prior written notice 34 cfr §300.503; wac 392-172a … safeguards for students and their families...

PURPOSE: Provide updated information that relates to the Notice of Special Education Procedural Safeguards for students and their parents.

Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747

Addendum to the Notice of Special Education Procedural Safeguardsfor Students and their Families

Requirements under Part B of the Individuals with Disabilities Education Act, the Federal Regulations, and the State Rules Governing Special Education.

The following addendum contains changes to the Notice of Special Education Procedural Safeguards for Students and Their Families published August 2007. Thisaddendum is to notify parents of changes that were effective December 31, 2008, asa result of federal rule amendments published in the Federal Register, Vol. 73, No. 231. The changes contained in this addendum will be incorporated into the State’s Notice of Special Education Procedural Safeguards when the state adopts final amended regulations. After the regulations are adopted, the State’s Notice of Procedural Safeguards may contain additional changes.

Please use the following information in place of the information contained in the State’s Notice of Special Education Procedural Safeguards:

• Prior Written Notice: Pages 2 and 3 of the State’s Notice of Special EducationProcedural Safeguards. Added an example of when a district sends prior written notice.

• Parental Consent – Definition: Page 4 of the State’s Notice of Special Education Procedural Safeguards. Added information that revocation of consent for continued services does not require a school district to amend educational records.

• Parental Consent for Initial Services: Pages 5 and 6 of the State’s Notice of Special Education Procedural Safeguards. The caption now reads, “Parent Consent for Initial Services and Revocation of Consent for Continued Services.” Added information regarding revocation of consent for continued special education services.

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1Addendum - Procedural Safeguards 2/2009Student Name CSRS ID# Birth date

The school district must provide you information in writing about important decisions that affect your child’s special education program. This is called a prior written notice and it is a document that reflects decisions that were made at a meeting or by the district in response to a request made by you. The district is requiredto send you a prior written notice after a decision has been made, but before implementing the decision. These are decisions made that are related to any proposal or refusal to initiate or change the identification, evaluation, placement, or provision of a FAPE to your child.

A prior written notice must include:

• What the district is proposing or refusing to do;• An explanation of why the district is proposing or refusing to take action;• A description of any other options considered by the IEP team and the reasons why those options

were rejected;• A description of each evaluation procedure, assessment, record, or report used as a basis for the

action;• A description of any other factors relevant to the action;• A description of any evaluation procedure the district proposes to conduct for the initial evaluation and

any reevaluations;• A statement that parents are protected by the procedural safeguards described in this booklet;• How you can get a copy of this notice of procedural safeguards booklet; or include a copy of this

notice of procedural safeguards booklet if one has not been provided to you; AND• Sources for you to contact to get help in understanding these procedural safeguards.

Examples of when you will receive a prior written notice are:

• Your child is referred because of a suspected disability and potential need for special education.• The district wants to evaluate or reevaluate your child, or the district is refusing to evaluate or

reevaluate your child.• Your child’s IEP or placement is being changed.• You have asked for a change and the district is refusing to make the change.• You have given the district written notice that you are revoking consent for your child to receive

special education services.

Prior written notice must be provided in your native language or other mode of communication that you use, such as sign language, unless it is clearly not feasible to do so.

If your native language or other mode of communication is not a written language, the district must take stepsto ensure that (1) the notice is translated orally or by other means in your native language or other mode of communication, (2) you understand the content of the notice, and (3) there is written evidence that these requirements have been met.

Prior Written Notice 34 CFR §300.503; WAC 392-172A-05010

You have the right to be given information in writing that explains what your school district is or is notdoing when it affects your child’s special education needs.


Parental Consent – Definition 34 CFR §300.9; WAC 392-172A-01040

The school district must get your written consent before evaluating your child. The district must alsoget your written consent before providing special education services for the first time to your child. There are some exceptions that apply to obtaining your consent for evaluations.

Consent means:

1. You have been fully informed in your native language or other mode of communication (such as sign language, Braille, or oral communication) of all information relevant to the action for which you are givingconsent;

2. You understand and agree in writing to that action, and the consent describes that action and lists the records (if any) that will be released and to whom; AND

3. You understand that the consent is voluntary on your part and you may revoke (withdraw) your consent at anytime.

Your withdrawal of consent, however, does not negate (undo) an action that began after you gave your consent and before you withdrew it. This means that if you provided consent for your child to initially receive special education services and you later revoke your consent allowing the district to provide special education services toyour child, the school district is not required to amend your child’s educational records to remove any reference to your child’s receipt of special education services.

Parental Consent – Requirements 34 CFR §300.300; WAC 392-172A-03000

Parental Consent for Initial Services and Revocation of Consent for Continued Services

Your district must obtain your informed written consent or must make reasonable efforts to obtain your informed written consent before providing special education and related services to your child for the first time.

If you do not respond to a request to provide your consent for your child to receive special education and related services for the first time, or if you refuse to give such consent, your district may not use mediation procedures in order to try to obtain your agreement or use due process hearing procedures in order to obtain a ruling from an administrative law judge to provide special education and related services to your child.

If you refuse or do not respond to a request to give your consent for your child to receive special education and related services for the first time, the school district may not provide your child with the special education and related services. In this situation, your school district:

1. Is not in violation of the requirement to make a free appropriate public education (FAPE) available to yourchild because of the failure to provide those services to your child; AND

2. Is not required to have an IEP meeting or develop an IEP for your child for the special education and related services for which your consent was requested.


Once you provide written consent for your child to receive special education and related services and the district begins to provide special education services, your child will remain eligible to receive special educationservices until:

1. He or she is reevaluated and found to no longer qualify for special education services;

2. He or she graduates with a regular high school diploma;

3. He or she reaches the age of 21 (or if your child turns 21 after August 31, he or she is eligible for services through the end of the school year.); or

4. You provide the district with a written revocation of your consent for the continued provision of specialeducation services.

If you revoke your consent in writing for continued provision of services after the district has initiated special education services, the district must give you prior written notice a reasonable time before it stops providing special education services to your child. The prior written notice will include the date that the district will stop providing services to your child and will inform you that the school district:

1. Is not in violation of the requirement to make a free appropriate public education (FAPE) available to your child because of the failure to provide those services to your child; AND

2. Is not required to have an IEP meeting or develop an IEP for your child for further provision of specialeducation services.

A district may not use due process to override your written revocation or use mediation procedures to obtain your agreement to continue to provide special education services. After the district stops providing special education services to your child, your child is no longer considered to be eligible for special education services.Your child will be subject to the same requirements that apply to all students.

You or others who are familiar with your child, including the school district, may refer the child for an initial evaluation at a future time. The district would then follow the procedures for an initial evaluation.

Parental Consent – Requirements 34 CFR §300.300; WAC 392-172A-03000

...continued

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Districts:

Name:

Title:

Phone #:

Buildings:

Use the “edit” feature of the fields below to input the districts and buildings you work with. These will then show up as adrop-down menu when creating a new student record and will auto-fill the student’s various forms.

Please use the following formats for district and school names and please don’t abbreviate, so there is consistency in entries:

Central Valley School District (not CVSD or CV School Dist)Sunrise Elementary SchoolSunrise Middle SchoolSunrise Junior High SchoolSunrise High SchoolSunrise Jr/Sr High School

Case Manager Contact Information

Districts and Buildings Supported


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Generally, you will fill this out when you firststart using the program and then revisit itwhen there are changes to the Case Managercontact info or districts/buildings served.


CHECKLIST FOR SPECIAL SERVICES FILES

Student Name School District/

Resident Serving

No Yes (1) Pre-referral completed

(2) Referral form completed- Vision/hearing- Interventions

(3) Need for surrogate parent checked

(4) Prior written notice COMPLETED (Referral)

(5) Prior written notice COMPLETED

(6) Parent permission for Initial Evaluation- Protections in testing- Descriptions of test

(7) Individual assessment results- Appropriate to disability- Includes Educational Performance Report by CRT- Administered by trained personnel- Native (Primary) language- Validated for specific purposes

(8) Evaluation Report- Summary of each (specific disability area)- Narrative form- Identified disability condition according to WAC- Recommendations as to:

- educational needs- instruction- instruct placement & services options- behavioral & instruction strategies- consideration of ESY- necessary related services- specially designed instruction

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

3-year Re-evaluationsDone within 3 years...............................Parent consent for re-evaluation...........Test descriptions...................................Safeguards............................................Protections in evaluations.....................

No YesNo Yes

No YesNo YesNo Yes

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1Checklist for Special Services FilesStudent Name CSRS ID# Birth date

No Yes Prior Written Notice

Parent Invitation to IEP- Time, place, date- Copy of procedural safeguards checked and initialed

IEP Current- within 20 days of Evaluation Team Meeting- conducted annual (on or before due date)

Appropriate IEP committee membersGeneral Ed ParentSpecial Ed Evaluation team memberDistrict Rep Student (if appropriate)

IEPDistrict Implementation Signature/DatePresent Level of PerformanceStudent Conduct checkedTransportation checkedExtended Instructional School Year checkedModifications checkedPre-vocational Education checkedTransition Plan on Secondary IEPsPlacement Decision (neighborhood school)Placement Options notedRegular Education Participation time notedSpecial Ed/Related Services Participation time notedProjected Dates for Initiation EducationService Providers statedAnnual Goals-related to education need in S.A.Instructional Objectives

- measurable- criteria stated/easy to locate and use

Parent Provided ITPParent Consent for initial placement

No Yes

No Yes

No Yes

No Yes

No Yes

CHECKLIST FOR SPECIAL SERVICES FILES (continued)

No YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo Yes

No YesNo Yes

Reviewer’s Signature






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2Checklist for Special Services FilesStudent Name CSRS ID# Birth date

Backup Data

File Maintenance ResourcesUse the buttons below to backup your file, export records to import into an updated program and other regular maintenance operations.

This button will create a backup file of your data. The file is called “Current_Backup” and is stored in a folder titled “Backups” in the IEP folder that includes this application.

Because clicking the button will replaceany previously created backup, it’s recommended that once you create a backup, you locate the file in the Backupfolder and rename it with the date (i.e. Backup-9-20-2008).

It’s a good idea to also save this backupfile on another type of media (thumb/flash drive, CD, another computer) in case your hard drive experiences a major crash.

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Restore from Backup

This button will restore your data froma backup file created when you used the Backup Data button.

After clicking the button above, you’ll be asked if you want to delete all current files. You should say YES or you’ll end up adding a duplicate set of files.

Next, you’ll be asked to locate the backup file you want to use for restoring data. Browse to where you have saved the backup files (the default is the Current_Backup file in the Backups folder located in this application’s folder).

DON”T use this button for importing data from a previous version of the program, since you’ll need to check tosee that all fields match prior to importing.

Find Student

Export Student Data

Click the “Continue” button then the “Find” button in the left-hand column. Double-check the student’s name as displayed below.

First Name Last Name

Enter the student’s first and/or last name below.

Click the “Find Student” button below to activate the First and Last Name fields for entry.

Click the “Export Student Data” button below to create a file entitled “Individual_Student_Data” located in the “Student Export” folder within the IEP program folder.

Export Individual Student’s Data

Then go to the Student Export folder and rename the file(i.e. Smith_Jane_9-21-2008.fp7)

You may be asked to confirm that all the field names matchand if they don’t, use the Arrange By: pop-up menu to select

Field Names. In the next window, be sure that the radio buttonfor keeping repeating fields in the same record is checked.

Educational Service District 101 , Special Services Program - IEP State Forms Program [ Rev 2.27.2009 ]

01 Special Education Referral Review

05aii SLD Supplement RTI

05b Reevaluation Waiver

06b Parent Input Form

06d IEP Form (with Transition)

06ci/di IEP Goals Form

06e Aversive Intervention Plan

06f Extended School Year Addendum

06c IEP Form (no Transition)

05c Evaluation Extension

05ai SLD Supplement Discrepancy

03 Parent Consent

02 Prior Written Notice

04 Meeting Invitation

05a Evaluation Report

06a IEP Team Member Excusal

06g IEP Amendment

07b Behavioral Intervention Plan

07a Functional Behavioral Assessment

07c Manifestation Determination

Current student record

Create new record & go to Student Input form

Student Roster

Washington State Forms

08c Private School Services

08b Private School Affirmation

08a Private School Consultation

09 Summary of Performance

12a Medicaid Eligibility Verification

13 Parent Consent for Insurance

14 File Access Log

15 Release of Records

12b Medicaid Consent for Billing

10 Due Process Hearing Request

11 Resolution AgreementWACs & Forms Alignment

Enter or view student information hereStudent Info Form

Enter Case Manager information hereCase Manager Info Entry Form

05a Indiv Doc of Assessment Results

Additional General Assistance Forms

Create new student record

Special Services Forms ListAccess any of the forms by clicking the colored box next to the form’s title.

View all students in a list

File maintenance resourcesBackup data, restore data and exportindividual student information

Navigation & Entry InstructionsUsing Filemaker navigation buttons andthe EDIT feature available in many text fields

03a Revocation of Consent (RoC)

03b Prior Written Notice - RoC

Intervention Form: General Ed Teacher

Student Study Team

Addendum Forms

Teacher Evaluation / Observation

February 2009Addendum - Procedural Safeguards

Documentation of IEP Invitation

Background Questionnaire

Termination of Special Services

Background Questionnaire Update

Student Progress Report

End of Year Summary

Proposed Areas of Evaluation

Transfer Student Evaluation

Checklist for Special Ed Files

Vision and Hearing Screening Form

Educational Service District 101 , Special Services Program - IEP State Forms Program [ Rev 3.19.2009 ]

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Print this form

Buttons to the upper left of the forms:

ENTER or edit information

FIND or search for records PREVIEW form layout

Not active (design only)

To use the EDIT feature of text fields:

You can enter common phrases, names, locations, etc., to create a list of choices in a drop-down list for ease in entering commonly repeating data.

1. Click on the text field and a drop-down list area will appearwith the word EDIT in it. It will be the only option there the first time you use it.2. Click on EDIT and a pop-up window will appear.3. Type your text in this box. Press the enter key to separatelist items.4. In additional student records, clicking on the text field will display your list plus the EDIT option.5. Click on the phrase or name from the list to enter it into thetext field. You can now click at the end of the text in the fieldand continue to enter information specific to that student.

NOTE: You cannot select multiple entries. One will overwritethe previous one. If you have several key phrases, include them as one list entry and once they are in the text field entera line return at the end of each and continue with your specific entries.

Moving around forms and student files

If you use a mouse with a scroll wheel, be careful using thewheel to move through a single student’s form.

Rolling the wheel when in a form will move through various student files. If you watch the name in the yellow box on each form while you move the wheel, you’ll see the names change.

Use the window’s scroll bars to move up or down in a form.

Working in one specific student file

If you want to make sure you’re working in the right student file, FIND that student’s file first.

1. Go to the Forms List page first.2. Under the VIEW menu, select FIND MODE.3. In the Current Student Record box in the upper right, typethe name (first, middle and/or last) of the student you want tolocate.4. Click the FIND button in the left-hand navigation section ofthe Filemaker window.5. In that same navigation pane, make sure that it found onlyone record. If it indicates more than one record found, scroll through the records by clicking the left or right arrow on the book-like icon to locate the correct student file.

In order to make sure you only have one record showing forediting, you may want to conduct a new search and use the student’s full name in the search field.

MOVING DATA FROM AN OLD FILE TO NEW, UPDATED ONEUse this only if there is a program update provided.

1. Download the new program file following the instructions providedand make sure you know where it has been saved. We'll use this file a little later.2. Open the old/original IEP_State_Forms file first.3. Follow the above instructions for backing up a file, but give it a different name (such as Export_Month-Day-Year)4. Open the new, updated program file downloaded in step 1.

Now, import your previous export file info into the new file...

