Prior Written Notice 34 CFR §300.503; WAC 392-172A … Safeguards for Students and Their Families...
Transcript of 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.
2Addendum - Procedural Safeguards 2/2009Student Name CSRS ID# Birth date
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.
3Addendum - Procedural Safeguards 2/2009Student Name CSRS ID# Birth date
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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4Addendum - Procedural Safeguards 2/2009Student Name CSRS ID# Birth date
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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Reviewer’s Signature
Reviewer’s Signature
Reviewer’s Signature
Reviewer’s Signature
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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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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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-03035 Evaluation Report.................................................................... 5a
392-172A-03040 Evaluation Report.................................................................... 5a
392-172A-03045 Supplementary report for SLD (severe discrepancy)...............5aiSupplementary report for SLD (response to intervention)....... 5aii
392-172A-03050 Supplementary report for SLD (severe discrepancy)...............5aiSupplementary report for SLD (response to intervention)....... 5aii
392-172A-03055 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-03075 Supplementary report for SLD (severe discrepancy)...............5aiSupplementary report for SLD (response to intervention)....... 5aii
392-172A-03080 Supplementary report for SLD (severe discrepancy)...............5aiSupplementary report for SLD (response to intervention)....... 5aii
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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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Contact Phone
2Form 2 - Prior Written NoticeStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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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Set “To” field name to:Parent 1
Parent 2
Both Parents
Student
Form 3 - Parent ConsentStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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:
Parent / guardian / adult student signature Date
** 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 &
Set “To” field name to:Parent 1
Parent 2
Both Parents
Student
1Form 3a - Revocation of ConsentStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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 &
Set “To” field name to:Parent 1
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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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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):
Parent / guardian / adult student signature Date
** PLEASE SIGN AND RETURN THIS PAGE TO YOUR CHILD’S SCHOOL. **
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2Form 4 - Meeting InvitationStudent Name CSRS ID# Birth date
Student Name Birth date
Grade
CSRS ID Age
School
Gender Race / Ethnicity
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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)
2Form 5a - Evaluation ReportStudent Name CSRS ID# Birth date
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
3Form 5a - Evaluation ReportStudent Name CSRS ID# Birth date
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
4Form 5a - Evaluation ReportStudent Name CSRS ID# Birth date
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:
Signature / Title: Date:
Signature / Title: Date:
Signature / Title: Date:
Signature / Title: Date:
Signature / Title: Date:
Signature / Title: Date:
Signature / Title: Date:
Signature / Title: Date:
Signature / Title: Date:
A copy of the evaluation report including documentation of eligibility as was provided to the parent(s) / guardian(s) by:
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5Form 5a - Evaluation ReportStudent Name CSRS ID# Birth date
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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Return toEvaluation Report Form
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
Student Name Birth date
Grade
CSRS ID Age
School
Gender Race / Ethnicity
/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).
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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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:
2Form 5ai - SLD Supplement (Discrepancy)Student Name CSRS ID# Birth date
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).
Eligibility Determination
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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3Form 5ai - SLD Supplement (Discrepancy)Student Name CSRS ID# Birth date
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
Student Name Birth date
Grade
CSRS ID Age
School
Gender Race / Ethnicity
/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:
2Form 5aii - SLD Supplementary (RTI)Student Name CSRS ID# Birth date
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).
Eligibility Determination
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.
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3Form 5aii - SLD Supplementary (RTI)Student Name CSRS ID# Birth date
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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):
Parent / guardian / adult student signature Date
School district representative signature Date
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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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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):
Parent / guardian / adult student signature Date
School district representative signature Date
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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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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.
Parent / guardian / adult student signature Date
School district representative signature Date
I do not agree to the excusal. Please contact me to reschedule the meeting when required members are able to attend.
Parent / guardian / adult student signature Date
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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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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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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?
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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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
INDIVIDUALIZED EDUCATION PROGRAM
Student Name Birth date
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.
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Parent 2
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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:
2Form 6c - IEP without TransitionStudent Name CSRS ID# Birth date
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________
________________________________________________
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.
3Form 6c - IEP without TransitionStudent Name CSRS ID# Birth date
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
(min/wk)Location of Service
(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
(min/wk)Location of Service
(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
4Form 6c - IEP without TransitionStudent Name CSRS ID# Birth date
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:
Other Considerations
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:
5Form 6c - IEP without TransitionStudent Name CSRS ID# Birth date
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.
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
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6Form 6c - IEP without TransitionStudent Name CSRS ID# Birth date
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
Objective 2 Progress NotesDates
Method/Criteria for Evaluating Progress
Objective 3 Progress NotesDates
Method/Criteria for Evaluating Progress
Input Area for Measurable Goal (filling in these fields will automatically insert text in the form narrative).
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1Form 6ci/di - IEP Goals 1.Student Name CSRS ID# Birth date
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
Objective 2 Progress NotesDates
Method/Criteria for Evaluating Progress
Objective 3 Progress NotesDates
Method/Criteria for Evaluating Progress
Input Area for Measurable Goal (filling in these fields willautomatically insert text in the form narrative).
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2Form 6ci/di - IEP Goals 1.Student Name CSRS ID# Birth date
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
Objective 2 Progress NotesDates
Method/Criteria for Evaluating Progress
Objective 3 Progress NotesDates
Method/Criteria for Evaluating Progress
Input Area for Measurable Goal (filling in these fields willautomatically insert text in the form narrative).
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3Form 6ci/di - IEP Goals 1.Student Name CSRS ID# Birth date
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
Objective 2 Progress NotesDates
Method/Criteria for Evaluating Progress
Objective 3 Progress NotesDates
Method/Criteria for Evaluating Progress
Input Area for Measurable Goal (filling in these fields willautomatically insert text in the form narrative).
