Education Triennial Assessment Plan

EDUCATION TRIENNIAL ASSESSMENT PLAN

Student Information

Student Name:

Date of Birth:    Student ID:

Parent / Guardian Contact

Referral and Timeline

Referred By:

Referral Date:

Proposed Assessment Start Date:    Anticipated Completion Date:

Proposed Areas of Assessment (check all that apply)

Cognitive / Intellectual Functioning
Academic Achievement (reading, math, written expression)
Speech and Language
Occupational Therapy (fine motor, visual-motor)
Physical Therapy (gross motor)
Functional Behavioral Assessment / Behavior
Social-Emotional / Adaptive Behavior
Sensory Processing
Assistive Technology Needs
Vocational / Transition Planning
Health / Medical Impact on Learning
Other:

Assessment Methods and Sources

Methods (check all that will be used):
Standardized tests
Curriculum-based assessment
Classroom observation
Parent interview
Student interview
Review of school and medical records
Informal assessment / work samples
Functional assessment
Behavior rating scales
Other methods (specify below)

Existing Data and Parent Input

Accommodations / Interpreter / Special Considerations

Interpreter Required:   If yes, Language:

Consent to Conduct Triennial Assessment

The school requests parental consent to conduct the evaluations described above for the purpose of determining continued eligibility for special education and related services. Assessments will be administered in accordance with applicable state and federal requirements and will be completed within the timeframe required by law following receipt of consent unless an agreed extension is documented.

I authorize the district to conduct the assessments and to review existing educational and medical records as necessary. I understand that I may revoke consent in writing prior to the administration of assessments, and that refusal to consent may affect the district's ability to evaluate eligibility. I also understand my rights regarding confidentiality of records and procedural safeguards, including the right to obtain copies of evaluation reports and to request an independent educational evaluation at my expense.

Parent/Guardian Provides Consent: Yes No

Release of records from outside providers may be necessary to complete the evaluation. I authorize release of relevant records as necessary for the purposes of this assessment: Yes No

Procedural Safeguards Acknowledgment

By signing below I acknowledge that I have been informed of my procedural safeguards and rights concerning assessment and special education. These rights include, but are not limited to: the right to review and obtain copies of records used in the evaluation, the right to participate in meetings regarding eligibility, the right to request an independent educational evaluation, and the right to challenge decisions through established dispute resolution processes.

Receipt of Notice of Procedural Safeguards: I acknowledge receipt

Additional Notes / Scheduling

Sign Now