Referral for Re-evaluation Template (Grades K-6) - South Bend Community School Corporation

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Date rec’d by
SOUTH BEND COMMUNITY SCHOOL CORPORATION
certified
Special Education Department,
personnel
215 South St.Joseph St., South Bend, IN 46601
____________
574-283-8130
REFERRAL FOR RE-EVALUATION (Grades K-6)
All referrals must be screened by school personnel for completeness. Incomplete referrals will be returned to
obtain necessary information.
If required, the case conference is to be conducted within 50 instructional days of the date the written consent is
received by school personnel. See information on the Consent page to assist in determining the need for a case
conference within 50 school days. If required, please schedule a date/time below.
**The case conference committee meeting has been scheduled for:
(Date)_________________ (Time)_____________________(Location)______________________
**This conference must be scheduled at the time of this referral. Be sure to inform all CC members
immediately. A formal Notice of Case Conference must still be sent prior to the scheduled CC.
This referral has been reviewed for completeness: _____________________________________________
Principal Signature required
*FOR OFFICE USE ONLY*
Sections Complete:
Attachments
I
II
III___IV
V
___ __________________________
___ Academic Record/Test Record
Date rec’d-certified personnel:
50 instructional days:__________________
Rec’d in office:_______________________
Assigned to: _________________________________
Student
Birth Date
Age ________
Student ID #_____________ STN# ______________________ Ethnic Code ___________ Sex: M
F
Parent/Guardian Name _____________________________________________________________________
Street Address ___________________________________________________________________________
City
State
Zip
Phone ______________
School (Attending)
Home School (if different)___________________________
If private/parochial school, provide school’s address ________________________________ Zip __________
Phone # _________________________
Teacher___________________________________ Grade __________
Home Room No._______________
(Full Name)
If kindergarten: Full Day
AM
PM _______
Referral Source ____________________________ Contact person at school __________________________
(Name and title)
Rev. 9/09
Date rec’d by
SOUTH BEND COMMUNITY SCHOOL CORPORATION
certified
Special Education Department,
personnel
215 South St.Joseph St., South Bend, IN 46601
____________
574-283-8130
REFERRAL FOR RE-EVALUATION (Grades K-6)
All referrals must be screened by school personnel for completeness. Incomplete referrals will be returned to
obtain necessary information.
If required, the case conference is to be conducted within 50 instructional days of the date the written consent is
received by school personnel. See information on the Consent page to assist in determining the need for a case
conference within 50 school days. If required, please schedule a date/time below.
**The case conference committee meeting has been scheduled for:
(Date)_________________ (Time)_____________________(Location)______________________
**This conference must be scheduled at the time of this referral. Be sure to inform all CC members
immediately. A formal Notice of Case Conference must still be sent prior to the scheduled CC.
This referral has been reviewed for completeness: _____________________________________________
Principal Signature required
*FOR OFFICE USE ONLY*
Sections Complete:
Attachments
I
II
III___IV
V
___ __________________________
___ Academic Record/Test Record
Date rec’d-certified personnel:
50 instructional days:__________________
Rec’d in office:_______________________
Assigned to: _________________________________
Student
Birth Date
Age ________
Student ID #_____________ STN# ______________________ Ethnic Code ___________ Sex: M
F
Parent/Guardian Name _____________________________________________________________________
Street Address ___________________________________________________________________________
City
State
Zip
Phone ______________
School (Attending)
Home School (if different)___________________________
If private/parochial school, provide school’s address ________________________________ Zip __________
Phone # _________________________
Teacher___________________________________ Grade __________
Home Room No._______________
(Full Name)
If kindergarten: Full Day
AM
PM _______
Referral Source ____________________________ Contact person at school __________________________
(Name and title)
Rev. 9/09
Referral for Re-Evaluation (K-6)
2
Student’s Name: ______________________________
School: ________________________________
REASON FOR REFERRAL:
Current Primary eligibility _____________________
Current Secondary eligibility(ies) _______________________________________________________
Check one of the following three options:
Option 1
________ I suspect that the student is no longer eligible for special education services under the category of
__________________________________
Option 2
_______
I suspect a change in the student=s eligibility from _______________ to _____________________
_______
I suspect an additional eligibility area of ______________________________________________
Option 3
______
Information is needed to inform the case conference committee of the student’s special education