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4Form 6ci/di - IEP Goals 1.Student Name CSRS ID# Birth date
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
Objective 2 Progress NotesDates
Method/Criteria for Evaluating Progress
Objective 3 Progress NotesDates
Method/Criteria for Evaluating Progress
Input Area for Measurable Goal (filling in these fields willautomatically insert text in the form narrative).
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5Form 6ci/di - IEP Goals 1.Student Name CSRS ID# Birth date
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 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).
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
Objective 2 Progress NotesDates
Method/Criteria for Evaluating Progress
Objective 3 Progress NotesDates
Method/Criteria for Evaluating Progress
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6Form 6ci/di - IEP Goals 1.Student 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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
INDIVIDUALIZED EDUCATION PROGRAM (WITH SECONDARY TRANSITION)
Student Name Birth date
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.
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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
2Form 6d - IEP with TransitionStudent Name CSRS ID# Birth date
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.
Transition Service Staff / Agency Responsible IEP Goal
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.
Transition Service Staff / Agency Responsible IEP Goal
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.
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Be sure to complete theGoal Forms for each student.
3Form 6d - IEP with 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 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:
4Form 6d - IEP with TransitionStudent Name CSRS ID# Birth date
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________
________________________________________________
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:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
5Form 6d - IEP with TransitionStudent Name CSRS ID# Birth date
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
(i.e. - minutes/week)Location of Service
(setting) DurationStaff Responsible
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
(i.e. - minutes/week)Location of Service
(setting) DurationStaff Responsible
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.
6Form 6d - IEP with TransitionStudent Name CSRS ID# Birth date
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:
Other Considerations
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:
7Form 6d - IEP with TransitionStudent Name CSRS ID# Birth date
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.
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
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8Form 6d - IEP with TransitionStudent Name CSRS ID# Birth date
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).
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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).
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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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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)).
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
(i.e. - minutes/week)Location of Service
(setting) Duration Provider
Revisions to Services Provided (if any)
Special Education and Related Services
ServiceInitiation
DateFrequency
(i.e. - minutes/week)Location of Service
(setting) Duration Provider
Supplementary Aids/Services, Program Modifications, and/or Support to School Personnel
Parent / guardian / adult student signature Date
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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)
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
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)
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)
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)
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
MANIFESTATION DETERMINATION
Student Name
Grade
CSRS ID
Case Manager
Disability Meeting Date
Parent / Guardian District Representative
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Signature of Officially Designated Representative of District Go to Forms List
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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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
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)
2Form 9 - Summary of PerformanceStudent Name CSRS ID# Birth date
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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3Form 9 - Summary of PerformanceStudent Name CSRS ID# Birth date
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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.
2Form 10 - Due Process Hearing RequestStudent Name CSRS ID# Birth date
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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3Form 10 - Due Process Hearing RequestStudent Name CSRS ID# Birth date
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
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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.
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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).
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
AUTHORIZATION FOR RELEASE OF RECORDS
Student Name Birth date
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.
Parent / guardian / adult student signature Date
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District Building
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Form 15 - Release of RecordsStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
ADDENDUM
AddendumStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Occupation Phone: Home ( ) Business ( )
Step parent’s name Age Education
Occupation Phone: Home ( ) Business ( )
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 Information
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 Information
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
Background Information
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 Information
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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:
Benchmark Score / Date:
Intervention Plan:
Progress MonitoringDates: Results:
________________________________________________
________________________________________________
________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Content:
Benchmark Score / Date:
Intervention Plan:
Progress MonitoringDates: Results:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Content:
Benchmark Score / Date:
Intervention Plan:
Progress MonitoringDates: Results:
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Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
1.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
2.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
3.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
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.
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1Student Progress ReportStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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:
Short-term Objectives
Annual Goal 2:
Present levels of performance as of
1.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
2.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
3.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
COMMENTS:
Measurable Goal:
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2Student Progress ReportStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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:
Short-term Objectives
Annual Goal 3:
Present levels of performance as of
1.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
2.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
3.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
COMMENTS:
Measurable Goal:
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3Student Progress ReportStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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:
Short-term Objectives
Annual Goal 4:
Present levels of performance as of
1.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
2.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
3.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
COMMENTS:
Measurable Goal:
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4Student Progress ReportStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
STUDENT PROGRESS REPORT
Student Name Birth date Grade School District
Surrogate needed? No Yes
Date of IEP meeting: IEP annual review date:Date of most recent summary analysis:
Short-term Objectives
Annual Goal 5:
Present levels of performance as of
1.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
2.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
3.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
COMMENTS:
Measurable Goal:
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5Student Progress ReportStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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:
Short-term Objectives
Annual Goal 6:
Present levels of performance as of
1.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
2.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
3.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
COMMENTS:
Measurable Goal:
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6Student Progress ReportStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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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Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
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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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
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
Test Date Given Evaluator/District
Articulation
Results: Rating:
Language
Test Date Given Evaluator/District
Results (scores):
ObservationsDate By
Motor:
Emotional/Behavioral Assessment:
Significance of Findings:
2Transfer Student EvaluationStudent Name CSRS ID# Birth date
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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3Transfer Student EvaluationStudent Name CSRS ID# Birth date
Educational Service District 1014202 South Regal Street • Spokane, WA 99223 Phone (509) 789-3527 • FAX (509) 323-2747
INDIVIDUAL VISION AND HEARING SCREENING FORM
Student Name Birth date
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