DURATION FREQUENCY DURATION FREQUENCY

Itinerant VI Min Per Min Per

Itinerant AI Min Per Min Per

In-Home Trainer Min Per Min Per

Other: Min Per Min Per




Revised Jul2009 ARD

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SCHEDULE OF GENERAL AND SPECIAL EDUCATION SERVICES INCLUDING PROGRAM MODIFCATIONSTo advance appropriately toward attaining the annual goals; To be involved in and make progress in the general education curriculum;To be afforded an equal opportunity to participate in extracurricular and other nonacademic activities; To be educated and participatewith other children with disabilities and nondisabled children in extracurricular and other nonacademic activities.

SCHEDULE OF SERVICES (B) Projected Date for the beginning of services: _________ PEIMS CODE:___________




TAKS-ALT)

DESCRIBE:

GeneralEducation

Time

SpecialEducation

Time




form)



G E N

E D

S P

E D

J O I N T


Reading

Math

Social Studies

Science / Health

Physical Education

Fine Arts

Elective / Other:





LOCATION OFSERVICES










Revised Jul2009 ARD

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SCHEDULE OF GENERAL AND SPECIAL EDUCATION SERVICES INCLUDING PROGRAM MODIFCATIONSTo advance appropriately toward attaining the annual goals; To be involved in and make progress in the general education curriculum;To be afforded an equal opportunity to participate in extracurricular and other nonacademic activities; To be educated and participatewith other children with disabilities and nondisabled children in extracurricular and other nonacademic activities.

SCHEDULE OF SERVICES (C) Projected Date for the beginning of services: _________ PEIMS CODE:___________




TAKS-ALT)

DESCRIBE:

GeneralEducation

Time

SpecialEducation

Time




form)



G E N

E D

S P

E D

J O I N T


Reading

Math

Social Studies

Science / Health

Physical Education

Fine Arts

Elective / Other:





LOCATION OFSERVICES










Revised Jul2009 ARD

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d. RELATED SERVICESThe term “related services” means transportation, and such developmental, corrective, and other services as may be REQUIRED toassist a student with a disability to benefit from SPECIAL EDUCATION. The amount of services should be stated in a manner that isappropriate to the specific service and clear to all who are involved in the development and implementation of the student’s IEP.

PROJECTED DATE FOR BEGINNING OF

SERVICES:___________

LOCATIONOF SERVICES



Audiology Services Min Per Min Per

Counseling Services Min Per Min Per

Medical Services Min Per Min Per

Occupational Therapy1 Min Per Min Per

Orientation & Mobility Min Per Min Per

Parent Training Min Per Min Per

Physical Therapy1 Min Per Min Per

Psychological Services Min Per Min Per

Recreation Services Min Per Min Per

School Health Services Min Per Min Per

Speech/language Services Min Per Min Per

Assistive Technology Min Per Min Per

Other:_________ Min Per Min Per

Personal Care:

YES NO

The ARD committee has determined that personal care services are necessary to ensure a free appropriate public education (FAPE) for the following

reasons: _________________________________________________________________________________________

Describe the necessary personal care services:

Supervision of daily living activities

Cuing \ Prompting

Escort \ Guiding

Toileting \ Diapering

Hygiene Assistance

Feeding Assistance

Transferring \Positioning

Physical Activity Assistance

Other:_______________________

Location Frequency andDuration:

Location

Min Per Min Per

Instructions:



Revised Jul2009 ARD

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1

Note: Occupational and Physical Therapy requires Form 182-MEDICAL/EDUCATIONAL COORDINATION to be on file.COMMENTS:

LENGTH OF SCHOOL DAY

The student will have available an instructional day commensurate with that of students without disabilities. If NO, justifyand attach medical information:

Yes No

LOCATION

Unless the IEP requires some other arrangement, the student is educated in the school that he or she would attend if nondisabled. The ARDcommittee believes the IEP can be implemented in the following campus location:

The designated campus location is the location the student would attend if not disabled. If NO :

Yes No

The designated campus location is as close as possible to the student’s home.

