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8. |
Referral for a Special Education
Early Childhood Evaluation |
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When to use this form:
This form is completed by the district’s
administrator/designee after an Informal Review has been
conducted with the person making the referral, the
child’s parents/guardian, or other qualified
individual(s) regarding the area(s) of concern. After
the informal review, a determination is made that there
is no need for a special education evaluation or that an
evaluation should be completed. If an evaluation is
needed, the referral form is completed by the school
administrator/designee on behalf of the child who has
not been placed in a special education program. The form
specifies the person(s) making the referral: parents,
teacher, or other individuals. If the referral is
submitted by a parent/guardian, the parent/guardian
areas of concern should be listed. If the determination
is made to refer the child for a special education
evaluation, the form is signed by the district’s
administrator/designee and parental/guardian consent is
requested to proceed with an evaluation. If the
determination is made not to refer the child for
an evaluation, the administrator/designee must notify
the parents/guardian in writing stating the reason(s)
why an evaluation is not necessary at this time and
provide a copy of the Parental Rights. |
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Printable Version
Computer Version
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9. |
Early Childhood
History |
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When to use this form:
This form is completed by the student’s parents/guardian
prior to completing a special education evaluation. The
form should be given to the parents/guardian for
completion and returned to the district/cooperative
staff. Parents/guardian should also be encouraged to
seek assistance in completing the form. |
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Printable Version
Computer Version
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11. |
Parental/Guardian In-put for an
Early Childhood Evaluation |
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When to use this form:
This form is completed by the student’s parents/guardian
prior to completing a special education evaluation. The
form should be given to the parents/guardian for
completion and returned to the district/cooperative
staff. Parents/guardian should also be encouraged to
seek assistance in completing the form. |
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Printable Version
Computer Version
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12. |
Prior
Written Notice -
Consent for an Evaluation  |
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When to use this form:
This form must be used prior to conducting a special
education evaluation for initial placement or conducting
a re-evaluation for special education services.
The form provides parents/guardian with prior notice and
also seeks parental/guardian permission to conduct the
evaluation or re-evaluation. The
evaluation/re-evaluation form identifies the types of
evaluations being proposed by the district/cooperative,
parents/guardian, or other qualified individuals.
Parents/guardian consent for evaluation/re-evaluation
may be revoked at any time. |
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(Updated
04-24-2011)
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14. |
Prior Written Notice
- Meeting |
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When to use this form:
This form is used any time the school or educational
agency proposes, or refuses, to change the student's
identification, evaluation, placement, or provision of a
free appropriate public education. Some of the
circumstances in which this form should be used include:
- When setting up a
meeting to discuss evaluation results and
eligibility.
- Before initially
placing a child in any program for special education
services.
- Before making a
change in placement (i.e., in services specified in
the IEP, such as adaptive PE, speech therapy, amount
of resource time provided; upon graduation; before
exiting a child from special education services; or
for expulsion or long-term suspensions sufficient to
constitute a change in placement.
- When proposing to
initiate or change the identification of the child.
- Before exiting a
child from special education services.
- When refusing a
parental request to initiate or change the
identification, evaluation, or placement of the
child.
- Before a change in
the student's annual goals that will constitute a
change in the provision of a free appropriate public
education (FAPE).
- In accordance with
discipline procedures (i.e., suspension/expulsion).
- After a parent
revokes consent for evaluation.
- After a parent
revokes consent for special education and/or related
services.
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(Updated
03-22-2011)
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17. |
Determination of
Eligibility/Continued Eligibility |
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The following Special
Education MDT Report shall be completed to determine
eligibility under the South Dakota Department of
Education Eligibility Criteria for ALL
categories.
When to use this
form:
This form is used by the student’s multidisciplinary
evaluation team in determining if the student has a
disability as determined by the South Dakota Department
of Education eligibility criteria. The form identifies
the disability categories, criteria, evaluation data
collected that was used in the determination, team
member’s agreement or non-agreement, and
parental/guardian notification. If the student’s is
determined eligible for special education services, the
MDT report is valid for up to 3 years or until a new
evaluation occurs.
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(Updated
04-24-2011)
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20. |
Individualized Education Program,
the IEP |
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When to use this form:
This form is the Department of Education’s IEP document.
The special education staff in conjunction with the IEP
team completes the IEP form. The IEP identifies the
special education services and related and supplementary
services that the student will be provided. The IEP form
reflects the student’s annual (1 year) educational plan
as agreed to by the student’s parents/guardian and the
school district. The School district/cooperative staff
should refer to the Department of Education’s IEP
Technical Assistance Guide during the development of an
IEP and in any subsequent modifications. |
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Printable Version
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20a. |
Addendum to the IEP |
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When to use this form:
This form is part of the Department of Education’s IEP document
and is completed when there is a change in any portion
of a current active IEP.
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Printable
Version
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22. |
Therapy Session
Statement |
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When to use this form:
When writing an IEP that requires related services,
be sure to include the statement that related services
will be provided when school is in session, except
when extended school year services are needed.
An example statement
may look like this:
Johnny will receive
speech therapy services two times a week for 20 minutes
each when school is in session. |
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Question and Answer |
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44. |
Individualized
Family Service Plan |
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When to use this form:
This form is a “Birth to Three Connections” document
that is completed by the service coordinators located
throughout the state of South Dakota. Any family,
parent and child who lives in South Dakota and is
eligible may receive services offered by “Birth to Three
Connections.” Children who have a developmental delay or
a disability can receive services under Birth to Three
Connections. |
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Printable Version |
