pa mapping document re-evaluate report (rr) reevaluation … · 2011-10-05 · reevaluation report...

REEVALUATION REPORT Student’s Name:

of 13 July 2008 Revisions

PA Mapping Document –Re-Evaluate Report (RR)

REEVALUATION REPORT (RR) School Age

Student Name:

Date of Report (mm/dd/yy): Date Report Provided to Parent/Guardian/Surrogate:

Student Birth Date: Age: Grade:

Local Education Agency (LEA):

School Student is Attending:

Current Educational Program:

County of Residence: Phone (Home):

Name and Address of Parent/Guardian/Surrogate: Phone (Work):

Other Information:

Date IEP Team Reviewed Existing Evaluation Data:

The IEP team must decide if it has enough data to determine: the student’s educational needs; the present levels of academic achievement and related developmental needs of the student; whether any additions or modifications to the special education and related services are needed to enable the student to meet the measurable annual goals in the IEP and to participate as appropriate in the general education

curriculum; and whether the student continues to need special education and related services. I. SUMMARIZE INFORMATION REVIEWED

Complete items 1-7 for all students.

1. Physical condition, social, or cultural background, and adaptive behavior relevant to the student’s disability and need for special education:

2. Evaluations and information provided by the parent (or documentation of LEA’s attempts to obtain

parental input):

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SUMMARY: Webform & Report. ADD Logo / Letterhead between header and Re-Eval Title below.

- Fits in address into Window envelope

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PA –Re-Evaluation Report (RR)

*(See documentation for ‘Goal Book Setup for PA Statement Lookup’)

- Enable user to Link Placement & Disabilities Referral Record to this form, Alternate Code = RE

- Start Date = Form Creation Date/Today, Enable user to change it - Ability to Finalize Form

Letterhead, System or User, Report Header (School

Address/Phone)

- Logo

A Page Header Form Name & Child’s Name (First, Middle, Last, Qualifier)

1 Student Name Student, Demographic: First, Middle, Last name, Qualifier

2 Date of Report Today’s date, enable user to change date

2a Date Report to P/G Today’s date, enable user to change date

3 DOB Student, Demographics, Date of Birth Field

3a Age Calculate student age, DOB to Today’s Date

3b Grade Form, Placement, Grade Field as of ER Form Current Date

4 Local Education Agency (LEA) Options, Systemwide Options, Organization - OR_Name of System Default Organization

5 Attending School Form, Placement, Location as of ER Form Current Date

6 Current Ed. Program Form, Placement, Placement/Supports as of ER Form Current Date - Display Primary & non-primary Placement - Indicate Primary with ‘*’

7 County of Residence Student, Address, Home, County field - AD_County of Address linked to Student where AD_Home=1

8 Parent/Guardian/ Surrogate Parent/Guardian Salutation, Address information - Basic Information, Contact, Type = Parent/Guardian, Surrogate

Parent - Addresses Tab = Mail - Mail Attention Line, if blank use Contact Name fields

9 Other Information - Text Box and pull data stored…

- Student, Demographics, Notes Box

10 Date IEP Team Reviewed Existing

Re-Eval Data

Today’s date; user can modify

11 Summarized Information 1. Physical Condition

Text Box Statement – Category = ‘Re-evaluation’, SubCategory = ‘Physical’

12 2. Evaluations Text Box Statement – Category = ‘Re-evaluation’, SubCategory = ‘Parent Information’



3. Aptitude and achievement tests:

4. Current classroom based assessments and local and/or state assessments:

5. Observations by teacher(s) and related services provider(s), when appropriate:

6. Teacher recommendations:

7. Determining factors: A student must not be found to be eligible for special education and related

services if the determining factor for the student’s suspected disability is any of those listed below.

Respond Yes or No to, and provide evidence for, each determining factor below.

Yes No Lack of appropriate instruction in reading, including the essential

components of reading instruction. Provide evidence:

Yes No Lack of appropriate instruction in math. Provide evidence:

Yes No Limited English proficiency. Provide evidence:

II. DETERMINATION OF NEED FOR ADDITIONAL DATA, SUMMARY AND CONCLUSIONS

Based on all evaluation data reviewed, complete item 1 or item 2.