and related services needs (describe: _________________________________________________)
SPEECH-LANGUAGE PATHOLOGIST=S REPORT (IF APPLICABLE)
To be completed if student receives speech/language therapy but there is no need for updated speech/language
evaluation
Name of Speech-language Pathologist___________________________________________________________
Therapy began________________________Frequency/Duration of therapy_____________________________
Test results:________________________________________________________________________________
__________________________________________________________________________________________
Current goals:______________________________________________________________________________
_________________________________________________________________________________________
Describe behavior during therapy: ______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________
______________________________________________
DATE
SIGNATURE OF SLP
Referral for Re-Evaluation (K-6)
3
RETURN TO PSYCHOLOGIST BY
_______________________
CLASSROOM TEACHER COMPLETES THIS SECTION
Student’s Name: ______________________________
School: __________________________________
CLASSROOM TEACHER REPORT
Name of teacher(s) providing information ________________________ Subject area ___________________
How long have you had this student in your class?_________________________________________________
Attendance Information
good attendance
punctual
frequently tardy (# of days_____)
frequently absent (# of days _______)
Number of out of school suspension days this year __________ Reasons _______________________________
Number of APPLE Room/ISS referrals
Reasons _______________________________
READING
Attach Latest Quarterly Assessment Results
NWEA Reading Results (date administered) _________ Score/Cut Score _______/________
ISTEP Reading Results (date administered)
Score/Cut Score_______/_________
Current Reading level based on benchmarks: ________________________________
Current Comprehension score based on benchmarks: ___________________________
Current Fluency score based on benchmarks: _________________________________
Current grades in Reading: _______________________________________________
Is a modified grading scale used? Yes ___ No ___
SPELLING/WRITTEN LANGUAGE
Attach Latest Quarterly Assessment Results
NWEA Writing Results (date administered)________) Score/Cut Score _______/_________
ISTEP Writing Results (date administered _________) Score/Cut Score_______/_________
Latest Writing Prompt Scores: __________________________________________________
Current grades in Spelling/English _______________
Is a modified grading scale used? ________________
MATHEMATICS
Attach Latest Quarterly Assessment Results
NWEA Math Results (date administered)________) Score/Cut Score _______/_________
ISTEP Math Results (date administered _________) Score/Cut Score_______/_________
Current math level ______________________
Current grades in Math __________________
Is a modified grading scale used? __________
Summarize current special education services, including related services:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe any other interventions the student has received in school: ___________________________________
__________________________________________________________________________________________
Referral for Re-Evaluation (K-6)
4
Describe current performance in academic areas:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What modifications work best for this student in the classroom?______________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What additional information is needed to help you serve this student in the classroom? ____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Social/Emotional Functioning
Describe the positive social and emotional characteristics of this student:_______________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe the student's classroom behavior: _______________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe the student’s work habits: _____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe how the student interacts with peers and adults: ___________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe the student’s social skills : ____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Does the student exhibit any unusual or atypical behaviors? Yes _____ No _____ If yes, describe: __________
__________________________________________________________________________________________
Does the student have a Behavioral Intervention Plan? Yes _________ No _________
If yes, attach a copy.
If referred for behavioral reasons, provide detailed documentation of behavioral interventions.
__________________________________________________________________________________________
__________________________________________________________________________________________
Indicate any other information that the Multi-disciplinary team should know about this student.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________
____________________________________________________________
DATE
SIGNATURE OF TEACHER

Download Referral for Re-evaluation Template (Grades K-6) - South Bend Community School Corporation

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