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__________________________ ___________________________ _____________________________ School
Signature of School Administrator
Date Received
REFERRAL TO DETERMINE ELIGIBILITY FOR SPECIAL EDUCAITON AND RELATED SERVICES
Student: _____________________________
DOB: ___________
Age: ________
Grade: _____________ Address:
______________________________ Referred by:
____________________________________
______________________________ Referral Date:
___________________________________ Telephone:
______________________________
Relationship to Child: ____________________________ 1.
AREA(S) OF CONCERN: Check major area(s)
of concern, and briefly describe the child's behavior, or performance in
each area checked. If you have identified more
than one area of concern, circle the area you consider to be the highest
priority.
__ Academic
___ Social/Emotional
___ Gross/Fine Motor
___ Activities of Daily Living
___ Health Related
___ Behavior
___
Communication
___
Other: ____________________ A.
Describe Specific Concerns: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ B.
Describe Alternative Strategies Attempted and Outcome
: (Use additional pages if necessary.)
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ED621 January 2006 |
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Student: ___________________________________________________
DOB: _______________________ 2.
Special Services History: Are you aware
of any special services provided for this child now or in the past?
___
Yes
__
No If Yes, describe the type, location, and provider
of the service. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 3.
Other Relevant Information: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 4.
Parent Notification: Has the parent/guardian
been notified about your concerns regarding this student?
___
Yes
__
No If Yes, method of
notification: _______________________________________________________________ Date(s) parent/guardian
was notified: __________________________________________________________ Signed:
_______________________________________________
Date: ____________________________
(Signature of individual completing
this form)
*Please note:
The special education referral date immediately affords
the student and parent(s) all special education procedural safeguards.
This referral also "starts the clock" with respect to
the timelines specified in RCSA 10-76d-13(a)(1) and (2) which provide that
"(1) The individualized education program shall be implemented
within forty-five days of referral or notice, exclusive of the time required
to obtain parental consent. (2) In the
case of a child whose individualized education program calls for out-of-district
or private placement, the individualized education program shall be implemented
within sixty days of referral or notice, exclusive of the time required
to obtain parental consent."
If a parent communicates in writing directly with
a staff member that they wish to refer their child for an evaluation to
determine his/her eligibility for special education services, the date the
staff member receives this written communication constitutes the date of
referral. If a parent communicates verbally
with a staff member that they wish to refer their child for an evaluation
to determine her/his eligibility for special education services, the staff
member should provide the parent with a copy of this referral form and,
when necessary, assist the parent in completing this form.
It should be understood that, in all instances, this is
a referral for an evaluation to determine eligibility for special education
services. Actual eligibility for special
education services is determined by the PPT only after an evaluation has
been completed. ED621 January 2006 |