1. The IEP team determined that additional data are not needed.

Reason(s) additional data are not needed:

Conclusion: Complete section A or B or C.

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A. The student has a disability AND continues to need specially designed instruction.

i. Disability Category

Primary disability category:

Secondary disability category(s), if any:

ii. Summary of Findings

Student’s educational strengths and needs:

Present levels of academic achievement and related developmental needs, including

transition needs as appropriate:

Recommendations for consideration by the IEP team regarding any additions or modifications to the special education and related services needed to enable the student to

meet the measurable annual goals in the IEP and to participate as appropriate in the general education curriculum (including special considerations the IEP team must consider before developing the IEP, measurable annual goals, specially designed instruction, and supplementary aids and services):

OR

B. The student does not have a disability and no longer is eligible for special education. (The

parent may request an assessment to determine whether the student continues to be a student with a disability.)

OR

C. The student has a disability but no longer needs specially designed instruction, and no longer

is eligible for special education. (The parent/guardian/surrogate may request an assessment to determine whether the student continues to be a student with a disability.)

2. The IEP team determined that there is a need for additional data.

The LEA must issue the Permission to Reevaluate – Consent Form and administer tests and other evaluation materials as may be needed to produce the data below.

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PA –Re-Evaluation Report (RR) - Continued

13 3. Aptitude Testes Text box

14 4. Assessments Text box

PerformancePLUS Assessment Look-up Utility enabled on form.

15 5. Observations Text Box

16 6. Teacher Recommendations Text Box

Statement – Category = ‘Re-evaluation’, SubCategory = ‘Teacher Recommendations’

17a 7. Determining Factors -Lack of Reading Instruction

Check Box, Text Box Statement – Category = ‘Re-evaluation’, SubCategory =

‘Reading Instructions’

17b - Lack of Math Instruction Check Box, Text Box

Statement – Category = ‘Re-evaluation’, SubCategory = ‘Math Instruction’

17c - LEP Check Box, Text Box Statement – Category = ‘Re-evaluation’, SubCategory = ‘LEP’

18 II. Determination, Conclusions 1. Additional Data NOT needed

Check Box, Text Box

18a 1a. Primary Disability & Secondary Disability

Radio Button - Student, Disability, Primary & Secondary Disabilities

- Disability must be within the date range of the form. - Ability to Manage Disabilities here also

19 ii. Summary of Findings Educational Strengths & Needs

Text box - Add ability to enter Evals/Test records

Handle Eval/Tests by security within form

20 Present Levels of Academic Text Box

21 Recommendations Considered Text Box

22 B. No Disability, no special Ed Radio Button - Disability ended on or before the date of the RR form

- If open disability, use RR date and end disability

23 C. Disability but no SDI, no special

ed

Radio Button

24 2. Need for Additional Data Check Box



NOTE: IF REEVALUATING THE STUDENT TO DETERMINE SPECIFIC LEARNING

DISABILITY, COMPLETE THE DETERMINATION OF SPECIFIC LEARNING DISABILITY

COMPONENT AT THE END OF THIS DOCUMENT BEFORE COMPLETING THE SECTION BELOW.

Interpretation of additional data:

Conclusion: Complete section A or B or C.

A. The student has a disability AND continues to need specially designed instruction.

i. Disability Category

Primary disability category:

Secondary disability category(s), if any:

ii. Summary of Findings

Student’s educational strengths and needs:

Present levels of academic achievement and related developmental needs, including transition needs as appropriate:

Recommendations for consideration by the IEP team regarding any additions or modifications to the special education and related services needed to enable the student to meet the measurable annual goals in the IEP and to participate as appropriate in the general

education curriculum (including special considerations the IEP team must consider before developing the IEP, measurable annual goals, specially designed instruction, and supplementary aids and services):

OR

B. The student does not have a disability and therefore no longer is eligible for special

education.

OR

C. The student has a disability but no longer needs specially designed instruction, and no longer is eligible for special education.

Upon completion of the reevaluation, the Local Education Agency will complete and issue the report to the members of the evaluation team.

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Evaluation Team Participation

Agreement and Disagreement

required ONLY when evaluating

students for specific learning

disability.