1. Under the FILE menu, select "Import Records" and then choose "File..."2. You'll now be able to locate the file you saved and select it. Be sure the Files of Type near the bottom of the window says "FileMaker Runtime File (*.USR;*.fp7)" BEFORE you click on your file name.3. You'll see two lists of field names. These need to match on both sides. If they don't, select "Field Names" or “Matching Names” from the drop down list next to "Arrange by." They should now match. Quickly scroll down the list to make sure they do.4. Under the "Import Action" check to make sure "Add Records" is checked and that the "Import values in repeating fields by KEEPINGTHEM IN THE ORIGINAL RECORD" is checked.5. Click the "Import" button. Once it's done, you'll see a summary window with number of records added/updated and any errors.6. Click the OK button and your data should all be in the new file.

BACKING UP YOUR DATA FILE

This operation has been automated using a button on the FileMaintenance page. If you need to manually export files, followthese directions.

1. Under the FILE menu, select "Export Records"2. You'll be asked where to save it and what you want to call it. Choose a location and give it a name (IEP_Backup_Mo-Day-Yr for example).3. Select the "Filemaker Pro Runtime (*.USR)" option from thedrop down menu near the bottom of the window.4. Click SAVE to move to the next window.5. In the upper left drop down menu, select "Current Table ("Student Info")"6. From the middle of the two columns, click the "Clear All" button first, the click the "Move All" button.7. Click the "Export" button.

It’s a good idea to also move the saved file to your portable thumb/flash drive as well as keeping it on your computer’s hard drive, or move it to another location in case your computer hard drive crashes and can’t be recovered.


Name:

CSRS ID#:

District ID#:

Birth date: Age:

Grade:

GenderMale Female

Ethnicity:Student’s Primary

Adult Student: No Yes

At Home

Student Information:

Parent / Guardian Information

School Information

Address:

City: State: ZIP:

Phone:Work / Cell

Email:

Interpreter needed? No Yes

Language:

1

2

Relationship:

First

Resident District:

Serving District:

Serving Building:

Resident Building:

Middle Last

Name:

First Last

Home

Address:

City: State: ZIP: Phone:

Home

Address:

City: State: ZIP:

Phone:Work / Cell

Email:

Interpreter needed? No Yes

Relationship:Name:First Last

Home

Internal reference only, not used in forms

Active Inactive

No YesIs surrogate needed?

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Does the student have a disability? No Yes If YES, disability category:

Student information entered here will automatically populate appropriate areas on the forms and cannot be changed on the forms themselves. If you find an error or need to adjust student information, return tothis entry form to do it.

Form 00 - Student InformationStudent Name CSRS ID# Birth date

Last Name First Name Birthdate Age District 1 Yr Review 3 Yr Eval

Student Roster as of


Forms List

NAVIGATION NOTE:You can select a student by clicking on the name. A blackbar will appear next to the name to show which student isselected.Then click on the Forms List button to select a form for thatstudent.

Case Manager1

1 Special Education Referral Review .................................... 392-172A-03005

2 Prior Written Notice..............................................................392-172A-03000 and -03005, 392-172A-03020, 392-172A-05010

3 Parent Consent.................................................................... 392-172A-03000

4 Meeting Invitation ................................................................392-172A-03095(2)(c), 392-172A-03100, 392-172A-05000

5a Evaluation Report................................................................ 392-172A-03015 through -03040

5ai Supplementary report for SLD (severe discrepancy)...........392-172A-03045 through -03055, 392-172A-03065 through -03080

5aii Supplementary report for SLD (response to intervention).. 392-172A-03045 through -03060, 392-172A-03075 and -03080

5b Reevaluation Waiver............................................................392-172A-03015(2)(b)

5c Agreement to Extend Evaluation Timeline ..........................392-172A-03005(3), 392-172A-03015(3)

6a IEP Team Member Excusal................................................. 392-172A-03095(5)

6b Parent Input Form................................................................ 392-172A-03110(1)(a) and (b)

6c/d IEP Form..............................................................................392-172A-03090 and -03095, 392-172A-03110, 392-172A-05135

6ci/di IEP Goal Forms...................................................................392-172A-03090 and -03095, 392-172A-03110, 392-172A-05135

6e Aversive Intervention Plan................................................... 392-172A-03135

6f Extended School Year.........................................................392-172A-02020, 392-172A-03090(1)(g)

6g IEP Amendment...................................................................392-172A-03110(2)(c) and (d)

7a Functional Behavioral Assessment......................................392-172A-05145(6)(a)

7b Behavioral Intervention Plan................................................ 392-172A-03110, 392-172A-05145(6)

7c Manifestation Determination................................................ 392-172A-05145

8a Private School Consultation.................................................392-172A-04020

8b Private School Affirmation....................................................392-172A-04025

8c Private School Services Plan.............................................. 392-172A-04040

9 Summary of Performance.................................................... 392-172A-03030(3)

10 Request for Due Process.....................................................392-172A-05080 and -05085

11 Resolution Agreement......................................................... 392-172A-05070

12a Medicaid – Eligibility Verification..........................................392-172A-07005

12b Medicaid – Consent for Billing............................................. 392-172A-07005(2)(d)

13 Permission to Bill Public/Private Insurance..........................392-172A-07005(3)

14 File Access Log....................................................................392-172A-05195

15 Release of Records ............................................................ 392-172A-05225


Form Form Name WACs Addressed

MODEL STATE FORM ALIGNMENT TO WACsAs of August 2008

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Download a PDF ofWAC 392-172a

If your computer is connected to the Internet, clicking the button below will openor download the WAC PDF file located on OSPI’s Web site.

http://www.k12.wa.us/SpecialEd/pubdocs/wac/WAC_392_172a.pdf

WAC Form Name Form

392-172A-02020 Extended School Year............................................................. 6f

392-172A-03000 Prior Written Notice..................................................................2Parent Consent........................................................................ 3

392-172A-03005 Special Education Referral Review ........................................ 1Prior Written Notice..................................................................2Agreement to Extend Evaluation Timeline ..............................5c

392-172A-03015 Evaluation Report.................................................................... 5aReevaluation Waiver................................................................5bAgreement to Extend Evaluation Timeline ..............................5c

392-172A-03020 Prior Written Notice..................................................................2Evaluation Report.................................................................... 5a

392-172A-03025 Evaluation Report.................................................................... 5a

392-172A-03030 Evaluation Report.................................................................... 5aSummary of Performance........................................................ 9



392-172A-03045 Supplementary report for SLD (severe discrepancy)...............5aiSupplementary report for SLD (response to intervention)....... 5aii



392-172A-03060 Supplementary report for SLD (response to intervention)....... 5aii

392-172A-03065 Supplementary report for SLD (severe discrepancy)...............5ai

392-172A-03070 Supplementary report for SLD (severe discrepancy)...............5ai



392-172A-03090 IEP Form..................................................................................6c/dExtended School Year............................................................. 6f

392-172A-03095 Meeting Invitation ....................................................................4IEP Team Member Excusal..................................................... 6aIEP Form..................................................................................6c/d

392-172A-03100 Meeting Invitation ....................................................................4IEP Form..................................................................................6c/d

392-172A-03110 Parent Input Form.................................................................... 6bIEP Form..................................................................................6c/dIEP Amendment.......................................................................6gBehavioral Intervention Plan.................................................... 7b

392-172A-03135 Aversive Intervention Plan....................................................... 6e

392-172A-04020 Private School Consultation.....................................................8a

392-172A-04025 Private School Affirmation........................................................8b

392-172A-04040 Private School Services Plan...................................................8c

392-172A-05000 Meeting Invitation ....................................................................4

392-172A-05010 Prior Written Notice..................................................................2

392-172A-05070 Resolution Agreement............................................................. 11

392-172A-05080 Request for Due Process.........................................................10

392-172A-05085 Request for Due Process.........................................................10

392-172A-05135 IEP Form..................................................................................6c/d

392-172A-05145 Behavioral Intervention Plan.................................................... 7bFunctional Behavioral Assessment..........................................7aManifestation Determination.................................................... 7c

392-172A-05195 File Access Log........................................................................14

392-172A-05225 Release of Records ................................................................ 15

392-172A-07005 Medicaid – Eligibility Verification..............................................12aMedicaid – Consent for Billing................................................. 12bPermission to Bill Public/Private Insurance..............................13

WAC Form Name Form(continued)

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Student Name Birth date

Grade

CSRS ID Age

School

Gender Race / Ethnicity

Home LanguageParent/Guardian Name(s) E-mail address

Address City

Home WorkIs surrogate needed? No Yes If YES, follow procedures for appointing a surrogate.

Person who made referral Position/Role

Reason for Referral (check all that apply)

Instructional Concerns Behavioral ConcernsPre-literacy skills

Basic reading skills

Pre-numeracy skills

Basic math skills

Written language skills

Cognitive learning strategies

Communications skills

Other:

Other:

Other:

No instructional concerns noted

Attention and concentration

Non-compliance with teacher directives

Following directions

Easily frustrated

Extreme mood swings

Social/peer interaction skills

Adaptive behavior skills

Other:

Other:

Other:

No behavioral concerns

Review of Medical Information/Records

Describe any medical concerns currently impacting the student. Consider whether the student has any medical diagnoses, if the student iscurrently taking any medication at school and/or at home, is the student currently using anyassistive technology devices, does the studentwear glasses, does the student wear a hearing aid,etc.

/District Building

State ZIP

Phone Numbers

REVIEW OF REFERRAL FOR SPECIAL EDUCATION EVALUATION

PURPOSE: The purpose of this form is to review information regarding a student who has already been referred and to make a decision whether to evaluate the student for special education services.


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&

Set Parent Name and Contact Info to:Parent 1

Parent 2

Both Parents w/student address

’s Address

’s Address

Choose address and contact info(if different than student)

Parent 1 Parent 2 Both Parents

Form was provided to:

Remove Address & Contacts

1Form 1 - Review of ReferralStudent Name CSRS ID# Birth date

Pre-referral Interventions (also see attached evidence)

Educational History

Other Relevant Information

Referral Team Recommendations

Additonal Referral Team Recommendations

Referral Team Members (including parent(s))

Describe any current or past supplemental programs/ services orinterventions provided to the child, such as Title 1, early intervention services, preschool, individualized interventions, etc. Describe any scientific research-based interventions implemented and the results.

** Procedural Safeguards notice must be provided to parent upon initial referral. **

Describe the student’s educational history, including appropriate instruction in reading and math and the student’s response, school attendance/ absences, whether the student has ever repeated a grade, the student’s English proficiency leveland how it was determined, current performance levels in academic and/or functional areas (primarily those areas of concern), any home/ environmental factors that might affect the student’s performance in school, whether the student has beenpreviously referred for special education services, etc.

Describe any other relevant information from the parent, school,other agencies, etc.

Special education evaluation recommended (parent receives Prior Written Notice and Consent for Evaluation).

Special education evaluation not recommended at this time (parent receives Prior Written Notice).

Title Name Date

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2Form 1 - Review of ReferralStudent Name CSRS ID# Birth date

We are:

to:

PRIOR WRITTEN NOTICE

PURPOSE: As a parent/guardian of a special education child or child suspected of needing special education services, the school district is required to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification, evaluation, educational placement, or provision of a free appropriate public education to your child. This notice should be given to you after a district makes a decision and before action is taken on the decision. The notice should be given to you in a reasonable amount of time before the district takes action.


Date:To:

Re: &

Set “To” field name to:Parent 1

Parent 2

Both Parents

StudentThe purpose of this prior written notice is to inform you that we are to a/an:

referralinitial evaluationeligibility categoryIEPeducational placementre-evaluationdisciplinary action that is a change of placement

Other (specify)Mark all items that apply.

Description of the proposed or refused action

The reason we are proposing or refusing to take action is:

Description of any other options considered and rejected

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proposing refusing

You must select appropriate actions below to be inserted in the body of theform.

initiate change

1Form 2 - Prior Written NoticeStudent Name CSRS ID# Birth date

The reason(s) we rejected those options

A description of each evaluation procedure, test, record or report we used or plan to use as the basis for taking this action

Any other factors that are relevant to the action

The action will be initiated on

Your child has procedural protections under IDEA. These protections are explained in the Notice of Procedural Safeguards for Special Education Students and Their Families. If this prior written notice is given to you (1) as part of your child’s initial referral for evaluation, (2) as part of a request for a reevaluation, or (3) as notice regarding disciplinary action that constitutes a change of placement, the procedural safeguards accompanies this notice. If a copy of the Notice of Procedural Safeguards for Special Education Students and Their Families is not enclosed and you would like a copy, or you would like help in understanding the content, please contact

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Input Contact info below to beprinted on form:

Contact Name

Contact Phone

2Form 2 - Prior Written NoticeStudent Name CSRS ID# Birth date


PARENT CONSENT

PURPOSE: A school district must inform parents/guardians of all information relevant to the district making a decision regarding the initial evaluation, initial placement, or reevaluation of a student. This form asks for your consent to the action indicated. It would be helpful to school personnel if you would share your reason(s) for not giving your consent for the proposed action. If you have questions regarding this request, you may call the school district director of special education for an explanation as to why the request is being made.

Date:To:

Initial evaluation of your child.Initial provision of special education and related services.

Reevaluation of your child (using additional assessments).Other:

We are requesting your consent for the action checked below regarding .The attached written notice explains the action to be taken.

We ask consent to take the following action:

By giving consent, you are acknowledging that (1) you have been fully informed of all information relevant to theactivity for which consent is sought; (2) you understand that the granting of consent is voluntary on your part and may be revoked at any time; (3) if you revoke consent, the revocation is not retroactive, which means that itdoes not negate any activity that has already taken place; and (4) if you refuse to give consent, the district may request mediation or a due process hearing to override your failure to give consent for evaluations or reevaluations. The district does not need your consent for a reevaluation if the district has made reasonable efforts to obtain your consent for tests administered for the reevaluation and you have failed to respond to theserequests.

The district may not ask an Administrative Law Judge to override your denial of consent if this is for the initial provision of special education and related services. However, if you do not provide consent for the initial provision of special education and related services, the district will not be considered to be in violation of the requirement to make a free, appropriate, public education (FAPE) available to your child.

I give my consent.

I do not give my consent. Reason (optional):

Parent / guardian / adult student signature Date

** PRIOR WRITTEN NOTICE MUST ACCOMPANY THIS FORM. ** Go to Forms List

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Parent 2

Both Parents

Student

Form 3 - Parent ConsentStudent Name CSRS ID# Birth date


REVOCATION (WITHDRAWAL) OF CONSENT FOR SERVICES

PURPOSE: A parent/guardian or adult student may revoke (withdraw) consent, in writing, for the continued provision of special education and relatedservices (parents are not required to use a specific form for their revocation). If a parent revokes consent in writing, the district must honor the revocation and provide the parent with prior written notice identifying the date the district will stop providing services. The district may not use due process or mediation procedures to challenge the parent’s revocation. Beginning the effective date indicated in the prior written notice, the district mayno longer provide special education and related services to the child. The district is not required to amend the child’s education records to remove references to the child’s receipt of special education and related services. Once the revocation is effective, the student is no longer entitled to receivespecial education or related services, and the district will not be considered in violation of the requirement to make FAPE (a free, appropriate public education) available to your child.

By signing below, you are acknowledging that:

1. the district will stop providing special education and related services to your child beginning the dateidentified in the prior written notice given to you by the district;

2. the district cannot use dispute resolution options to challenge your right to terminate special education services for your child;

3. the district will no longer be required to conduct reevaluations, convene an IEP team meeting, or develop an IEP for your child;

4. the district will not be considered in violation of the requirement to make FAPE (a free, appropriate public education) available to your child;

5. the district is not required to amend your child’s education records to remove references to your child’s receipt of special education and related services; and

6. your child will be subject to all of the same requirements that apply to general education students, such as academics, statewide and districtwide assessments, extracurricular activities, graduation requirements, discipline, and all other general education requirements.