Yes No

Transportation Services Does the student require special transportation, beyond what is part of the regular transportation system, inorder to receive a free appropriate public education (FAPE)?

If YES, provide justification:

Insert and complete FORM DETERMINATION OF SPECIAL TRANSPORTATION

YES NO



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13.GRADUATION

a. The ARD Committee has determined that this student will graduate and be awarded a high school diploma based on the following(mark applicable boxes):

Regular Graduation

The LEA must provide the student with a SUMMARY OF PERFORMANCE and the parent(s) and adult student with a PRIOR WRITTENNOTICE.

For a student with a disability to graduate and receive a regular high school diploma under this part, the following activity must occur(check to indicate accomplished):

OPTIONONE

The student has satisfactorily completed the State’s or LEA’s (whichever is greater) minimum curriculum and creditrequirements for graduation (under the recommended or distinguished achievement high school programcurriculum requirements) applicable to students in general education.

The student achieved satisfactory performance on the exit-level assessment instrument.

OPTIONTWO

The student has satisfactorily completed the State's or LEA’s (whichever is greater) minimum curriculum and creditrequirements for graduation (under the minimum high school program curriculum requirements) applicable tostudents in general education.

The student participated in required State assessments.

The ARD committee determined as part of the student’s participation in State and districtwide assessmentswhether satisfactory performance on a required State assessment would be required for graduation, and thestudent met those expectations.

Graduation under this part terminates the student’s eligibility for special education services and entitlement to the benefits of theFoundation School Program.




10 __ of __

GRADUATION

b. The ARD Committee has determined that this student will graduate and be awarded a high school diploma based on the following(mark applicable boxes):

Graduation Pursuant to an IEP Statement

The LEA must provide the student with a SUMMARY OF PERFORMANCE and the parent(s) and adult student with a PRIOR

WRI TTEN NOTICE.

STEPONE

For a student with a disability to graduate and receive a regular high school diploma pursuant to an IEP, the followingactivity must occur (check to indicate accomplished):

A REVIEW OF EXISTIN G EVALUATION DATA was conducted on ________________.

A reevaluation was completed according to the REVIEW OF EXISTING EVALUATION DATA on ________________ and is included as part of the SUMMARY OF PERFORMANCE.

STEPTWO

Determination of Graduation:

The student has successfully completed his/her IEP;

AND

The student has successfully completed the State’s or LEA’s (whichever is greater) minimum credit requirementsfor students without disabilities;

AND

The student has successfully completed the State’s or LEA’s minimum curriculum requirements to the extentpossible with modifications/substitutions only when it is determined necessary by the ARD committee for thestudent to receive an appropriate education;

AND

Consistent with the student’s IEP, the student has successfully completed one of the following conditions:

Full-time employment, based on the student's abilities and local employment opportunities, in addition tosufficient self-help skills to maintain the employment without direct and ongoing educational support of theLEA;

OR

Access to outside services or employment, or educational options for which the student has been prepared bythe academic program;

OR

Demonstrated mastery of specific employability skills and self-help skills which do not require direct ongoingeducational support of the LEA (employability and self-help skills are those skills directly related to thepreparation of students for employment, including general skills necessary to obtain or retain employment).

For students who receive a diploma under this part, the ARD committee must determine needed educational services upon the request of the student or parent to resume services, as long as the student meets the age eligibility requirements.




10 __ of __

GRADUATION

c. The ARD Committee has determined that this student will graduate and be awarded a high school diploma based on the following(mark applicable boxes):

Graduation of Student Who Will No Longer M eet Age Eligibility Requirem ents Statement

The LEA must provide the student with a SUMMARY OF PERFORMANCE and the parent(s) and adult student with a PRIOR

WRI TTEN NOTICE.

Determination of Graduation:

The student no longer meets age eligibility requirements;

AND

The student has completed the requirements specified in the IEP.