Evaluation Team Participants* Title Agree Disagree**

* A certified school psychologist is required for evaluation of the following disability categories: Autism,

Emotional Disturbance, Mental Retardation, Multiple Disabilities, Other Health Impairments, Specific Learning Disability or Traumatic Brain Injury. A certified school psychologist is not required for Deaf-blindness, Deaf and Hard of Hearing, Speech/Language Impairment, Visual Impairment and Orthopedic Impairment.

** For specific learning disability only, if a team member disagrees with the team’s conclusion related to the identification of the student as having a specific learning disability, the member must submit a separate statement presenting the member’s dissent to the LEA. This information must be attached to the Reevaluation Report. Please submit this statement to:

LEA Representative Name Phone Number

Email Address

A copy of the Procedural Safeguards Notice is available upon request from your child’s school. This document explains your rights, and includes state and local advocacy organizations that are available to help you understand your rights and how the special education process works.

For help in understanding this form, an annotated Reevaluation Report is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on the website. If you do not have access to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.

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http://www.pattan.net/



PA –Re-Evaluation Report (RR)

25 Interpretation Addtl Data Text box

26 Conclusion 2a.Disability & Needs

SDI

Radio Button (dependent on 26, 30, 31) - Student, Disability

- Primary & Secondary Disabilities - Ability to Manage Disabilities here also

27 ii. Summary of Findings Educational Strengths

Text Box

28 Present Levels Academic Achievement

Text Box

29 Recommendations Text Box

30 B. No Disability, no longer eligible

Radio Button (dependent on 26, 30, 31)

31 C. Disabled but no SDI Radio Button (dependent on 26, 30, 31)

32 Evaluation Team

Text Box

33 LEA Representative, Phone, Position, Email.

- Text box and/or Add, Manage Code Tables, Letterhead Enclosure = ‘School District Contact’

(Note: Add if not in districts code tables) Maintenance, Letterhead, Staff Type/Enclosure = School District Contact

(Letterhead_Enclosure_sub.rpt-01) Name: Letterhead, Staff type/Enclosure = School District contact, Line 1 Phone: Letterhead, Staff type/Enclosure= School District contact, Line 3

Email: Letterhead, Staff type/Enclosure= School District contact, Line 4 - Enable user to change text or manually enter text here

NEW: Display text from Letterhead addition on screen currently it only displays on the report.



DETERMINATION OF SPECIFIC LEARNING DISABILITY

NOTE: This component must be completed when reevaluating students for Specific Learning Disability. The information must be attached to and/or incorporated into Section II Item 2 of the completed Reevaluation Report.

Provide documentation for items 1-10.

1. The student does not achieve adequately for the student’s age or does not meet State-approved grade-

level standards in one or more of the following areas when provided with learning experiences and scientifically based instruction appropriate for the student’s age or State-approved grade level standards and level of English language proficiency: oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, mathematics calculation, and

mathematics problem-solving.

2. Check below to identify the process(es) used to determine eligibility.

Response to Scientific Research-Based Intervention (RtI). Document the criteria below.

The student does not make sufficient progress to meet age or State-approved grade-level standards

in one or more of these areas: oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, mathematics calculation, and mathematics problem-solving:

Severe Discrepancy between Intellectual Ability and Achievement. Document the criteria below.

The student exhibits a pattern of strengths and weaknesses in performance, achievement or both relative to age, standards or intellectual development:

3. The instructional strategies used and the student-centered data collected:

4. The educationally relevant medical findings, if any:

5. The effects of the student’s environment, culture, or economic background:

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6. Data demonstrating that prior to referral or as part of the referral process for an evaluation for specific learning disability, the student’s regular education instruction was delivered by qualified personnel, including the English as a Second Language (ESL) program, if applicable:

7. Data based documentation of repeated assessments of achievement at reasonable intervals, reflecting

progress during instruction, which was provided to the parents:

8. An observation in the student’s learning environment (including the regular classroom setting) to

document the student’s academic performance and behavior in the areas of difficulty. Note the

relationship of that behavior to the student’s academic functioning:

9. Other data, if needed, as determined by the evaluation team:

10. Include a statement for each item below to support the conclusions of the evaluation team that the

findings are not primarily a result of

Visual, hearing, motor disability:

Mental retardation:

Emotional disturbance:

Cultural factors:

Environmental or economic disadvantage:

Limited English proficiency:

Upon completion of the SLD Component, attach and/or incorporate this information into Section II Item 2 of the completed Reevaluation Report.