I revoke my consent for special education and related services to be provided to my child.

Date:

To: RE:


** PARENTS MUST BE GIVEN PRIOR WRITTEN NOTICE AFTER THEY REVOKE CONSENT. ** Go to Forms List

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Parent / guardian / adult student Student’s name &


Parent 2

Both Parents

Student

1Form 3a - Revocation of ConsentStudent Name CSRS ID# Birth date


PRIOR WRITTEN NOTICE - REVOCATION OF CONSENT

PURPOSE: If a parent/guardian or adult student revokes consent, in writing, for the continued provision of special education and related services, thedistrict must honor the revocation and provide the parent with prior written notice identifying the date the district will stop providing services. The district may not use due process or mediation procedures to challenge the parent’s revocation. Beginning the effective date indicated in the prior written notice, the district may no longer provide special education and related services to the child. The district is not required to amend the child’s education records to remove references to the child’s receipt of special education and related services. Once the revocation is effective, the student isno longer entitled to receive special education or related services, and the district will not be considered in violation of the requirement to make FAPE (a free, appropriate public education) available to your child.

The purpose of this prior written notice is to inform you that, while the district believes that your childcontinues to be in need of services, the district will stop providing special education and related services to your child, based on your written revocation of consent.

Date:

To: RE:

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Parent / guardian / adult student Student’s name &


Parent 2

Both Parents

StudentBirth date :

Service to your child will be discontinued on:

When you revoke (withdraw) consent for the continued provision of special education services for your child, the district may not challenge your decision using any formal dispute resolution options. The district must honor your revocation within a reasonable time after you have provided the district with the written revocation.

Once your revocation is effective, your child will no longer be considered a child with a disability for educationalpurposes. This means that your child will no longer be eligible to receive a free appropriate public education (FAPE) as defined under IDEA, and will no longer be entitled to protections he or she received when identifiedas a child eligible for special education. The district will not be required to conduct reevaluations, convene an IEP team meeting, or develop an IEP for your child.

Your child will be subject to all of the same requirements that apply to general education students, such as academics, statewide and districtwide assessments, extracurricular activities, graduation requirements, discipline, and all other general education requirements.

Revocation of consent is not retroactive. Your child’s records will not be amended to remove references to thereceipt of special education and related services prior to your revocation of consent.

If, after the revocation is effective, you change your mind and wish for your child to again receive special education services, you may refer your child for an initial evaluation and the district will follow procedures, including all associated timelines, for an initial special education eligibility request.

1Form 3b - Revocation of Consent Prior Written Notice Student Name CSRS ID# Birth date

is is not

Other considerations or additional information:

A copy of the Notice of Procedural Safeguards for Special Education Students and Their Families

enclosed with this notice.

Until the date the district discontinues services (as specified on this notice), your child has procedural protections under IDEA. These protections are explained in the Notice of Procedural Safeguards for SpecialEducation Students and Their Families. If a copy of the Notice of Procedural Safeguards for Special Education Students and Their Families is not enclosed and you would like a copy, or you would like help in understanding the content, please contact at .

Contact:

Enter contact information below to be inserted in the body ofthe form.

Phone:

Safeguard enclosed?

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29:45 PMForm 3b - Revocation of Consent Prior Written Notice Student Name CSRS ID# Birth date

INVITATION TO ATTEND A MEETING

PURPOSE: This invitation requests your attendance at a meeting concerning the educational program/needs of your child. You have the opportunity toparticipate in any meeting regarding the identification, evaluation, educational placement, and the provision of a free appropriate public education for your child.


Date:To:

You are invited to attend a meeting concerning .

Purpose of Meeting (check all that apply)

IEP Development/ReviewIEP AmendmentSecondary Transition Planning

Manifestation DeterminationDiscuss Special Education ReferralDiscuss Evaluation/Reevaluation Results

Consider Extended School Year (ESY) ServicesOther:

No Yes

The meeting has been scheduled for:Location:

at

Meetings addressing IEPs and placement are scheduled at a mutually agreed upon place and time by you and the school district. If you are unable to attend this meeting you may request participation through other means. If you are unable to attend this meeting, please contact

, at .

You and the district may invite individuals to participate in the IEP team meeting who have knowledge or special expertise about your student’s educational needs. You may also request, by contacting the individual named above, that a birth to three service coordinator be invited to participate in an initial IEP meeting if your child was previously served through an Individualized Family Service Plan (IFSP). If the district intends to invite representatives of any agency that is likely to be responsible for providing or paying for secondary transition services to the IEP meeting, your consent is required (see page two of this invitation if transition agency representatives are being invited).

Below is a list of the names and roles of those individuals the district will be inviting to attend the meeting (representatives from secondary transition agencies are marked with a “*” below):

We have attached a copy of the Notice of Procedural Safeguards.

For District use - if contact is made by phone:Date Initials Date Initials Date Initials

Parents:

Set “To” field to:

Parent 1 & Student

Parent 2 & Student

Both Parents & Student

Include student if appropriate or if transition planning will be discussed.

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Input Contact info below to be printed on form:

Contact Name

Contact Title

Contact Phone

1Form 4 - Meeting InvitationStudent Name CSRS ID# Birth date

PARENT CONSENT TO INVITE TRANSITION AGENCY PERSONNEL

If the district intends to invite representatives of any agency that is likely to be responsible for providing or paying for secondary transition services to the IEP meeting, your consent is required.

I give my consent for the secondary transition agency representative(s) marked with an “*” on the invitation to be invited to the IEP meeting.

I give my consent for the secondary transition agency representatives marked with an “*” on the invitation to beinvited to the IEP meeting, except for the following representative(s):

Reason (optional):

I do not give consent for the secondary transition agency representative(s) marked with an “*” on the invitation to be invited to the IEP meeting.

Reason (optional):


** PLEASE SIGN AND RETURN THIS PAGE TO YOUR CHILD’S SCHOOL. **

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2Form 4 - Meeting InvitationStudent Name CSRS ID# Birth date


Grade

CSRS ID Age

School


Home Language

Parent/Guardian Name Is surrogate needed? No Yes

/District Building

EVALUATION REPORT

PURPOSE: The evaluation report documents whether the student is eligible or continues to be eligible for special education and provides information tothe IEP team to assist them in the development of the IEP. The evaluation process should be sufficient in scope to determine: (1) whether a student hasa disability, (2) whether the disability adversely affects his/her performance in the general education curriculum, and (3) the nature and extent of the student’s need for specially designed instruction and any necessary related services. If the evaluation group believes the student may have a specific learning disability, the Supplementary Report for SLD should be completed and attached.


Primary Language

Is interpreter needed? No Yes

Parent/Guardian Name Is interpreter needed? No Yes If YES, name:

Adult Student? No Yes

Eligibility determination date 3 year reevaluation due date Primary Staff Contact Title

Background Information

Relevant medical/developmental historySensory lossTeacher recommendationsAcademic/preacademic history

Current placement in general educationInstructional HistoryGrade retentionAny previous interventions implemented and their results

Parent concernsAdditonal information provided by parentsOther factors (identify below)

Reason(s) for referral or presenting concerns (mark all that apply and then provide details below).

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1Form 5a - Evaluation ReportStudent Name CSRS ID# Birth date

Evaluation Procedures and Results

Record findings from the review of existing data and any additional assessments conducted, including the date and source (specific tool, instrument, ordata collection method used) of these data. Individual group members may choose to use the Individual Documentation of Assessment Results form or members may wish to incorporate individual assessment results into this report).

Area(s) Current Levels of Performance (based on existing data and/or additional assessments)


Academic Assessment and Analysis

A comparison of the student’s standard scores on the achievement test and the intellectual ability measure is made to determine if a student is acquiring academic knowledge up to his or her ability expectations. The formula is based on the student’s chronological age and intellectual ability score, or Intelligence Quotient (IQ).

According to Washington Administrative Code, a regression table is used to obtain a standard score that is compared to the student’s achievement scores. If an achievement score is at or below this “Criterion Score,” there is a severe discrepancy between intellectual ability and achievement, whichmay indicate a possible learning disability.

Intellectual tests administered

Achievement tests administered

Basic Reading Skills

Reading Comprehension

Math Calculation

Math Reasoning &Application Problems

Written Expression &Broad Written Language

Clusters Age Score Attained SS Criterion SS Severe Discrepancy?

Woodcock Johnson - IIIWoodcock Johnson - Revised

Other (describe):

Test Date

WISC-IV Full Scale IQ Score

WISC-III Full Scale IQ Score

WJ_R or WJ-III Broad Cognitive Ability

SB5 Full Scale IQ Score

SBFE Test Composite Score

C-TONI Quotient

OTHER INTELLECTUAL TESTS/NOTES:

ADDITIONAL NOTES:

Test Date

Test Administered


Eligibility Determination

Does the student have a disability? No Yes

No Yes

No Yes

No Yes

Evaluation SummaryAn analysis of the educational relevance of the evaluation results, including individual assessment results, and a description of the adverse educational impact, including how the disability affects involvement and progress in the general education curriculum (or for preschool children, in appropriate activities)).

The student has received appropriate instruction in reading and math:If NO, the student is not eligible for special education services. If YES, describe the basis for this determination:

Consideration of other factors, including English proficiency, cultural impacts, attendance, etc.NOTE: The student is not eligible for special education services if the determinant factor is limited English proficiency.

The student was assessed in all areas related to the suspected disability, including, if appropriate, health, vision, hearing, social/ emotional status, general intelligence, academic performance, communication, and motor abilities.

If NO, the evaluation is incomplete.

If YES, disability category:

If SLD, complete and attach the SupplementaryReport for SLD.Is the student in need of specially designed instruction?

If NO, recommended interventions for student:

Be sure to include the Specialist’s Individual Reports.

Go to:Individual Documentation

of Assessment ResultsForms


Recommended Specially Designed InstructionRecommendations to the IEP team to assist in the development of the IEP’s present levels of performance and annual goals. Specify the areas in which the student requiresspecially designed instruction (i.e. math, gross motor, social skills, etc.)).

Necessary Related ServicesSpecify the related services needed in order for the student to benefit from special education (i.e. speech therapy, physical therapy, counseling, audiology services, interpreting services, etc.)).

Other Information Needed to Develop the IEPDetermined through the evaluation process and from parental input, including any recommended supplementary aids and services for the student and program modificationsor supports for school personnel, if needed).

Group SignaturesThe date and signature of each member of the evaluation group below certifies that the evaluation report represents his/her conclusions. If the evaluation report does not reflect his/her conclusions, he/she must include a separate statement representing his/her conclusions.).

Signature / Title: Date:










A copy of the evaluation report including documentation of eligibility as was provided to the parent(s) / guardian(s) by:

Name / Title Dateon Go to Forms List

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Individual Documentation of Assessment Results: Specialist’s Report

Description of assessment procedures and instruments used including testing behavior.

Assessment summary including specific data and analysis.

Classroom observations

Specialist’s Report: Examiner:

Evaluation Dates:

Area(s) ofassessment:

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1Form 5a - Specialist’s ReportStudent Name CSRS ID# Birth date

Individual Documentation of Assessment Results (continued)

Educational considerations including recommendations for specially designed instruction, related services, program modifications and/or support for school personnel, as may be needed by the student.

Examiner’s signature / Title DateGo to Forms List

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2Form 5a - Specialist’s ReportStudent Name CSRS ID# Birth date

PURPOSE: The evaluation report documents whether the student is eligible or continues to be eligible for special education and provides information to the IEP team to assist them in the development of the IEP. Additional evaluation procedures are required for identifying whether a student has a specific learning disability. If the evaluation group believes the student may have a specific learning disability using the severe discrepancy methodology, this supplementary report should be completed and attached to the evaluation report.

SUPPLEMENTARY REPORT FOR SPECIFIC LEARNING DISABILITIESUSING SEVERE DISCREPANCY


Grade

CSRS ID Age

School


/District Building Date of Report

Initial EvaluationReevaluation

Achievement and Progress

Describe data that demonstrate the following two areas. This description may also include documentation of a pattern of strengths and weaknesses in performance, achievement, or both, relative to age, Washington’s Grade Level Expectations, or intellectual development.

Lack of Adequate Achievement Describe data that demonstrate that the student does not achieve adequately and does not make sufficient progress for the student’s age or to meet the state’s grade level standards in one or more of the eight qualifying areas).

Appropriate Instruction Describe data that demonstrate that the student’s inadequate achievement is not due to a lack of appropriate instruction inreading and math, including data that demonstrate that the student was provided appropriate instruction in general education settings delivered by qualified personnel and data-based documentation of repeated assessments of achievement at reasonable intervals reflecting formal assessment of thestudent’s progress during instruction).


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1Form 5ai - SLD Supplement (Discrepancy)Student Name CSRS ID# Birth date

No YesNo YesNo YesNo YesNo YesNo YesNo YesNo Yes

Documentation of Severe Discrepancy

Summarize the comparison of the student’s intellectual ability to his/her achievement, as documented on page 2 of the evaluation report, including whether the student met the severe discrepancy in one or more of the eight qualifying areas (oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, math calculation, and/or math problem solving)).

Full scale intellectual ability score:

Criterion discrepancy score: WJ-R or WJ-III Broad Cognitive Ability:WISC-IV Full Scale IQ Score: SB5 Full Scale IQ Score:

Area / Subtest Standard Score Met Criterion?

Achievement test scores:

Professional Judgment

If the evaluation group believes that the evaluation results do not accurately represent the student’s intellectual ability, the group may apply professional judgment. If applying professional judgment, provide an explanation as to why the student has a severe discrepancy, including a description of the basisfor the decision. Include data used to make the determination through the use of professional judgment, including data obtained from formal assessments, review of existing data, assessments of student progress, observation of the student, and information gathered from other evaluation processes. Note: evaluation groups must use professional judgment when documenting a severe discrepancy in the area of reading fluency skills sinceno standardized, norm-referenced measure exists to measure the three components of reading fluency skills - accuracy, rate, and prosody.).

C-TONI Quotient:Other:Other:


No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

Observation

Describe (or attach) the results from an observation of the student during routine classroom instruction, or in a learning environment appropriate for thatstudent. The observation should be conducted in an environment in which the suspected disability would be manifested. Include a description of relevant behavior and the relationship of that behavior to the student’s academic functioning.

Other Considerations

Is the determinant factor for special education eligibility primarily the result of:

A visual, hearing or motor disability?

A health impairment?

A cognitive impairment?

An emotional disturbance?

Limited English proficiency?

If YES, the student cannot have a primaryeligibility of specific learning disability.

If YES, the student is not eligible for special education.

Describe any relevant medical findings that could impact the student’s education.

Describe the effects on performance, if any, from environmental, cultural, or economic disadvantages (if not already addressedin the Evaluation Report).


There is a severe discrepancy between achievement and ability that cannot be corrected without special education and related services. If YES, describe recommendations for special education and related services in the Evaluation Report.

The determination of eligibility has been made in accordance with WAC 392-172A-03040. Go to Forms List

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SUPPLEMENTARY REPORT FOR SPECIFIC LEARNING DISABILITIESUSING RESPONSE TO INTERVENTION

PURPOSE: The evaluation report documents whether the student is eligible or continues to be eligible for special education and provides information tothe IEP team to assist them in the development of the IEP. Additional evaluation procedures are required for identifying whether a student has a specific learning disability. If the evaluation group believes the student may have a specific learning disability using the response to intervention methodology, this supplementary report should be completed and attached to the evaluation report.



Grade

CSRS ID Age

School


/District Building Date of Report

Initial EvaluationReevaluation

Achievement and Progress

Describe data that demonstrate the following two areas. This description may also include documentation of a pattern of strengths and weaknesses in performance, achievement, or both, relative to age, Washington’s Grade Level Expectations, or intellectual development.