Revised Jul2009 ARD

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14. EXTENDED SCHOOL YEAR (ESY) SERVICES

ESY is required if, in one or more critical areas addressed in the current IEP objectives, the student has exhibited, or reasonably may be expectedto exhibit, severe or substantial regression that cannot be recouped within a reasonable period of time.

ESY consideration is:

Recommended by parent.

Recommended by LEA personnel directly involved in the student’s educational program.

Not recommended for discussion by either parent or school.

If recommended for discussion, continue EXTENDED SCHOOL YEAR (ESY) SERVICES analysis.

[IS IT POSSIB LE TO HAVE THE REMAINI NG PART OF THIS ESY SECTION POP ULATE ONLY IF ONE OF THE FIRST TWO BOXES

ABOVE IS CHECKED?]



Revised Jul2009 ARD

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EXTENDED SCHOOL YEAR (ESY) SERVICES

a. Review of Evaluation Data

The need for ESY is demonstrated by evidence of one or more of the following:

Formal evaluation results (FULL AND INDIVIDUAL EVALUATION report, achievement tests, academic skills tests, etc.) provided bythe LEA or parent(s). Describe:

Informal evaluation results (progress reports, work samples, observations, etc.) provided by the LEA or parent(s). Describe:

For students enrolling in a LEA during the school year, information obtained from the prior LEA:

b.Severe or Substantial Regression in Critical Areas Addressed in the Current IEP

Severe or substantial regression means that the student has been, or will be, unable to maintain one or more acquired critical skills in theabsence of ESY services.

In the following critical areas addressed in the current IEP objectives, the student has exhibited or may be expected to exhibit severe orsubstantial regression:

Placement in a more restrictive instructional arrangement.

If YES, list critical skills in current IEP objective(s): Yes No

Significant loss of acquired skills necessary for the student to appropriately progress in the general curriculum.


Significant loss of self-sufficiency in self-help skills areas as evidenced by an increase in the number of direct service staff and/or amount of time required to provide special education or related service.


Loss of access to community-based independent living skills instruction or an independent living environment provided bynoneducational sources as a result of regression in skills.


Loss of access to on-the-job training or productive employment as a result of regression in skills.


ther Critical Area(s).

Yes No If YES, list critical skills in current IEP objective(s):

If NO is indicated in response to all of the above Severe or Substantial Regression in Critical Areas Addressed in the Current IEP statements, student does not qualify for ESY. If YES is indicated in response to any of the above statements, continue ESY consideration.



Revised Jul2009 ARD

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c. Reasonable Period of Time for Recoupment

The reasonable period of time for recoupment of acquired critical skills must be determined in each student’s IEP. If the loss of acquired criticalskills would be particularly severe or substantial, or if such loss results, or reasonably may be expected to result, in immediate physical harm tothe student or to others, ESY services may be justified without consideration of the period of time for recoupment of such skills. In any case, theperiod of time for recoupment must not exceed eight weeks.

ESY is justified, without consideration of the period of time for recoupment of acquired critical skills, because the loss of suchskills would be particularly severe or substantial.

Yes No

ESY is justified, without consideration of the period of time for recoupment of acquired critical skills, because the loss of suchskills results, or reasonably may be expected to result, in immediate physical harm to the student.

Yes No

ESY is justified, without consideration of the period of time for recoupment of acquired critical skills, because the loss of suchskills results, or reasonably may be expected to result, in immediate physical harm to others.

Yes No

ESY is justified because the critical skills that the student is expected to lose cannot be recouped within a reasonable period of time for this student:____________ (days or weeks). (The reasonable period of time for recoupment of acquired critical skillsshall be determined on the basis of needs identified in the student’s IEP and shall not exceed eight weeks.)

Yes No

If YES is indicated in response to any of the above Reasonable Period of Time for Recoupment statements, student qualifies for ESY.

