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7. |
Referral for a
Speech/Language Evaluation |
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When to use this form:
This form is completed by the speech/language
pathologist 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 speech and/or language 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 speech and/or language
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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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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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 |
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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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Printable Version
Computer 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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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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