Lack of Adequate Achievement Describe data that demonstrate that the student does not achieve adequately and does not make sufficient progress for the student’s age or to meet the state’s grade level standards in one or more of the eight qualifying areas.

Appropriate Instruction Describe data that demonstrate that the student’s inadequate achievement is not due to a lack of appropriate instruction inreading and math, including data that demonstrate that the student was provided appropriate instruction in general education settings delivered by qualified personnel and data-based documentation of repeated assessments of achievement at reasonable intervals reflecting formal assessment of thestudent’s progress during instruction.

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1Form 5aii - SLD Supplementary (RTI)Student Name CSRS ID# Birth date

Describe two or more Tier 3 Scientific, Research-based Intervention(s) Used

Describe, or attach a description of two or more Tier 3 interventions that are matched to the student’s need, including the intensity (i.e., time per session), frequency (i.e., number of sessions per week), and duration (i.e., length of interventions, at least 8-12 weeks).

Progress Monitoring

Description of instructional strategies used and the student-centered data collected in accordance with the district’s response to intervention procedures across all tiers.

Deficit Area Intervention (matched to need) Intensity Frequency Duration

Description of Instructional Strategies

Resistance to Interventions

Describe, or attach, the results from progress monitoring, including comparisons of rate of improvement (ROI); graphs with aimlines, trendlines, intervention lines; and decision rules (if applicable).

Assessment Tool / Measure / Skill Date AdministeredNorm / Peer

Performance ROIStudent’s

Performance ROIDiscrepancy

from Peers’ ROI

Describe, with evidence, the student’s significant resistance to the scientific, research-based interventions listed above.

Parent Notification

The student’s parents were notified about (attach documentation as appropriate):State and school district policies regarding the amount and nature of studentperformance data that would be collected and the general education servicesthat would be provided.

Strategies for increasing the student’s rate of learning (attach as appropriate).

Their right to request an evaluation (attach as appropriate).

No Yes

No Yes

No Yes

Please explain:


No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

Observation

Describe (or attach) the results from an observation of the student during routine classroom instruction, or in a learning environment appropriate for thatstudent. The observation should be conducted in an environment in which the suspected disability would be manifested. Include a description of relevant behavior and the relationship of that behavior to the student’s academic functioning.


Is the determinant factor for special education eligibility primarily the result of:

A visual, hearing or motor disability?

A health impairment?

A cognitive impairment?

An emotional disturbance?

Limited English proficiency?

If YES, the student cannot have a primaryeligibility of specific learning disability.

If YES, the student is not eligible for special education.

Describe any relevant medical findings that could impact the student’s education.

Describe the effects on performance, if any, from environmental, cultural, or economic disadvantages (if not already addressedin the Evaluation Report).


There is a severe discrepancy between achievement and ability that cannot be corrected without special education and related services. If YES, describe recommendations for special education and related services in the Evaluation Report.

The determination of eligibility has been made in accordance with WAC 392-172A-03040.Go to Forms List

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PURPOSE: A school district must ensure that a reevaluation of each student eligible for special education is conducted at least once every three yearsor when the school district determines that the educational or related services needs of the student warrant a reevaluation, unless the parent and the school district agree that a reevaluation is unnecessary. Parents have the right to request that a reevaluation is conducted. This sample form documents the decision made by the parent and district that a triennial reevaluation is not necessary.


AGREEMENT TO WAIVE A REEVALUATION

Date:

To: RE:

A reevaluation of your student is due on:

We believe that a reevaluation to determine whether your child continues to be a child with a disability in need of special education and related services, and to address the current educational needs of your child, is not necessary atthis time. This decision was made for the following reason(s):

If you agree, the date of your signature below will be considered the date from which the next three-year reevaluation willbe due. You may always request that a reevaluation is conducted sooner than the next three-year reevaluation date. Please sign, date, and return a copy of this form to the school district.

I agree that a reevaluation is unnecessary at this time.

I do not agree. Reason (optional):


School district representative signature Date

Remember to print 2 copies

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Parent 2

Both Parents

Student

Form5b - Reevaluation WaiverStudent Name CSRS ID# Birth date

PURPOSE: A school district must fully evaluate a student and arrive at a decision regarding the student’s eligibility for special education within 35 school days of receiving written parent consent, unless the parent and the district agree to extend the 35-day timeline. If the district and parent agreeto extend the timeline, the extension must be documented by the school district, including the reason(s) for extending the timeline.


AGREEMENT TO EXTEND EVALUATION TIMELINE

Date:

To:

RE:

Due to the reason(s) specified below, your child’s evaluation for special education services will not be completed within the 35 school day timeline.

Both Parents

Reason(s):

We plan to complete this evaluation by:

The 35 school day timeline may be extended if the district and parent agree to the extension. Please sign, date, and return a copy of this form to the school district.

I agree to the extension and the proposed completion date indicated above.

I do not agree to the extension. Reason (optional):




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Parent 2

Both Parents

Student

Form 5c - Evaluation ExtensionStudent Name CSRS ID# Birth date

PURPOSE: A school district member of the IEP team may be excused from attending the IEP meeting if the parent(s) and the district agree in writing that the member’s attendance is not necessary because his/her area of curriculum/services is not being modified or discussed in the meeting. A member whose area of the curriculum/services will be modified or discussed may be excused from the IEP meeting if the district and parent(s) consent, and the member provides written input into the development of the IEP prior to the meeting.


REQUEST TO EXCUSE AN IEP TEAM MEMBER

Date:

To: RE:

, a required member of your child’s IEP team has asked to be excused, in whole or part, from the IEP meeting scheduled for .

A required team member may be excused from attending an IEP meeting with the agreement/consent of the parent(s)and the district. Excusing the attendance of a teacher or related service provider at an IEP meeting is optional.

We agree to excuse the attendance of this team member at the IEP meeting specified above because this member’s area of the curriculum or related services is not being modified or discussed at this IEP meeting.

We consent to excuse the attendance of this team member at the IEP meeting specified above because,although the IEP meeting involves a modification to or discussion of this staff member’s area of the curriculum or related services, he/she will submit in writing, to the parent and IEP team, input into the development of the IEP prior to the meeting.

Your agreement or consent to excuse the above identified IEP team participant from attending the meeting must be inwriting. Please sign, date, and return one copy of this form to the school district.



I do not agree to the excusal. Please contact me to reschedule the meeting when required members are able to attend.



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Student

Put the team member’s name below to be printed on form:

Form 6a - IEP Team Member ExcusalStudent Name CSRS ID# Birth date

PURPOSE: The purpose of this form is to gather parent input prior to an IEP meeting, which will assist the IEP team in developing the IEP. This formcan also be used to gather parent input for other purposes, such as during the referral and evaluation process, preparation for other meetings with the parent, etc.


PARENT INPUT FORM

Date:

To: RE:

The IEP team, which includes you, will be meeting soon to discuss your child’s IEP. The information you provide can help our team develop the most appropriate IEP for your child. Your input is extremely valuable. Please take a few moments tocomplete the following questions, and return this form to your child’s school by: .

&

What are the strengths of your child?

What motivates your child?

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Print this form for parents/guardians


Parent 2

Both Parents

Student

1Form 6b - Parent Input FormStudent Name CSRS ID# Birth date

Are there areas of concern regarding your child that we should be aware of?

When he/she is at home? When he/she is at school?

What techniques have you used to address the concern(s) noted above? Were they successful?

What is/are the most important goal(s) that you would like to see accomplished in the upcoming year?

Is there any other information that we should know that would assist us in developing the IEP?

Go to Forms List

Go to Roster

2Form 6b - Parent Input FormStudent Name CSRS ID# Birth date

PURPOSE: The IEP is designed to clearly communicate to the parents, the student, and providers the type and amount of special education and anynecessary related services or supports that will be made available to the student. The most recent evaluation report is used to develop the IEP. TheIEP is individualized to reflect the unique needs of the student and how these needs will be addressed to permit the student to be included and progress in the general education curriculum.


INDIVIDUALIZED EDUCATION PROGRAM


Grade

CSRS ID Age

School District Race / Ethnicity

Home LanguageParent/Guardian Name(s)

Surrogate needed?No Yes

Primary staff contact Position/Role

Present Levels of Academic Achievement and Functional Performance

/Resident Serving

No YesInterpreter needed? If YES, surrogate name:

Eligibility Category

Date of IEP meeting:

IEP annual review date:

Date of most recent eval:

Reevaluation due date:

Points that must be considered in developing the IEP (refer to WAC 392-172A-03110)

• Results of the most current evaluation, and the academic, developmental, and functional needs of the student.

• Positive behavioral supports and interventions, if the student’s behavior impedes the student’s learning or that of others.

• Language needs of students with limited English proficiency as they relate to the child’s IEP.

• Supports for blind/visually impaired students, include Braille instruction.

• Communication needsof the student, including the needs for deaf and hard of hearing students.

• Assistive technology devices and services.

• Supplementary aids/services, programmodifications, and support for school personnel.

Present levels of academic achievement

Present levels of functional performance i.e. – communication, motor, social, behavior, life/adaptive skills, etc

Effect of the disability on involvement/progress in general education curriculum/appropriate activities See points to consider.

Go to Goal Forms

Go to Forms List


Check spelling

&


Parent 2

Both Parents

Be sure to complete theGoal Forms for each student.

1Form 6c - IEP without TransitionStudent Name CSRS ID# Birth date

PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the student’seducational needs that result from the student’s disability to enable the student to be involved and make progress in the general education curriculum. For students who take alternate assessments aligned to alternate achievement standards (WAAS Portfolio), benchmarks or short-term objectives must also be included. In order to be measurable, the goal should include a baseline (“from”), a target (“to”), and a unit of measure.

REPORT OF STUDENT PROGRESS

Points to consider

• Parents are to be informed at least as often as parents of non-disabled students.

Participation in State and Districtwide Assessments of Student Achievement

State how the parents will be regularly informed of student’s progress toward meeting the annual goal(s) concurrent wit the issuance of report cards (such as through the use of quarterly or other periodic reports).

Points to consider

• The IEP team makes the determination of what type of assessmentthe student will take andwhat administrative modifications and individual accommodations are necessary.

• Accommodations provided on state and districtwide assessmentsshould be those that areprovided as part of the regular instructional program.

• Locally-determined assessments (LDAs) and WAAS-DAW are available to students after they have participated in the high school assessment process.

• Parents and students should be informed thatWASL-Basic, LDAs, WAAS Portfolio, and WAAS-DAW lead to a Certificate of Individual Achievement (CIA), rather than a Certificateof Academic Achievement (CAA).

• For further informationregarding the WASL, allowable accommodations, and graduation requirements,please refer to OSPI’s website (www.k12.wa.us).

State Assessment: The student will participate in the following state assessment(s) this school year:

Reading Math Writing ScienceGrades 3-8 and 10 Grades 4, 7, 10 Grades 5, 8, 10

WASL

All alternate assessments below require benchmarks and objectives.

Districtwide Assessment: The student will participate in the following districtwide assessments this school year.

Accommodations: List any individual accommodations in the administration of the state or districtwide assessments that are necessary for the student to participate.

If the student (a) will not participate in the grade-level WASL (with or without accommodations) or (b) is unable to participate in a regular districtwide assessment, explain why the student cannot participate in the regular assessment andwhy the selected assessment option is appropriate.

WASL-Basic (Level 2)

WASL with accommodations

WAAS Portfolio

Graduation: The following will be used for graduation purposes (specify grade level or grade equivalent in the box).

Developmentally-appropriate WASL (WAAS-DAW)

Locally-determined Assessment (LDA) Identify below:

State how the student’s progress toward the annual goal(s) will be measured.

Other:


________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________

________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________

________________________________________________

Use large print/Braille/recorded books

Presentation________________________________________________________________________________________________

________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________

Sign Language – ASL or SEEShortened assignmentsPreview test proceduresLimited multiple choiceRephrase test questions and/or directionsProvide test/quiz study guideProvide extra credit optionsSimplify test wordingRead class materials orallyAssign peer tutor/note takerOther:

Low-vision devices (magnifiers, ClosedCircuit TV, etc.)

Alter format of materials (highlight,type, spacing, color-code etc.)

Timing / SchedulingPrior notice of tests/quizzesExtra time to complete assignments

Extra time on tests/quizzes

Other:

Modify student’s schedule(describe below):

Allow breaks (during work, betweentasks, during testing, etc.)

________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________

PURPOSE: The purpose of this page is to document the modifications and/or accommodations that the student requires, based on the student’s assessed needs, in order to advance appropriately toward attaining the identified annual goals, to be involved and make progress in the general education curriculum, and to be educated with non-disabled peers to the maximum extent appropriate.

ACCOMMODATIONS, MODIFICATIONS AND ASSISTIVE TECHNOLOGYPoints to consider

• The IEP team makes the determination of what modifications and individual accommodations are necessary for the student.

• Copies of this page should be provided to the general education teacher(s) or other staffwho will be responsible for making these accommodations.

• Accommodations provided on state and districtwide assessments(as noted on the previous page) should be those that are provided as part of the regular instructional program.

CODES

A. All subjects

B. Reading

C. English

D. Spelling

E. Math

F. Science

G. Social Studies

H. History

I. Health

J. Economics

K. Physical Education

L. Music/Art

M. Vocational

N. Lunch/Recess

O. Library

P. Extracurricular Activity

Q. Other:

R. Other:

________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________

Setting

Provide individualized/small groupinstruction

Response

Provide study outlines/guides/graphic organizers

Modify/repeat/model directionsTake test in separate locationPreferential seatingOther:

Read class materials orally

Utilize oral responses to assignments/tests

Allow dictation to a scribeAllow use of a calculatorAllow use of tape recorderSpelling and grammar devicesSpeech-to-text softwareHands-on assignmentsOther:

Text-to-Speech (Kurzweil, WYNN, Text Help, etc.)

Provide desktop list of tasksProvide homework listsBehavior plan/contractProvide daily assignment listModified gradingOther:

Other

Assistive Technology

Describe:

Describe:

Describe:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

ENTRY NOTE:If you do not have any necessary accomodations in a category, place an “X” in the left column next to other and put “None needed” so it’s apparent that this category has not been skipped.


PURPOSE: The information on this page is a summary of the student’s program/services, including when services will begin, where they will be provided, who will be responsible for providing them, and when they will end.

SUMMARY OF SERVICES MATRIXPoints to consider

• If the position responsible for providing the specially designed instruction is anyone other than a certificated special education teacher or related service provider, then the certificated teacher/ provider must design and supervise the instruction, and monitor and evaluate the student’s progress.

• For definitions of special education, related services, and supplementary aids and services, refer to WAC 392-172A-01020 through -01200.

• When completing section B. at the bottom of this page, remember that job placements and community-based instruction are considered to be generaleducation settings, unless only disabled individuals are present (such as in a sheltered workshop).

ServiceInitiation

DateFrequency

(min/wk)Location of Service

(setting) DurationStaff

Responsible

ServiceInitiation

DateFrequency


(setting) Duration Staff Responsible

Special Education (specially designed instruction)

Related Services (i.e. - speech motor, counseling, vision/hearing, transportation, interpreting services, orientation/mobility, parent training, etc.)

ServiceInitiation

DateFrequency


(setting) Duration Staff Responsible

Supplementary Aids and Services (allows student to be educated with non-disabled peers to the maximum extent in general education orother educational setting)

Program Modifications or Support for School Personnel (i.e. - staff development/training, technical assistance, etc.)

A.

B.

= Total building instructional minutes per week (excluding lunch time)

= Total minutes per week student is served in a special education setting

= % of time spent in general education setting (A minus B divided by A)C.

Delivered by

Delivered by

Delivered by


PURPOSE: The purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum, participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students. Other education-related factors that may impact the student should also be considered.

Does this student require special transportation?

Does this student require ExtendedSchool Year (ESY) services?