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PA –Re-Evaluation Report (RR) – Continued

Determination of SLD *(See documentation for ‘Goal Book Setup for PA Statement Lookup’- Set Active, use SPI Default Goalbook)

34 1. SLD Standards not

met

Text Box

Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Adequate Achievement’

35 2. SLD RTI not making progress

Check box, Text Box

36 SLD Intellectual

Discrepancy

Check box, Text box

Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Severe Discrepancy’

37 3. SLD Instructional Strategies

Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Instructional Strategies’

38 4. SLD Educationally

Relevant Medical

Text Box

Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Medical Finding’

39 5. SLD Background Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Effects of

Environment’

40 6. SLD qualified Regular

Ed staff

Text Box

Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Qualified Personnel’

41 7. SLD Assessments Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Progress

Monitored’

42 8. SLD Observation Text Box

Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Student Behavior’

43 9. SLD Other Data Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Other Data’

44 10. SLD Vision/Hearing Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD

Visual/Hearing’

45 SLD Mental Retardation

Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD MR’

46 SLD Emotional Disturbance

Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD ED’

47 SLD Cultural Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Cultural’

48 SLD Environmental Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD

Environmental Disadvantage’

49 SLD LEP Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD LEP’

Print Form Number / Date

Print on the bottom of the form.



PA – Re-Evaluation Report Form

Q&A’s FORM ID#_______

Field QU_Area QU_Section QU_Subsection

FAW_State

FAW_Notes

9 PA_RR_OtherInformation Text Text 11 PA_RR_Summarize Physical Text 12 PA_RR_Summarize Evaluation Text 13 PA_RR_Summarize Tests Text 14 PA_RR_ Summarize Assessments Text

15 PA_RR_ Summarize Observation Text

16 PA_RR_ Summarize TeacherRecommendations Text

17a PA_RR_ Summarize Reading X Text

17b PA_RR_Summarize Math X Text

17c PA_RR_Summarize LEP X Text

18 PA_RR_Determination NoAdditionalData X Text

18a PA_RR_Determination DisabilityandSDI X

19 PA_RR_Determination Needs Text

20 PA_RR_Determination PresentLevels Academic Text

21 PA_RR_Determination Recommendation Text

24 PA_RR_Determination NeedAdditionalData X

25 PA_RR_Determination InterpretationAdditionalData

Text

27 PA_RR_Conclusions SummaryofFindings Text

28 PA_RR_Conclusions PresentLevelsAcademic Text

29 PA_RR_Conclusions Recommendations Text

33 LEARepresentative Text

34 PA_RR_SLD NotMeetStandards Text

35 PA_RR_SLD RTI X Text

36 PA_RR_SLD SevereDiscrepancy X Text

37 PA_RR_SLD InstructionalStrategies Text

38 PA_RR_SLD EducationallyMedical Text

39 PA_RR_SLD Effects of environment Text

40 PA_RR_SLD DataInstructionbyQualifiedPersonnel

Text

41 PA_RR_SLD Data Text

42 PA_RR_SLD Observation Text

43 PA_RR_SLD OtherData Text

44 PA_RR_SLD VisualHearingMotor Text

45 PA_RR_SLD MentalRetardation Text

46 PA_RR_SLD EmotionalDisturbance Text

47 PA_RR_SLD Cultural Text

48 PA_RR_SLD Environmental Text

49 PA_RR_SLD LEP Text

Revision History: 7/2010: Ability to used goal book statements if SPS Default Goal Book is active and statements have been added to this book. 7/30/10: Evaluation Team Participation section now has a total of 15 signature lines on the report.



8/17/2011: Added line indicated the PeformancePLUS Assessment Look-Up Utility is enabled on this

form.

pa mapping document re-evaluate report (rr) reevaluation … · 2011-10-05 · reevaluation report...

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