Goals and Objectives for ESY Services From Current IEP (for student who qualifies for ESY)

If the ARD committee determines that the student is in need of ESY services, then the IEP must also include goals and objectives for ESY

services from the student’s current IEP.

IEP goal/objective to be maintained:




OR The IEP goals/objectives to be maintained are attached.

Extended School Year Services to maintain skills (for student who qualifies for ESY)

Type (special education service or related service):

Frequency of service(s):

Duration of service(s):

Location of service(s):

Instructional arrangement (PEIMS Code):



Revised Jul2009 ARD

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16. NOTICE AND INFORMED CONSENT TO ACCESS MEDICAID FOR SCHOOL HEALTH AND RELATED RECORDS

(SHARS)

Last Name, First DOB ID Number Grade School

School Health and Related Services (SHARS) is a joint program of the Texas Education Agency (TEA) and the Texas Healthand Human Services Commission (HHSC) that allows local school districts to obtain federal reimbursement for some of thehealth services and related services that they provide to students in special education. The El Paso Independent SchoolDistrict (EPISD) has been approved as a SHARS provider – and, as such, it routinely submits claims for such Federalreimbursement to HHSC.

As you are aware, your child currently receives a variety of health services and related services from the EPISD in conjunctionwith an “Individualized Education Plan” (IEP) that was developed by an Admission, Review & Dismissal (ARD) Committee. Inthis regard, some of the services that are listed in your child’s IEP may be eligible for reimbursement under the SHARSprogram.

If your child is eligible for the Title XIX/Medicaid program or the Title XXI and you give your consent for the EPISD to claimthe available Federal reimbursement for any eligible services – the EPISD will be able to reduce its out-of-pocket costs forthose services. Reimbursement programs such as this enable school districts to continue to meet the needs of all studentswithout increasing the amount of funds it must raise via local property taxes.

Federal law requires the EPISD to provide all of the services that are listed in your child’s IEP at no cost to you, regardless of whether you choose to enroll your child in Medicaid or CHIP – and regardless of whether you permit the EPISD to seek federalreimbursement for some of those services. Thus, your child will continue to receive all of the services listed in his or her IEPwhether or not you give consent for the EPISD to submit claims for federal reimbursement.

IF YOU DO GIVE PERMISSION FOR THE EPISD TO SEEK FEDERAL REIMBURSEMENT THROUGH THE SHARSPROGRAM FOR SOME OF THE HEALTH SERVICES AND R ELATED SERVICES THAT IT PROVIDES TO YOUR CHILD,

YOUR CHILD’S ELEGIBILI TY TO RECEIVE OTHER MEDICAID/ CHIP SERVICES WI LL NOT BE COMPROMISED IN ANY WAY. IN THIS REGARD, THE SUBMISSION OF SUCH SHARS CLAIM S WILL N OT RESULT IN ANY COST TO YOUR FAMILY OR AFFECT YOUR CHILD’S MEDICAI D/ CHIP STATUS WI TH RESPECT TO THOSE SERVICES SINCETHERE IS NO “ANNUAL CAP” OR “LIFETIME BENEFITS CAP” FOR STUDENTS UNDER THE AGE OF 21 WITHRESPECT TO EITHER OF THOSE PROGRAM S.

If you agree to allow the EPISD to submit claims for Federal reimbursement with respect to the health services and related

services that it provides to your child, the School District will need to disclose some information from your child’s educationrecords. With your consent (below), the School District will only submit appropriate claims – and only disclose the minimumamount of such information – in order to obtain the available Federal reimbursement.

Yes □ No □ I have been fully informed in my native language or other mode of communication and understand theSchool District’s request for my consent, as described above.

Yes □ No □ hereby give the EPISD permission to submit appropriate claims for Federal reimbursement with respect tothe eligible services that are specified in my child’s IEP/ARD. My permission to submit appropriate claims forreimbursement for each Medicaid/CHIIP-eligible service begins on the projected date for the beginning of the services, and is for the frequency and duration that is specified in my child’s IEP/ARD record.