Does the student’s behavior negatively impact his/her learning orthe learning of others?

Does this student require the use ofaversive interventions?

Are there any other factors not already addressed (such as medicalconcerns or other issues), or other adaptations needed?

Points to consider

• Children should be educated with non-disabled peers to the maximum extent appropriate.

• The IEP Team, including the parent(s),is responsible for determining the educational placementof the child.

• Refer to the percentage of time spent in a general education setting foundat the bottom of the Summary of Services Matrix to complete thissection.

LEAST RESTRICTIVE ENVIRONMENT

No Yes

No Yes

No Yes

No Yes

No Yes

Students ages 6 and above (check one) Students ages 3 to 5 (check one)

In general education setting 80 to 100% of the timeIn general education setting 40 to 79% of the timeIn general education setting 0 to 39% of the timeIn separate day school (public or private)Residential facility (public or private)Homebound/Hospital

In Early Childhood setting 80 to 100% of the timeIn Early Childhood setting 40 to 79% of the timeIn Early Childhood setting 0 to 39% of the timeIn separate day school (public or private)Residential facility (public or private)Homebound/Hospital

An explanation of the extent, if any, to which thestudent will not participatewith nondisabled studentsin the general education class, and in non-academic and extra-curricular activities, including a description ofany adaptations needed for participation in physical education:


1.

2.

3.

4.

5.

If yes, describe (if not already addressed on the service matrix):

If ESY is determined by the IEP team to be necessary, complete and attach the ESY addendum.

If yes, consider the student’s need for positive behavioral supports/ interventions, a Functional Behavioral Assessment, and/or a BehavioralIntervention Plan.

If yes, complete and attach the Aversive Intervention Plan addendum.

If yes, describe:


Points to consider




Participants in IEP Meeting

Signatures are used to document participation in the meeting and do not constitute agreement or disagreement.

Parent / Guardian District Representative

Parent / Guardian Name / Title

Student Name / Title

Special Education Teacher Name / Title

General Education Teacher Name / Title

Other individuals who should be informed of his/her responsibilities in implementing the IEP (bus driver, librarian, etc.)

REQUIRED FOR INITIAL PROVISION OF SERVICES ONLY: WRITTEN PARENTAL CONSENT FOR SERVICESMy rights and those of my child regarding procedural safeguards have been fully explained. I understand thatmy child requires special education and before initial provision of special education and related services may occur, I must give consent for services. I understand when I give consent, it is voluntary, and that while it canbe revoked, revocation is not retroactive. This means that the revocation does not undo services that occurred after my consent was given and before my consent was revoked. If I refuse consent, I understand that the district may not request mediation to obtain my consent or ask for a due process hearing to override my consent. If I do not give consent for initial services, the district may not provide services until I provide written consent. I understand that if I refuse consent, the district will not be considered to be in violation of therequirement to make FAPE available to my child.

I give consent for my child to receive special education services.

Parent / Guardian Signature Date

TRANSFER OF RIGHTS: Beginning at least one year beforereaching age 18, the student has been informed that all rightswill transfer to the student at age 18, unless there is a guardianship or other determination that the student cannot make educational decisions.

Points to consider

• When the student reaches age 18 (or majority), the district must notify the parents and the studentthat rights have transferred to the student, and provide any notices required to the student and parents.

NoYes

Go to Forms List

Go to Roster


MEASURABLE ANNUAL GOAL(S)

PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the student’seducational needs that result from the student’s disability to enable the student to be involved and make progress in the general education curriculum. Inorder to be measurable, the goal should include a baseline (“from”), a target (“to”), and a unit of measure. For students who will be assessed through theWAAS Portfolio this year, the IEP team should use the “Measurable Annual Goal(s) with Short-term Objectives/Benchmarks” page.

Points to consider

• Measurable annual goals stem from the recommendations for specially designed instruction in the evaluation report.

• Measurable annual goals must relate to thegeneral education curriculum or, for preschool students, participation in appropriate activities.

• Measurable annual goals must also addressother educational needsthat result from the student’s disability.

• The IEP must include adescription of how the district will measure thestudent’s progress and when progress will be reported to parents (concurrent with the issuance of report cards).

Present Level of Academic Achievement and Functional Performance (baseline)

Goal date:

Will:

From current level:

To target skill:

Measured by evaluation tool:

Measurable Goal: By , will from to as measured by .

Objective 1 Progress NotesDates

Method/Criteria for Evaluating Progress





Input Area for Measurable Goal (filling in these fields will automatically insert text in the form narrative).

Go to IEP no Transition

Go to IEP with Transition

Go to Forms List


Check spelling

1Form 6ci/di - IEP Goals 1.Student Name CSRS ID# Birth date



Points to consider






Goal date:

Will:

From current level:

To target skill:









Input Area for Measurable Goal (filling in these fields willautomatically insert text in the form narrative).






Points to consider






Goal date:

Will:

From current level:

To target skill:















Points to consider


• Measurable annual goals must relate to the general education curriculum or, for preschool students, participation in appropriate activities.

• Measurable annual goals must also addressother educational needs that result from the student’s disability.

• The IEP must include adescription of how the district will measure the student’s progress and when progress will be reported to parents (concurrent with the issuance of report cards).


Goal date:

Will:

From current level:

To target skill:












PURPOSE: The IEP is designed to clearly communicate to the parents, the student, and providers the type and amount of special education and anynecessary related services or supports that will be made available to the student. The most recent evaluation report is used to develop the IEP. TheIEP is individualized to reflect the unique needs of the student and how these needs will be addressed to permit the student to be included and progress in the general education curriculum.


INDIVIDUALIZED EDUCATION PROGRAM (WITH SECONDARY TRANSITION)


Grade

CSRS ID Age

School District Race / Ethnicity

Home LanguageParent/Guardian Name(s)

Surrogate needed?No Yes

Primary staff contact Position/Role

Present Levels of Academic Achievement and Functional Performance

/Resident Serving

No YesInterpreter needed? If YES, surrogate name:

Eligibility Category

Date of IEP meeting:

IEP annual review date:

Date of most recent eval:

Revaluation due date:

Points that must be considered in developing the IEP (refer to WAC 392-172A-03110)

• Results of the most current evaluation, and the academic, developmental, and functional needs of the student.

• Positive behavioral supports and interventions, if the student’s behavior impedes the student’s learning or that of others.

• Language needs of students with limited English proficiency as they relate to the child’s IEP.

• Supports for blind/visually impaired students, include Braille instruction.

• Communication needsof the student, including the needs for deaf and hard of hearing students.

• Assistive technology devices and services.

• Supplementary aids/services, programmodifications, and support for school personnel.

Present levels of academic achievement

Present levels of functional performance i.e. – communication, motor, social, behavior, life/adaptive skills, etc

Effect of the disability on involvement/progress in general education curriculum/appropriate activities See points to consider.

Go to Forms List


Check spelling

&


Parent 2

Both Parents

1Form 6d - IEP with TransitionStudent Name CSRS ID# Birth date

PURPOSE: The purpose of transition planning is to develop a coordinated set of activities designed within a results-oriented process that is focused on improving the academic achievement and functional performance of the student in order to facilitate the student’s movement from school to post-school activities, including postsecondary education/training, employment, and if appropriate, independent living skills.

SECONDARY TRANSITION

Points to Consider

• Secondary transition must be addressed in the first IEP to be in effect when the student turns 16,or younger if determined appropriate by the IEP team, and updated annually.

• Measurable post-secondary goals, based upon age-appropriate transition assessment results, must be included in the areas of education/training, employment, and (if appropriate) independent living skills.

• Transition services should be based on the individual student’s needs,taking into account the student’s preferences andinterests, and may includeinstruction, related services, community experiences, the development of employment and other postschool adult living objectives, and if appropriate, the acquisition of daily living skills and provision of a functional vocational evaluation.

No Yes

Surveys / questionnairesProfiles / portfoliosVocational assessment(s)

Other:

Student participated in IEP meeting?If no, what steps were taken to ensure that the student’s preferences/interests were considered?

Age Appropriate Transition Assessments

Include results of informal and/or formal assessments including student’s needs, preferences and interest(s).

Education / Training (Required to be addressed for all students)

Measurable Post-secondary Goal(s)What the student will do after graduation from high school in the area of education/training.

Transition Services List Transition Services related to Education / Training, including IEP goal number(s) if applicable.

Transition Service Staff / Agency Responsible IEP Goal


Employment (Required to be addressed for all students)

Measurable Post-secondary Goal(s)What the student will do after graduation from high school in the area of employment.

Transition Services List Transition Services related to Employment, including IEP goal number(s) if applicable.


Independent Living Skills (Must be addressed if determined appropriate by the IEP Team)

Measurable Post-secondary Goal(s)What the student will do after graduation from high school in the area of living skills.

Transition Services List Transition Services related to Living Skills, including IEP goal number(s) if applicable.


Course(s) of StudyList the course(s) of study needed to assist the student in reaching his/her postsecondary goals, unless already describedabove, or attach a list of courses.

Points to Consider

• A course of study is “amulti-year description ofcoursework to achieve the student’s desired post-school goals, from the student’s current to anticipated exit year.” (NSTTAC, 2007).

Points to Consider

• Independent living skills are “those skills or tasks that contribute to the successful independent functioningof an individual in adulthood” (Cronin, 1996) in the following domains: leisure/recreation, homemaintenance and personal care, and community participation.

Points to Consider

• Transition services may be special education, if provided asspecially designed instruction or related services, if required to assist the student in benefitting from special education.

• Representatives of anyagencies that are likely to be responsible for providing or paying for transition services to thestudent should be invitedto the IEP meeting, withparent consent.

Go to Goal Forms

Be sure to complete theGoal Forms for each student.


PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the student’seducational needs that result from the student’s disability to enable the student to be involved and make progress in the general education curriculum. For students who take alternate assessments aligned to alternate achievement standards (WAAS Portfolio), benchmarks or short-term objectives must also be included. In order to be measurable, the goal should include a baseline (“from”), a target (“to”), and a unit of measure.

REPORT OF STUDENT PROGRESS

Points to consider

• Parents are to be informed at least as often as parents of non-disabled students.

Participation in State and Districtwide Assessments of Student Achievement

State how the parents will be regularly informed of student’s progress toward meeting the annual goal(s) concurrent wit the issuance of report cards (such as through the use of quarterly or other periodic reports).

Points to consider

• The IEP team makes the determination of what type of assessmentthe student will take andwhat administrative modifications and individual accommodations are necessary.

• Accommodations provided on state and districtwide assessmentsshould be those that areprovided as part of the regular instructional program.

• Locally-determined assessments (LDAs) and WAAS-DAW are available to students after they have participated in the high school assessment process.

• Parents and students should be informed thatWASL-Basic, LDAs, WAAS Portfolio, and WAAS-DAW lead to a Certificate of Individual Achievement (CIA), rather than a Certificateof Academic Achievement (CAA).

• For further informationregarding the WASL, allowable accommodations, and graduation requirements,please refer to OSPI’s website (www.k12.wa.us).

State Assessment: The student will participate in the following state assessment(s) this school year:Reading Math Writing Science

Grades 3-8 and 10 Grades 4, 7, 10 Grades 5, 8, 10

WASL

All alternate assessments below require benchmarks and objectives.

Districtwide Assessment: The student will participate in the following districtwide assessments this school year.

Accommodations: List any individual accommodations in the administration of the state or districtwide assessments that are necessary for the student to participate.

If the student (a) will not participate in the grade-level WASL (with or without accommodations) or (b) is unable to participate in a regular districtwide assessment, explain why the student cannot participate in the regular assessment andwhy the selected assessment option is appropriate.

WASL-Basic (Level 2)

WASL with accommodations

WAAS Portfolio

Graduation: The following will be used for graduation purposes (specify grade level or grade equivalent in the box).

Developmentally-appropriate WASL (WAAS-DAW)

Locally-determined Assessment (LDA) Identify below:

State how the student’s progress toward the annual goal(s) will be measured.

Other:


________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________

________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________

________________________________________________

Use large print/Braille/recorded books

Presentation________________________________________________________________________________________________

________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________

Sign Language – ASL or SEEShortened assignmentsPreview test proceduresLimited multiple choiceRephrase test questions and/or directionsProvide test/quiz study guideProvide extra credit optionsSimplify test wordingRead class materials orallyAssign peer tutor/note takerOther:

Low-vision devices (magnifiers, ClosedCircuit TV, etc.)

Alter format of materials (highlight,type, spacing, color-code etc.)

Timing / SchedulingPrior notice of tests/quizzesExtra time to complete assignments

Extra time on tests/quizzes

Other:

Modify student’s schedule(describe below):

Allow breaks (during work, betweentasks, during testing, etc.)

________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________

PURPOSE: The purpose of this page is to document the modifications and/or accommodations that the student requires, based on the student’s assessed needs, in order to advance appropriately toward attaining the identified annual goals, to be involved and make progress in the general education curriculum, and to be educated with non-disabled peers to the maximum extent appropriate.

ACCOMMODATIONS, MODIFICATIONS AND ASSISTIVE TECHNOLOGYPoints to consider

• The IEP team makes the determination of what modifications and individual accommodations are necessary for the student.

• Copies of this page should be provided to the general education teacher(s) or other staffwho will be responsible for making these accommodations.

• Accommodations provided on state and districtwide assessments(as noted on the previous page) should be those that are provided as part of the regular instructional program.

CODES

A. All subjects

B. Reading

C. English

D. Spelling

E. Math

F. Science

G. Social Studies

H. History

I. Health

J. Economics

K. Physical Education

L. Music/Art

M. Vocational

N. Lunch/Recess

O. Library

P. Extracurricular Activity

Q. Other:

R. Other:

________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________

Setting

Provide individualized/small groupinstruction

Response

Provide study outlines/guides/graphic organizers

Modify/repeat/model directionsTake test in separate locationPreferential seatingOther:

Read class materials orally

Utilize oral responses to assignments/tests

Allow dictation to a scribeAllow use of a calculatorAllow use of tape recorderSpelling and grammar devicesSpeech-to-text softwareHands-on assignmentsOther:

Text-to-Speech (Kurzweil, WYNN, Text Help, etc.)

Provide desktop list of tasksProvide homework listsBehavior plan/contractProvide daily assignment listModified gradingOther:

Other

Assistive Technology

Describe:

Describe:

Describe:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________


PURPOSE: The information on this page is a summary of the student’s program/services, including when services will begin, where they will be provided, who will be responsible for providing them, and when they will end.

SUMMARY OF SERVICES MATRIXPoints to consider

• If the position responsible for providing the specially designed instruction is anyone other than a certificated special education teacher or related service provider, then the certificated teacher/ provider must design and supervise the instruction, and monitor and evaluate the student’s progress.

• For definitions of special education, related services, and supplementary aids and services, refer to WAC 392-172A-01020 through -01200.

• When completing section B. at the bottom of this page, remember that job placements and community-based instruction are considered to be generaleducation settings, unless only disabled individuals are present (such as in a sheltered workshop).

ServiceInitiation

DateFrequency

(i.e. - minutes/week)Location of Service

(setting) DurationStaff Responsible

for Delivering

ServiceInitiation

DateFrequency



for Delivering

Special Education (specially designed instruction)

Related Services (i.e. - speech motor, counseling, vision/hearing, transportation, interpreting services, orientation/mobility, parent training, etc.)

ServiceInitiation

DateFrequency



for Delivering

Supplementary Aids and Services (allows student to be educated with non-disabled peers to the maximum extent in general education orother educational setting)

Program Modifications or Support for School Personnel (i.e. - staff development/training, technical assistance, etc.)

A.

B.

= Total building instructional minutes per week (excluding lunch time)

= Total minutes per week student is served in a special education setting

= % of time spent in general education setting (A minus B divided by A)C.


