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Forms Checklist
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When to use this form:
These are the forms that are
generally used for an initial evaluation or reevaluation.
This page outlines the forms you will need and whom they are
given to. The numbers correspond to the form numbers on the
Coop website (www.cornbeltcoop.k12.sd.us). |
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Printable Version
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4. |
Parent Contact Concerning a Referral |
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When to use this form:
The school administrator/designee uses this form to
communicate to parents/guardian that a referral has been
submitted regarding their child’s progress at school. The
form invites the parents/guardian to call the school and
speak with the administrator or designee to set up a time to
discuss the referral. |
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Printable Version
Computer Version
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5. |
Referral for a Special Education Evaluation
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When to use this form:
This form is completed after the district’s Assistance Team
has made its determination that the student should be
referred for special education services. The form is
completed by a school administrator/designee on behalf of a
student who has not been placed in a special education
program. This form specifies the person making the referral
(parents, teacher, other individuals). If the referral is
submitted by a parent/guardian, the parent/guardian areas of
concern should be listed. The referral form is then
submitted along with the required documents listed on page 2
of the form to the school district/Cooperative’s evaluation
team. The referral form requires the school district’s
administrator/designee signature for authorizing the
evaluation. |
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6. |
Evaluation Cover
Letters |
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Psychological Evaluation Cover Letter |
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When to use this cover
letter:
This letter should be sent to parents/guardians whenever
a psychological evaluation is initiated, both for
initial evaluations and re-evaluations. This
letter should be sent home with the Parental/Guardian
Consent for Evaluation/Re-evaluation and
Parental/Guardian In-put for Evaluation forms. |
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BASC-2 Parent
Cover Letter |
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When to use this
letter: This letter should be sent to
parent/guardians along with the Parent BASC rating scale
when there are behavioral and/or social-emotional
concerns. |
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BASC-2
Teacher Cover Letter |
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When to use this letter
This letter should be given to at least one teacher
along with the Teacher BASC rating scale when there are
behavioral and/or social-emotional concerns. |
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Conners'
Parent Cover Letter |
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When to use this
letter: This letter should be sent to the
parent/guardian along with the Conners' Parent Rating
Scale when there are attention concerns. |
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Conners'
Teacher Cover Letter |
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When to use this
letter: This letter should be given to at
least one teacher along with the Conners' Parent Rating
Scale when there are attention concerns. |
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ABBAS Parent Cover Letter |
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When to use this
letter: This letter should be sent to the
parent/guardian when there are concerns about adaptive
behavior. |
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10. |
Parental/Guardian In-put for
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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10a. |
Parent Checklist |
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When to use this form: This
form is used to obtain background information from a
student's parent or guardian. |
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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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13. |
Classroom Observation Report
1 |
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When to use this form:
This form is to be completed by a special education
staff member while observing a student in a “general
education” classroom setting. The form identifies the
observer, the student, date of observation, classroom,
subject area, time started and ended. The form requests
that the observer record a summary paragraph describing
the student’s responses to instruction and curriculum. |
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Computer Version
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13a |
Classroom Behavior Observation |
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When to
use this form: This form is structured so that
evaluators can easily integrate information from direct
classroom observations into a comprehensive report.
One or two classroom observations may be included into a
single report. |
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Printable Version
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13b |
Teacher Checklist |
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When to use this form:
This form
integrates information provided by the student's
teacher(s) into a comprehensive report. For each
category the teacher is asked to check Yes or
No. For each Yes response (indicating
that the student exhibits the problem in the classroom),
the teacher is asked to specifically describe the
behavior, and rate how seriously the behavior impedes
the ability to learn. |
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Printable Version
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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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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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24. |
IEP Team
Placement Committee Over-Ride |
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When to use this form:
This form is used by the student’s IEP team to justify
the student’s eligibility for special education services
when evaluation data reflects that the student did not
meet the Department of Education’s eligibility criteria.
This form allows the district/cooperative IEP Committee
Team to provide for an exception (over-ride), by citing
other relevant evaluation data that would justify the
student’s eligibility for special education services.
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Printable Version
Computer Version
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