Yes

□No

□ I understand that my permission must be obtained each time changes are made to the Medicaid/CHIP-

eligible services contained in my child’s IEP/ARD record (at least annually).

Yes □ No □ I hereby give the EPISD permission to release the necessary information from my child’s education recordsin order to obtain the available Federal reimbursement.

Yes □ No □ I understand that my consent is voluntary and that I can revoke it at any time (If I do choose to revoke myconsent at a later date that revocation will only be effective from the date of the revocation forward).

ARD Date:______________ PARENT'S SIGNATURE: ______________________________ DATE: _______________



Revised Jul2009 ARD

13-2

SIGNATURE OF INTERPRETER, IF USED: _______________________________ DATE: _______________

17.SIGNATURES OF ARD COMM ITTEE MEMBERS

STUDENT AMPUS GRADE

Signature and Title Membersh ip Role Agree Disagree

Parent(s)

Regular Education Teacher

Special Education Teacher/Provider

LEA Representative1

Individual who can interpret instructional implications2

Other3

Student4

AI Teacher5

VI Teacher6

Representative of LPAC7

CTE Representative8

The committee mutually agreed to all required elements of the IEP.

OR

The members of the ARD committee have not reached mutual agreement. Members who disagree have been offered the opportunityto write their own statements. The ARD record contains a written statement of the basis for the disagreement. The school has offereda single opportunity for, and the parent(s) have agreed to a recess of not more than 10 school days. During the recess, the membersshall consider alternatives, gather additional data, prepare further documentation and/or obtain additional resource persons to enablethem to reach mutual agreement. This recess does not apply if the student presents a danger of physical harm to himself/herself orothers, or if the student has committed an expellable offense, or an offense which may lead to a placement in an alternative educationprogram (AEP). The ARD committee will reconvene on:

at

Date and Time Place

ARD records shall reflect why mutual agreement has not been reached. Individual statements may be attached.

If a 10-day recess is implemented and the ARD committee still cannot reach a mutual agreement, the LEA must provide the parent(s) with prior written notice and implement the IEP which it has determined to be appropriate for the student. When a LEA implements an IEP with which the parent disagrees or the adult student disagrees, the LEA shall provide prior written notice to the parent(s) or adult student.

1The LEA representative is one who is qualified to provide, or supervise the provision of, specially designed instruction to meet the needs of students with

disabilities; is knowledgeable about the general curriculum; and is knowledgeable about the resources of the LEA

2 An individual who can interpret the instructional implications of evaluation results who may be one of the other members

3 Other individuals who have knowledge or special expertise regarding the student, at the discretion of the parent(s) or the LEA, including in the case of a studentwho was previously served under the Early Childhood Intervention (ECI) program, at the request of the parent(s) by invitation to the initial ARD meeting, theECI Service Coordinator or other representatives of the ECI system to assist with the smooth transition of services.

4The student with a disability, whenever appropriate and when the purpose of the meeting will be the consideration of transition services

5For a student with an auditory impairment including deaf-blindness, a teacher who is certified in the education of students with auditory impairments

6For a student with a visual impairment including deaf-blindness, a teacher who is certified in the education of students with visual impairments

7LPAC representation for any student who is Limited English Proficient/Bilingual

8When considering initial or continued placement of a student in career and technical education (CTE), a representative from CTE, preferably the teacher



18. FOR INI TIAL PLACEMENT (If applicable)

Check all that apply.

_____ _____ I have been fully informed and understand the admission, review and dismissal (ARD) committee report(s) which have been prepared YES NO for my child/me.

_____ _____ I understand and agree with the ARD committee’s decisions and give permission for the provision of special education services. YES NO

_____ _____ I understand that my consent for placement is voluntary and may be revoked at any time. YES NO

_____ _____ I understand that if I revoke consent, that revocation is not retroactive.

Parent Signature _______________________________________________________________

ard form episd 2009 revised version 4

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