PURPOSE: The purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum, participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students. Other education-related factors that may impact the student should also be considered.

Does this student require special transportation?

Does this student require ExtendedSchool Year (ESY) services?

Does the student’s behavior negatively impact his/her learning orthe learning of others?

Does this student require the use ofaversive interventions?

Are there any other factors not already addressed (such as medicalconcerns or other issues), or other adaptations needed?

Points to consider




LEAST RESTRICTIVE ENVIRONMENT

No Yes

No Yes

No Yes

No Yes

No Yes

Students ages 6 and above (check one) Students ages 3 to 5 (check one)

In general education setting 80 to 100% of the timeIn general education setting 40 to 79% of the timeIn general education setting 0 to 39% of the timeIn separate day school (public or private)Residential facility (public or private)Homebound/Hospital

In Early Childhood setting 80 to 100% of the timeIn Early Childhood setting 40 to 79% of the timeIn Early Childhood setting 0 to 39% of the timeIn separate day school (public or private)Residential facility (public or private)Homebound/Hospital

An explanation of the extent, if any, to which thestudent will not participatewith nondisabled studentsin the general education class, and in non-academic and extra-curricular activities, including a description ofany adaptations needed for participation in physical education:


1.

2.

3.

4.

5.

If yes, describe (if not already addressed on the service matrix):

If ESY is determined by the IEP team to be necessary, complete and attach the ESY addendum.

If yes, consider the student’s need for positive behavioral supports/ interventions, a Functional Behavioral Assessment, and/or a BehavioralIntervention Plan.

If yes, complete and attach the Aversive Intervention Plan addendum.

If yes, describe:


Points to consider




Participants in IEP Meeting

Signatures are used to document participation in the meeting and do not constitute agreement or disagreement.


Parent / Guardian Name / Title

Student Name / Title

Special Education Teacher Name / Title

General Education Teacher Name / Title

Other individuals who should be informed of his/her responsibilities in implementing the IEP (bus driver, librarian, etc.)

REQUIRED FOR INITIAL PROVISION OF SERVICES ONLY: WRITTEN PARENTAL CONSENT FOR SERVICESMy rights and those of my child regarding procedural safeguards have been fully explained. I understand thatmy child requires special education and before initial provision of special education and related services may occur, I must give consent for services. I understand when I give consent, it is voluntary, and that while it canbe revoked, revocation is not retroactive. This means that the revocation does not undo services that occurred after my consent was given and before my consent was revoked. If I refuse consent, I understand that the district may not request mediation to obtain my consent or ask for a due process hearing to override my consent. If I do not give consent for initial services, the district may not provide services until I provide written consent. I understand that if I refuse consent, the district will not be considered to be in violation of therequirement to make FAPE available to my child.

I give consent for my child to receive special education services.

Parent / Guardian Signature Date

TRANSFER OF RIGHTS: Beginning at least one year beforereaching age 18, the student has been informed that all rightswill transfer to the student at age 18, unless there is a guardianship or other determination that the student cannot make educational decisions.

Points to consider

• When the student reaches age 18 (or majority), the district must notify the parents and the studentthat rights have transferred to the student, and provide any notices required to the student and parents.

NoYes

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PURPOSE: The purpose of the Aversive Intervention Plan addendum is to uniformly address the conditional use of aversive interventions (see WAC 392-172A-03120 through -03135).


AVERSIVE INTERVENTION PLAN ADDENDUM

Specify the aversive intervention(s) that may be used.

Describe the positive interventions attempted and the reasons they failed, if known.

Describe the circumstances under which the aversive intervention(s) may be used.

Describe or specify the maximum duration of any isolation or restraint.

Specify any special precautions that must be taken in connection with the use of aversive intervention techniques.

Specify the person(s) permitted to use the aversive intervention(s), and the current qualifications and required training of thepersonnel permitted to use the aversive interventions.

List the means of evaluating the effects of the use of the aversive interventions and a schedule for periodically conducting theevaluation.

State the reason(s) why the aversive interventions are judged to be appropriate and the behavioral objectives sought to be achieved.

POINTS TO CONSIDER 1) Aversive interventions, to the extent permitted, should only be used as a last resort. 2) Positive interventions must be attempted and described in the IEP prior to the use of aversive interventions. 3) The IEP team must include a school psychologist and/or other certificated employee who understands the appropriate use of the aversive intervention(s).

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Form 6e - Aversive Intervention Plan AddendumStudent Name CSRS ID# Birth date

PURPOSE: The purpose of the Extended School Year (ESY) addendum to the IEP is to identify services that the student requires beyond the normalschool year. This decision is made in accordance with the IEP and at no cost to the parents of the student (see WAC 392-172A-02020).


EXTENDED SCHOOL YEAR (ESY) ADDENDUM

Student Name:

NoYes

Addendum Date

The IEP team has determined that this student is eligible for ESY services because these services are necessary for the provision of a free, appropriatepublic education (FAPE) to the student.

Description of the skills and/or behaviors that require ESY services in order to be maintained.

POINTS TO CONSIDER:

The purpose of ESY services is themaintenance of the student’s learning skills or behavior, not the teaching of new skills or behaviors.

The IEP team’s decision for ESY should be based upon regression and recoupment time based on documented evidence, or on the determinations of the IEP team, based upon the professional judgment of the team and consideration of the nature and severity of the student’s disability, rate of progress, and emerging skills, with evidence to support theneed.

POINTS TO CONSIDER: For definitions of special education, related services, and supplementary aids and services, refer to WAC 392-172A-01020 through -01200.

ServiceInitiation

DateFrequency(min/wk)

Location of Service(setting) Duration Staff Responsible

Special Education and Related Services to be provided during ESY

Supplementary Aids/Services, Program Modifications, or Support for School Personnel needed during ESY

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Delivered by

Form 6f - Extended School Year AddendumStudent Name CSRS ID# Birth date

Description of Proposed Revision(s)

PURPOSE: After the annual IEP team meeting for a school year, the parent and the school district may agree not to convene an IEP team meeting for the purpose of making changes to the IEP, and instead may develop a written document to amend or modify the student’s current IEP. If changes aremade to the student’s IEP, the district must ensure that the IEP team and other providers responsible for implementing the IEP are informed of the changes. Upon request, the parent must be provided with a revised copy of the IEP with the amendment(s) incorporated. Note: Other provisions of WAC 392-172A-03110(3) apply. (See also WAC 392-172A-03015 (1)(a)).


IEP AMENDMENT WITHOUT RECONVENING THE IEP TEAM

Date:

To: RE:

Amendmenet of the IEP dated:

Below is a description of the IEP revision(s) we discussed and agreed to make without reconvening the full IEP Team.

This IEP amendment revises or modifies (check all that apply):

Present levels of educational achievement and functional performance.Instructional goals and objectives.Frequency, location and/or duration of special education services provided.Related services.Supplementary aids/services, accomodations and/or transportation.State and/or district assessment participation and/or testing accomodations.Transition services.

Other.

Attach revised goal pages or other IEP pages as may be appropriate.

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Parent 2

Both Parents

Student

1Form 6g - IEP AmendmentStudent Name CSRS ID# Birth date

ServiceInitiation

DateFrequency


(setting) Duration Provider

Revisions to Services Provided (if any)

Special Education and Related Services

ServiceInitiation

DateFrequency


(setting) Duration Provider

Supplementary Aids/Services, Program Modifications, and/or Support to School Personnel


Team members participating in this IEP amendment

Name / Title Date

Name / Title Date

Parents have the right to request a copy of the IEP with these changes incorporated.

Note: A revision/amendment to the IEP does not reset the due date for the next annual IEP review. Parents shouldbe provided a Prior Written Notice addressing the results of the amendment.

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2Form 6g - IEP AmendmentStudent Name CSRS ID# Birth date

PURPOSE: A Functional Behavioral Assessment (FBA) is used to gather information about a student’s behavior to determine the need for, and providethe foundation for, a Behavioral Intervention Plan (BIP). An FBA is required to be conducted if the student’s violation of a code of conduct (resulting ina change of placement) is determined to be a manifestation of the student’s disability.


FUNCTIONAL BEHAVIORAL ASSESSMENT

Student Name

GradeCSRS ID School/

District Building

Disability Case Manager Meeting Date

Student’s StrengthsInclude a description of the student’s behavioral strengths, such as positive interactions with staff, ignoring the inappropriate behavior of peers, accepts responsibility, etc

Description of Proposed Revision(s)

Include a description of the frequency, duration, and intensity of the behavior(s).

Setting(s)

Include a description of the setting(s) in which the behavior occurs, i.e. – physical setting, time of day, persons involved.

Antecedent(s)

Include a description of the relevant events that preceded the behavior.

Name/Title

Name/Title

Name/Title

Name/Title

Name/Title

Name/Title

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1Form 7a - Functional Behavioral AssessmentStudent Name CSRS ID# Birth date

Consequences and Educational Impact

Include a description of the result of the behavior (i.e. – removed from class, not able to complete assignments/tests, etc.), and the impact on the student, peers, and the instructional environment.

Other Potential Variables

Include a description of any other factors/variables that may affect the behavior, such as medication, weather, diet, sleep, substance abuse, attendance, social factors, etc

Prior Interventions

Include a description of the behavioral interventions that have been implemented in the past, including the date(s) of implementation, length of intervention, the impact of the intervention on the student’s behavior, etc. Attach data summary, if appropriate.

Hypothesis of Behavioral Function

Describe the team’s hypothesis of the relationship between the behavior and the environment in which it occurs – what function is this behavior serving for the student? What is the student trying to get? What is he/she trying to avoid?

Summary / Recommendations

Provide recommendations for prevention of the target behavior, replacement skills/behavior(s) to be taught, reinforcements for positive behaviors, etc .

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2Form 7a - Functional Behavioral AssessmentStudent Name CSRS ID# Birth date

PURPOSE: The purpose of a Behavioral Intervention Plan (BIP) is to address behaviors that are interfering with the student’s education. The goal ofa BIP is to teach the student positive behavioral strategies to replace the problem behavior(s). A BIP is required to be developed and implemented ifthe student’s violation of a code of conduct (resulting in a change of placement) is determined to be a manifestation of the student’s disability, or if theIEP team determines it is appropriate


BEHAVIORAL INTERVENTION PLAN

Student Name

GradeCSRS ID

Disability Case Manager Meeting Date

Name/Title

Name/Title

Name/Title

Name/Title

Name/Title

Name/Title

Target Behavior (behavior to be extinguished) Person(s) Responsible

Intervention Strategies

Alternative behaviors to be taught/reinforced Reinforcers Consequences for target behavior

Data Collection Procedures (methods and timelines)





1

2

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School/

District Building

Form 7b - Behavioral Intervention PlanStudent Name CSRS ID# Birth date













3

4

5

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Form 7b - Behavioral Intervention PlanStudent Name CSRS ID# Birth date

PURPOSE: Within 10 school days of any decision to change the placement of a student eligible for special education because of a violation of a codeof student conduct, the school district, the parent, and relevant members of the student’s IEP team (as determined by the parent and the school district) must review all relevant information to determine if the conduct in question was caused by, or had a direct, substantial relationship to, the student’s disability; or if the conduct in question was the direct result of the district’s failure to implement the IEP.


MANIFESTATION DETERMINATION

Student Name

Grade

CSRS ID

Case Manager

Disability Meeting Date


Name / Title Name / Title

Name / Title Name / Title

Team Members Present at Meeting (must include a district representative, the parent(s), and relevant members of the IEP team as determinedby the district and parent)

Description of behavior(s) / incident(s) that resulted in disciplinary action.

Description of relevant information

Include a review of relevant information from the student’s file including the student’s IEP, any teacher observations, and any relevant information provided by the parent(s). Consider the behavioral/disciplinary history of the student.

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School/

District Building

1Form 7c - Manifestation DeterminationStudent Name CSRS ID# Birth date

NoYes

NoYes

Determination

Based on the information described above.

The conduct in question was caused by, or had a direct and substantial relationship to, the student’s disability.

Discussion:

The conduct in question was the direct result of the district’s failure toimplement the student’s IEP.

Discussion:

NOTE: If either of the above is YES, the behavior must be considered a manifestation of the student’s disability.

Check one:

The conduct in question WAS a manifestation of the student’s disability.The IEP team must conduct a functional behavioral assessment, unless one was conducted prior to the behavior incident, and develop and implement a behavioral intervention plan. If a behavioral intervention plan has already been developed, the IEP team must review and modify (if necessary) the plan.

The conduct in question WAS NOT a manifestation of the student’s disability.Disciplinary action(s) that apply to students without disabilities may be taken, but the school district must continue to provide a FAPE to enable the student to continue to participate in thegeneral education curriculum and to progress toward meeting his/her IEP goals. If necessary,the district should also conduct a functional behavioral assessment and develop/implement a behavioral intervention plan that is designed to address the behavior violation so that it does not, or is less likely to, recur.

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2Form 7c - Manifestation DeterminationStudent Name CSRS ID# Birth date

PURPOSE: Local school districts must consult with private school representatives and representatives of parents of parentally placed private school students eligible for special education. When timely and meaningful consultation has occurred, the school district must obtain and retain a written affirmation signed by the representatives of participating private schools. If the representatives do not provide the signed affirmation, the district must forward the documentation of the consultation process to OSPI. There are five primary points of discussion that are required to be included in the timelyand meaningful consultation process during the design and development of special education and related services for parentally placed private school students with disabilities, as required by WAC 392-172A-04020.


DOCUMENTATION OF PRIVATE SCHOOL CONSULTATIONParticipantsName(s) of

Private Schools

Dates of Consultation

Points of Discussion

Discussion of how parentally placed private school studentssuspected of having a disabilitycan participate equitably, including how individuals will be informed of the process.

1. Child Find

Review the formula for determining the proportionate amount of federal funds available to serve parentally placed private school studentswith disabilities.

2. Proportionate Share

Identify how the process will operate throughout the school year to ensure that parentally placed private school students with disabilities can meaningfullyparticipate in special education and related services.

3. Consultation Process

Discussion of how, where, andby whom special education services will be provided for parentally placed private school students with disabilities, including how andwhen decisions will be made.

4. Special Education Services

Review how the district will provide a written explanation ifin disagreement with the private school officials on the provision or types of services.

5. Written Explanation if Disagreement

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Form 8a - Private School ConsultationStudent Name CSRS ID# Birth date

PURPOSE: Local school districts must consult with private school representatives and representatives of parents of parentally placed private school students eligible for special education. When timely and meaningful consultation has occurred, the school district must obtain and retain a written affirmation signed by the representative(s) of participating private schools.


PRIVATE SCHOOL WRITTEN AFFIRMATION

By signing below as a private school representative, I affirm that the school district has engaged in timely and meaningful consultation during thedesign and development of special education and related services for parentally placed private school students with disabilities, as required by WAC 392-172A-04020.

Topic(s) of consultation included (check all that apply):

The child find process and how parentally placed private school students suspected of having a disability canparticipate equitably, including how parents, teachers, and private school officials will be informed of the process.

The determination of the proportionate amount of federal funds available to serve parentally placed private school students with disabilities, including the determination of how the amount was calculated.

The consultation process among the school district, private school officials, and representatives of parents of parentally placed private school students with disabilities, including how the process will operate throughout the school year to ensure parentally placed private school students with disabilities identified through child findcan meaningfully participate in special education and related services.

How, where, and by whom special education services will be provided for parentally placed private school students with disabilities, including a discussion of the types of services, including direct services and alternateservice delivery mechanisms, how such services will be apportioned if funds are insufficient to serve all students, and how and when these decisions will be made.

How, if the school district disagrees with the views of the private school officials on the provision of services orthe types of services, whether provided directly or through contract, the school district will provide private school officials a written explanation of the reason(s) why the school district chose not to provide services directly or through a contract.

Other:

Name of Private School Representative

Date signed

Name of Private School

Signature of Private School Representative

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Form 8b - Private School AffirmationStudent Name CSRS ID# Birth date

PURPOSE: A Services Plan must be developed and implemented for each private school student eligible for special education who has been designated by the school district to receive special education and/or related services. The school district must provide to OSPI the number of studentsevaluated, the number of students determined eligible, and the number served through a Services Plan.


PRIVATE SCHOOL SERVICES PLAN

Student Name CSRS ID

School/

District Building

Eligibility CategoryBirthdate

Evaluation Date Meeting Date(s)

Service Plan participants (sign below, including title/role)

General Student Information

Service Need(s)

Academic / Cognitive Motor Behavior Communication Self-help Social Transition

Present Level of Academic and Functional Performance as it pertains directly to identified service need(s)

Measurable Academic/Functional Goal(s)

Method of Measurement

Personnel Responsible for Implementing Goal

Date Achieved:

Title(s)

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1Form 8c - Private School Services PlanStudent Name CSRS ID# Birth date

Special Education and Related Services

Service Area Initiation Date Duration LocationSessionsper week

Individual/Group

Transportation (if required)

Accommodations for Classroom

Supports for School Personnel

Transition (if appropriate)

Comments (if applicable)

The district assures that the program and service described in the Service Plan will be provided. The schedule for describing the progress towards achievement of the academic and/or functional annual goal(s) will be every 0 weeks, concurrent with the issuance of report cards. Achievement will be documented through the use of Progress Reports.

Beginning at least one year before the age of majority, I (my child) have been informed that my (his or her) rights under Part B of the Act will transfer to me (my child) on my (his/her) reaching the age of majority.

I understand that IDEA due process hearing procedures do not apply to parentally-placed private school students.

I give consent for my child to receive these services. I understand when I give consent, it is voluntary, and that while it can be revoked, revocation is not retroactive. This means that the revocation does not undo services that occurred after my consent was given and before my consent was revoked.

0

Enter number of weeks below to insert into letter.

Format can be 23 or twenty-three (23)

Signature of Parent / Guardian / Surrogate Parent / Adult Student

Date

Date

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23/22/2009

9:53 PMForm 8c - Private School Services PlanStudent Name CSRS ID# Birth date

PURPOSE: For a student who is graduating or exiting special education due to exceeding age eligibility, the school district must provide the studentwith a summary of the student’s academic achievement and functional performance, including recommendations on how to assist the student in meeting his/her postsecondary goals (WAC 392-172A-03030). The Summary of Performance is important to assist the student in the transition fromhigh school to higher education, training, and/or employment, and to help establish a student’s eligibility for reasonable accommodations and supports in postsecondary settings.


SUMMARY OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Student Name Birth dateYear of Graduation / Exit:

Primary Language

Address City

Student’s Primary Disability

State ZIP

Phone Number

Student’s Secondary Disability(if applicable)

When was the student’s disability(or disabilities) formally identified?

Date this Summarywas completed:

Person completing this form (Name) Title School Phone

E-mail

Student’s Post-secondary Goals

Post-secondary Area Post-secondary Goal

Education / Training

Employment

Independent Living(if appropriate)

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School/

District Building

1Form 9 - Summary of PerformanceStudent Name CSRS ID# Birth date

Summary of Performance

Complete all sections that are relevant to the student. Attach copies of any assessment/data reports that provide additional or supplementary information, if appropriate

ReadingBasic reading/decoding, reading comprehension, reading fluency

MathematicsCalculation skills, algebraicproblem solving, quantitative reasoning

Written LanguageWritten expression, writing fluency, spelling

Functional Performance(i.e. - general ability and problem solving, attention and organization, communication, social skills,behavior, independent living, self-advocacy, learning style, vocational, employment, etc

Present Level of Performance(i.e. - grade level, standard scores,strengths, preferences, needs, etc.)

Essential accommodations, assistive technology, and/or modifications utilized in high school

Recommendations to Assist the Student in Meeting Post-secondary Goals

Post-secondary Area Recommendations

OtherRecommendations

Education / Training

Employment

Independent Living(if appropriate)


Other InformationInclude here any other relevant information provided by the student, parent(s), school staff, and/or other agency personnel that may assist the student in transitioning from high school to post-high school.

A copy of this Summary was provided to the student on

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PURPOSE: This form is used to request a due process hearing under the Individuals with Disabilities Education Improvement Act of 2004 (IDEA). This request is provided directly to the other party and a copy is provided to the Office of Superintendent of Public Instruction (OSPI), AdministrativeResources Services.


DUE PROCESS HEARING REQUEST

TO:

NOTE:Insert the name and address of the party (parent or district) to whom you are providing this notice. If the notice is to the school district,use the school district superintendent’s name and the district superintendent administration address for purposes of notification.

NoYes

And a copy to:Office of Superintendent of Public Instruction (OSPI)PO Box 47200, Olympia, WA 98504-7200Phone: (360) 725-6142 Fax: (360) 753-4201

You must provide your request for due process directly to the other party and provide a copy ofthe request to OSPI Administrative Services.

Student Information

Student Name

Birth date

Address

City/State/Zip

School District

School Name

Parent Name

Address

City/State/Zip

Home Phone

Name of person requesting hearingand relationship to student:

Parent / Guardian Information

For a child who is homeless, contactname and address, if different from above:

If different from student’s:

Discipline

Does this due process hearing request involve a special education disciplinary matter?Hearings for violations of special education disciplinary matters involve removals of a student formore than ten school days in a school year, manifestation determination procedures, or other placement decisions resulting from the disciplinary removal.

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Parent 2

Both Parents w/student address

1Form 10 - Due Process Hearing RequestStudent Name CSRS ID# Birth date

Problem and FactsWhat is the nature of the problem that relates to the child’s special education program and what are the facts that relate to the problem?

Proposed SolutionDescribe the things that you believe will resolve the issue(s) based on the information available to you.


I certify that on , I provided this due process request to (list name(s) & address):

Please provide your due process request to the other party and a copy of this notice to OSPI, Administrative Resources Services, at the address provided. Keep a copy of your request and proof of delivery to the other party. Do not submit supporting documents with your request for a due process hearing.

This form is provided to you as a model for your use. You are not required to use this form; however, failure to address theelements required in IDEA 2004 or failure to provide the other party, or his/her representative with a due process hearing request, may result in a delay of the hearing and/or in a reduction of attorney fees, if awarded.

IMPORTANT INSTRUCTIONS

Certification of Delivery

Regular postpaid mailCertified mailFaxHand Delivery

Other (specify):By:

Position / Title

Signature of person certifying delivery Date

Print name

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PURPOSE: A resolution session is required when a parent files a request for a due process hearing, unless both the parent and the district waive therequirement for a resolution session, or the parties agree to use mediation instead of resolution. The purposed of the resolution session is to provideparents and districts an opportunity to resolve the issues contained in the due process hearing request prior to the beginning of the due process hearing timelines.


RESOLUTION SESSION PARTICIPANTS AND AGREEMENT

Resolution Session ParticipantsList all resolution session participants, whether or not an agreement is reached.

Agreement reached -- see below. No agreement reached.

Name Position and Agency Date(s) of Participation

Outcome

Resolution AgreementComplete if the parent(s) and district/program reach an agreement.

and agree to the following:

1.

2.

3.

4.

5.

The parties understand that:1. This agreement is voluntary, legally binding, and enforceable in any State court of competent jurisdiction or in a district court of the United States.

2. Any party signing below may void this agreement by sending a written, signed, dated statement which is received by the other party within three business days of the last date signed below.

Signature DatePrint name

Parent(s) or adult student:

Signature DatePrint name

District / program authorized representative:

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Form 11 - Resolution AgreementStudent Name CSRS ID# Birth date

PURPOSE: This form asks for your consent to obtain information from the Department of Social and Health Services, Health and Recovery ServicesAdministration for the purpose of Medicaid eligibility verification. If you have questions regarding this request, you may call the school district directorof special education for an explanation as to why the request is being made.


MEDICAID ELIGIBILITY VERIFICATION

State law requires the school district to submit claims for health-related services provided to special education students or students referred for special education. These services include physical therapy, occupational therapy, speech-language therapy, audiology, nursing, counseling, and psychological evaluation.

With your permission, we will submit your student’s name and birth date to the Department of Socialand Health Services (DSHS) to verify Medicaid eligibility. Such a request will in no way negatively impact services included in your child’s individualized education program (IEP).

By giving consent, you are acknowledging that (1) you have been fully informed of all information relevant to the activity for which consent is sought; (2) you understand that the granting of consent isvoluntary on your part and may be revoked at any time; and (3) if you revoke consent, the revocationis not retroactive; which means that it does not negate any activity that has already taken place.

I give consent to verify Medicaid eligibility with DSHS.

I do not give consent to verify Medicaid eligibility with DSHS.

Parent / guardian signature Date

Student Name Birth Date

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Form 12a - Medicaid Eligibility VerificationStudent Name CSRS ID# Birth date

PURPOSE: This form is to obtain parent consent to bill the Department of Social and Health Services, Health and Recovery Services Administration.The district is required to obtain parent consent each time they bill for a new procedure. Billing DSHS does not affect individual benefits under Medicaid or require a co-pay or deductable. If parents have questions regarding this request, they may call the school district’s director of special education for an explanation as to why the request is being made.


CONSENT TO BILL FOR SCHOOL-BASED MEDICAID REIMBURSEMENT

A school district is required to obtain your consent when it bills Medicaid for reimbursable school basedservices.

I authorize to share necessary identifying information from my child’s education record to access federal Medicaid reimbursement from the Department of Social and Health Services (DSHS).

I understand that if any additional Medicaid reimbursable services are added to the IEP, the school district will request additional consent.

I understand that this consent is good for 365 days. If my child no longer is served by this school district, this consent does not transfer to a new district. I also understand that I can revoke my consentat any time.

By giving consent, you are acknowledging that (1) you have been fully informed of all information relevant to the activity for which consent is sought; (2) you understand that the granting of consent is voluntary on your part and may be revoked at any time; and (3) if you revoke consent, the revocation isnot retroactive; which means that it does not undo any activity that has already taken place.

I give my continuing permission to the to submit health claims to DSHS for a period of 365 days from the date of this signature. I understand that if the District needs to bill for anew procedure, it will seek my consent for that procedure.

I do not give consent to verify Medicaid eligibility with DSHS. I understand that my refusal to allow the district to submit billing for Medicaid does not allow the District to make a claim for reimbursement for services that might otherwise be covered by DSHS.I also understand that my refusal does not affect my child’s access to services under theIndividualized Education Program.

Parent / guardian signature Date

Student Name Birth Date

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Form 12b - Medicaid Consent for BillingStudent Name CSRS ID# Birth date

PURPOSE: This form is to obtain parent consent to access public benefits/insurance or private insurance in which his/her student participates, toprovide or pay for services required under IDEA. The district may not require parents to sign up for or enroll in public benefits or insurance programs in order for their student to receive FAPE under Part B. Parents are not required to consent to the use of insurance benefits. If parentshave questions regarding this request, they should call the school district’s director of special education for an explanation as to why the request isbeing made.


PARENT CONSENT FOR USE OF PUBLIC OR PRIVATE INSURANCE BENEFITS

To: Re: :Student’s name : Date of birthParent / guardian / adult student

We are asking for your consent to allow us to make use of your insurance benefits for the following service(s):Specify service such as – Dr.’s appointment; evaluation; speech therapy; etc.) .

This means that you agree to file an insurance claim for the service(s) specified above. If you give your consent, the district will reimburse you for any out of pocket expenses that you may incur, including co-pays or deductibles. For reimbursement, you must provide the district with copies of any uncovered medical bills associated with the service(s) specified above within 60 daysof receiving the bill.

The district may not ask you to use your insurance if it would decrease your child’s available lifetime coverage or other benefit; result in you having to pay for services your child might need outside of the time your child is in school; increase premiums; or lead to discontinuation of these benefits or services.

If the district wishes to use your child’s insurance or benefits for services that are not specified above, the school district must getyour consent for any new procedure.

If you refuse to provide consent, this refusal does not relieve the school district of its obligation to provide required services to your child.

This consent is good for 365 days. If your child is no longer served by this school district, this consent does not transfer to a newdistrict. You can revoke your consent at any time.

By giving consent, you are acknowledging that (1) you have been fully informed of all information relevant to this activity; (2) youunderstand that granting consent is voluntary on your part and may be revoked by you at any time; and (3) if you revoke consent,the revocation is not retroactive; which means that it does not undo any activity that has already taken place.

I give my consent to use my insurance benefits for the service(s) specified above.

I do not give consent to use my insurance benefits for the service(s) specified above. I understand thatmy refusal does not affect my child’s access to any services to which he/she is entitled.

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Student

Form 13 - Consent to Use Insurance BenefitsStudent Name CSRS ID# Birth date

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

PURPOSE: The district shall keep a record of access to education records collected, maintained, or used. However, the district is not required to keep a record of access by parents, adult students, and authorized employees of the school district or other public agency with a legitimate educational interest in the records.


RECORD OF FILE ACCESS

Name of Student: Student ID Number:

Date of Access Name of Reviewer Purpose for Review of Files

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Form 14 - File AccessPage #Student Name CSRS ID# Birth date

PURPOSE: As a parent, guardian or student, you have the right to give permission or not give permission for the release of your child’s records with other persons or agencies. This request provides you with the opportunity to approve or not approve such a request unless release of records is allowed under one of the exceptions under the rules implementing the Family Education Rights and Privacy Act, FERPA, (for example, transfer of records from one school district to another).


AUTHORIZATION FOR RELEASE OF RECORDS


Date

I hereby authorize the release of records

FROM: TO:

Name of agency / person

Street Address

City / State / ZIP

Name of agency / person

Street Address

City / State / ZIP

Describe the records to be disclosed:

The reason for disclosing the record(s) is:

I understand that this information obtained will be treated in a confidential manner by the school district under the provisions of the Family Education Rights and Privacy Act (FERPA). FERPA prohibits disclosure of personally identifiable information without consent except in limited circumstances. Please note that if the request is for health or medical information, the medical informationreceived by the district is protected under FERPA privacy standards and not the Health Insurance Portability and Accountability Act(HIPAA).

This authorization is valid from: ____________________________________ to ____________________________________ .

Note: For release of medical records, the authorization can be no longer than 90 days after this authorization is signed.

I understand that my consent for the release of records is voluntary and I can withdraw my consent at any time in writing. Should Iwithdraw my consent, it does not apply to information that has already been provided under the prior consent for release.


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School/

District Building


Form 15 - Release of RecordsStudent Name CSRS ID# Birth date


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AddendumStudent Name CSRS ID# Birth date


ADDENDUM



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ADDENDUM



BACKGROUND QUESTIONNAIREGo to Forms List


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This is a “Print Only” formFamily Data

Child’s full name SS# Today’s Date

Birth date Age Gender: Male Female

Home address Phone

School Grade

Person filling out this form : Mother Father Stepmother Stepfather Other

Mother’s name Age Education

Occupation Phone: Home ( ) Business ( )

Father’s name Age Education


Step parent’s name Age Education


List all people living in the household:

Name Relationship to the child Age

If any brothers or sisters are living outside the home, list their gender and whether they are younger or older than the student:

Primary languages spoken in the home:

Other languages spoken in the home:


BACKGROUND QUESTIONNAIRE

Family Data continued

Page 2

Briefly describe your child’s current difficulties.

When was the difficulty first noticed?

What seems to help your child with this difficulty?

What seem to make the difficulty worse for your child?

Has the child received evaluation or treatment for the current problem or similar difficulties? YES NO

If YES, when and with whom?

Is the child on any medication at this time? YES NO

If YES, please note what kind of medication:

Social and Behavior Checklist

Place a check next to any behavior that your child currently exhibits.

Has difficulty with speech

Has difficulty with hearing

Has difficulty with language

Has difficulty with vision

Has difficulty with coordination

Prefers to be alone

Does not get along well with brothers and sisters

Is aggressive

Is shy or timid

Is more interested in things (objects) than people

Engages in behavior that could be dangerous to self or others (describe)

Has special fears, habits, or mannerisms (describe)

Is slow to learn

Wets bed

Bites nails

Sucks thumb

Has frequent tantrums

Has frequent nightmares

Has trouble sleeping (describe)

Rocks back and forth

Bangs head

Holds breath

Eats poorly

Is stubborn

Has poor bowel control (soils self)

Is much too active

Is clumsy

Has blank spells

Is impulsive

Shows dare devil behavior

Gives up easily

Other (describe)


BACKGROUND QUESTIONNAIRE

Educational History

Page 3

Place a check next to any educational problem that your child currently exhibits.

Has difficulty with reading

Has difficulty with arithmetic

Has difficulty with spelling

Has difficulty writing

Has difficulty with other subjects (please list)

Does not like school

Did anyone else in your family have academic difficulties?

Is your child in a special education class? YES NO

If YES, what type of class?

Has your child been held back in a grade? YES NO

If YES, what grade and why?

Has your child ever received special tutoring or therapy in school? YES NO

The following is a list of infant and preschool behaviors. Please indicate the age at which your child first demonstrated each behavior.If you are not certain of the age but have some idea, write the age followed by a question mark. If you don’t remember the age at whichthe behavior occurred, please write a question mark.

Showed response to mother

Rolled over

Sat alone

Crawled

Walked alone

Babbled

Spoke first word

Puts several words together

Dressed self

Became toilet trained

Stayed dry at night

Fed self

Rode tricycle

Behavior Age Behavior Age

Place indicate in the space below any current health problems, allergies, medications, or condition we need to know about. Use theback of this page if you have more information than the space allows you to write.

Child’s Medical History


What are your child’s favorite things to do?

Other Information

BACKGROUND QUESTIONNAIRE Page 4

1.

4.

2.

5.

3.

6.

What activities would your child like to do more often than he/she does now?

1. 2. 3.

What activities does your child not like?

1. 2. 3.

Has your child ever been in trouble with the law? YES NO

If YES, please describe briefly:

What disciplinary techniques do you usually use when your child behaves inappropriately? Place a check next to each techniquethat you usually use. There also is space for writing in any other disciplinary techniques that you use.

Ignore problem behavior

Scold child

Spank child

Threaten child

Reason with child

Redirect child’s interest

Tell child to sit on chair

Send child to his or her room

Take away some activity or food

Other technique (describe)

Don’t use any technique

Which disciplinary methods usually work for your child?

With what type of problem(s)?

Which disciplinary methods usually do not work for your child?

What have you found to be the best ways of helping your child?

What are your child’s strengths?

Is there any other information that you think may help us in working with your child? Use the back if necessary.

Thank you.



BACKGROUND QUESTIONNAIRE UPDATE

Student Name

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Please find enclosed a copy of the Developmental History/Background Questionnaire that you filled out on your child some timeago. The law requires us to have this updated every three years. So, could you please take a few minutes to fill in the informationbelow and return it to us. Thanks. Your help and cooperation in this matter is greatly appreciated.

1. Briefly explain any current medical or behavioral difficulties your child may be having.NONE See below

2. When was the difficulty first noticed?

3. What seems to help the difficulty?

4. What seems to make it worse?

5. Has your child received any evaluation or treatment for the current problem or similar problems? YES NOIf YES, then when and by whom?

6. Is your child on any medication at this time? YES NO

If YES, what kind of medication?

7. What disciplinary methods are usually effective with this child?

8. Which are not?

9. Would you like to add any additions or corrections to your original questionnaire? YES NO

If YES, what?

Signature Date

Date:

Background Information Update


DOCUMENTATION OF INVITATION TO INDIVIDUALIZED EDUCATION PROGRAM (IEP) MEETING

Student Name Birth date School DistrictResident Serving

1st Attempt

2nd Attempt

3rd Attempt

Method of Contact Date Attempted Results

IEP meeting scheduled date: and time:

My signature below assures that parent(s)/guardian(s) were:Informed of purpose, time, and location of meeting early enough to ensure an opportunity to attend and that the time and location of the meeting were agreed upon.Informed of persons invited to participate in the IEP meeting (include student if transition discussed).Informed that they may invite others to participate in the IEP meeting.Informed that the district would make any special accommodations necessary.Informed in native language or other mode of communication used by parent.

Signature

Title School Date

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ENTRY NOTE:Be sure to print the form out and sign it for each attempt made.

COMMENTS

1Documentation of IEP Meeting InviteStudent Name CSRS ID# Birth date


END OF YEAR SUMMARY

Student NameDate:

Birth date

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IEP Objectives Progress Made

Annual Goals

Continuing Goals

Summer Activities

1End of Year SummaryStudent Name CSRS ID# Birth date


END OF YEAR SUMMARY

Student NameDate:

Birth date

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IEP Objectives Progress Made

Annual Goals

Continuing Goals

Summer Activities

2End of Year SummaryStudent Name CSRS ID# Birth date


INTERVENTION FORM: GENERAL EDUCATION TEACHER

District:

Student Name:

Grade:

Date:Birthdate:

CSRS ID#:

Parents/Guardians:

Teacher: Para-educator:

Contact Phone:

Area(s) of Concern: Initial in class interventions / dates / evidence attached:________________________________________________

________________________________________________

________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Content:

Benchmark Score / Date:

Intervention Plan:

Progress MonitoringDates: Results:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Content:


Intervention Plan:


________________________________________________

________________________________________________

________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Content:


Intervention Plan:


________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Content:


Intervention Plan:


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PROPOSED AREAS OF EVALUATION / RE-EVALUATION

Date:

This letter is to inform you that your child, (Birthdate: ), has been referred for individual assessment to provide information for the determination of eligibility for special education and/or related services. The referral was made by .Your permission to assess your child is required. The evaluation will be performed by qualified personnel including a special education teacher, school psychologist, speech/language pathologist, or other specialists as needed. The evaluation is designed tomeasure skills, functioning levels, and classroom performance. The following checked areas may be evaluated:

Intellectual Ability........................Assesses your child’s ability to learn. Administered by a trained professional in a one-to-one setting.

Social Emotional.........................Collects information about your child’s social and emotional development. May include rating scales, personal inventories, behavioral observations, projective tests, and personal interviews.

Academic Achievement..............Measures your child’s achievements in such areas as listening comprehension, oral and reading comprehension, math calculation and reasoning, and written language.

Speech........................................Assesses your child’s articulation (speech sounds), voice, fluency, and oral motor skills forspeech.

Language....................................Assesses your child’s receptive and expressive language skills, including phonology, morphology, syntax, semantics and pragmatics.

Hearing....................................... Screens your child for hearing acuity,. Includes pure tone testing and impedance testing ofmiddle ear functioning.

Vision.......................................... Screens your child for visual acuity.

Adaptive Behavior...................... Assesses your child’s general behaviors at home, school, and community.

Classroom Observation..............Assesses your child’s performance and behavior in a classroom setting. Conducted by someone other than your child’s classroom teacher.

Physical Therapy........................Assesses your child’s gross motor (large muscles) skills and abilities for general or specificactivities.

Occupational Therapy................ Assesses your child’s fine motor (small muscles) skills and abilities for general or specific activities.

Vocational Interests/Aptitude......Assesses interests and capabilities for different types of work.

Developmental/Medical History..Collects information about your child’s developmental progress or medical history.

Other (describe)..........................May be suggested by the evaluation team to ensure that your child is assessed in all areas.

PROTECTION IN EVALUATIONAssessment materials, evaluation procedures, and tests shall be:a. Racially and culturally nondiscriminatory.b. Administered in the native language or mode of communication of the child

unless it is not feasible to do so.c. Validated for the specific purpose for which they are used or intended to be

used.d. Administered by qualified personnel such as special educator, school

psychologist, speech therapist, or a reading improvement specialist in conformance with the instructions provided by the producers of the testing instruments.

e. Administered in a manner so no single procedure is the sole criterion for determining an appropriate educational program for a child with a disability.

f. Selected to assess specific areas of educational need, not merely to provide a single general intelligence quotient.

This evaluation shall be conducted by a multidisciplinary team or group of persons from multiplediscipline, and shall include a teacher or other specialistwith knowledge in the area(s) of suspected disability.a. The current level of functioning (academically, socially,

intellectually).b. Visual and auditory acuity.c. Observation in an educational environment.d. Current physical status, including perceptual and motor

abilities.e. Vocational educational assessment.

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Name of referring person:

ENTRY NOTE:Put the name of the referring person below and it will be entered in the bodyof the letter.

Evaluation Re-evaluation

Proposed Areas of Evaluation


STUDENT PROGRESS REPORT

Student Name Birth date Grade School DistrictSurrogate needed? No Yes

Date of IEP meeting: IEP annual review date:Date of most recent summary analysis:

Measurable Goal:

Short-term Objectives

Annual Goal 1:

Present levels of performance as of

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COMMENTS:

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Date Status Additional Notes

FORM NOTES:There is a hidden calendar/date field to the right of the heading “Present levels of performance as of ....” Click to the right of the phrase to view the drop-down calendar. Youcan also manually adjust the date in that field.

Measurable Goals and Short-term Objectives fields pull from the Goals form and cannot be modified here.

Date and Status fields automatically populate information from the Goals form, but can be manually adjusted here. WARNING: Any changes made will also change the information on the Goals form.

Additional Notes are specific only to this form.

!Remember to indicate whichpages you want to print in theprint dialog box.

1Student Progress ReportStudent Name CSRS ID# Birth date






Annual Goal 2:


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3.

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COMMENTS:

Measurable Goal:

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Annual Goal 3:


1.

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3rd Quarter

4th Quarter

2.

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COMMENTS:

Measurable Goal:

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Annual Goal 4:


1.

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COMMENTS:

Measurable Goal:

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Student Name Birth date Grade School District

Surrogate needed? No Yes



Annual Goal 5:


1.

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4th Quarter

2.

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3.

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COMMENTS:

Measurable Goal:

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Annual Goal 6:


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2.

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3.

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COMMENTS:

Measurable Goal:

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STUDENT STUDY TEAM: CLASSROOM INTERVENTION RECORD

District:

Student Name:

Grade:

Date:Birthdate:

CSRS ID#:

Team Members Area(s) of Concern

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

In class interventions / dates / evidence attached (include grade-level universal screens attempted)

Benchmark date and score:

Progress monitoring dates (graph attached):

Progress monitoring dates (graph attached):

Diagnosis:

Tools used / Date:

Results:

Intervention Plan:

Progress Monitoring Dates (graph attached):

Plan Review:


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TEACHER EVALUATION / OBSERVATION DOCUMENT

Student Name Birth date GradeAge

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DateTeacher

Please address the following areas of concern and give specific information about your concerns.

Skills below grade level:

READING SKILLSword attackword recognitioncomprehensionother:

MATH SKILLScomputationrecall of factsconcept understandingother:

WRITTEN LANGUAGE SKILLSspellingpunctuationcontent, structureother:

FINE/GROSS MOTOR SKILLSgeneral coordinationbilateral integrationmobility (negotiating obstacles, stairs, runningphysical skills (jumping, ball skills, endurance, muscle strength)muscle tone (stiff, floppy)moving body in space (body awareness, clumsiness)fine motor skills (cutting, coloring, manipulatives)penmanship, copying, imitating shapes, designsself-help skills (buttoning, tying)eating skills (drools, spills, chewing, swallowing)other:

HEALTHenergy level (hyper, sleepy)nutritionhygienevisionhearingmedical problemsother:

Areas of Concerns Strategies Tried


1Teacher Intervention Document

Skills below grade level:

COMMUNICATIONS SKILLSfollows through on oral directionsparticipates in discussionexpression of thoughts/feelingsconcept developmentability to use and respond to a variety of question formssentence structure, complexitycommunication with peersarticulation of sounds: r l th s k (circle those that apply)voice quality, fluency (hoarse, stuttering, slow speech)other:

BEHAVIOR/STUDY SKILLSactivity level (overactive, underactive)attention spanself-organizationassignment completionworks independentlyfollows written directionsfollows oral directionscomplies with requestsother:

EMOTIONAL DEVELOPMENT/SOCIAL SKILLSpeer relationshipsinteraction with adultsself image, confidencefrustration, toleranceself control, temperassertiveness, aggressionmood, emotion, affectsensory defensiveness (tactile, auditory)play development (parallel, constructive, sensorimotor)other:

Areas of Concerns Long-term Interventions

LONG-TERM INTERVENTIONS: List all long-term instructional approaches to address the concern(s) (e.g., Chapter 1, LAP, individual tutor, social skills training, study skills training, peer tutoring, ongoing regular counseling), the dates and length (minimumtwo weeks) of intervention and its impact on the concern.

Adaptive Intervention Dates/Duration Impact/Change

Classroom Teacher DateReview by Evaluation Team on

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2Teacher Intervention Document


TERMINATION OF SPECIAL SERVICESGo to Forms List


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Student Name School DistrictResident ServingDate:

School district’s decision to terminate the Special Program:

Explanation (please include summary of assessment resultsIEP Goals and Objectives mastered as demonstrated through reevaluationGraduationStudent is 21 years of ageParent’s Right of Refusal

Additional information (include reevaluation results):

TEAM MEMBERS TITLE DATE

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1Termination of Special ServicesStudent Name CSRS ID# Birth date


TRANSFER STUDENT EVALUATION

Student Name Birth date Grade School District/

Resident ServingC.A.

Previous School District Contracted by Date

Data from previous school district

Student’s Disability Date receivedDetermined by

Date of most recent evaluation: Re-evaluation Due:

Review Due Date:

Current IEP date(s):

(Attachments)

Intellectual Cognitive

Academic

Adaptive Behavior

Test Date Given Evaluator/District

Results:VIQ PIQ FSIQ

Test Date Given Evaluator/DistrictWJ Clusters Grade Score Attained SS Criterion SS Severe DiscrepancyBasic Reading Skill:

Reading Comprehension:

Mathematics Calculation:

Mathematics Reasoning:

Broad Written Language:

Reading Fluency:

Oral Expression:

Oral Comprehension:

Other Evaluation Information

Scale Date By

Results

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1Transfer Student EvaluationStudent Name CSRS ID# Birth date

Medical

Scale Date By

Vision/Hearing Date:

Summary:

Communications


Articulation

Results: Rating:

Language


Results (scores):

ObservationsDate By

Motor:

Emotional/Behavioral Assessment:

Significance of Findings:


Based on the above information, the Evaluation Team has found with the findings for determination of eligibility as according to WAC .

Recommendations

The Evaluation Team agrees with the eligibility determination for this student as appropriately identified.

The Evaluation Team has found the student does not meet eligibility.

Signature Title

Signature Title

Signature Title

Signature Title

Signature Title

Signature Title

ENTRY NOTE:Enter the information below and it willbe inserted into the form text.

Evaluation Team Identifier:

Disability Identified:

WAC:

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INDIVIDUAL VISION AND HEARING SCREENING FORM


Grade

Age School District/

Resident Serving

Teacher

Date

Date

Frequencies failed:

Date Health File Review

Other

Vision Screening

Uncorrected

Corrected

Right

Pass

Left

FailBoth

Hearing Screening

Screened at 1000Hz, 2000Hz and 4000Hz bilaterally Pass Fail

Right ear

Left ear

1000

10002000

20004000

4000

School Health Records

No health concerns

Health concerns (please list to the right)

Student has a health plan (please see attached plan)

Submitted by:

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1Vision/Hearing Screening FormStudent Name CSRS ID# Birth date

prior written notice 34 cfr §300.503; wac 392-172a … safeguards for students and their families...

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