Student Reevaluation Determination

STUDENT REEVALUATION DETERMINATION

School and Case Information

School District:    School Name:

Student Information

Date of Birth:    Student ID:    Grade/Program:

Parent / Guardian / Adult Student

Referral and Evaluation History

Referral Requested By:    Date of Referral:

Reason for Reevaluation

Primary Reason(s) for Reevaluation (check all that apply):

Academic progress concerns   Behavioral/emotional concerns   New medical/health information   Parent/guardian request

Sources of Information to Be Considered

Documentation and data to be reviewed as part of the reevaluation (check all that apply and add specifics where indicated):

Review of school records (attendance, grades, prior IEPs)
Classroom observation by qualified personnel
Standardized achievement/cognitive assessments
Curriculum-based measures
Parent/guardian input and interview
Teacher input and rating scales
Medical/health records and reports

Determination

After review of existing data and consideration of the factors described above, the multi-disciplinary team makes the following determination:

Reevaluation is required to determine continued eligibility, educational needs, or program placement.
Reevaluation is not required; sufficient information exists to make educational decisions at this time.

If Reevaluation Is Required — Proposed Assessment Plan

The following evaluations and procedures are proposed to complete the reevaluation (check all that apply and provide details as needed):

Cognitive assessment (intellectual functioning)
Academic achievement testing
Speech-language evaluation
Occupational therapy evaluation
Physical therapy evaluation
Functional behavior assessment / behavior observation
Psychological evaluation
Other:

Anticipated Start Date:    Expected Completion Date:

Parental / Adult Student Acknowledgment and Procedural Notice

By signing below, the parent/guardian or adult student acknowledges receipt of this determination and the proposed assessment plan where applicable. The parent/guardian or adult student retains the right to participate in planning, to provide written input, and to request an independent educational evaluation at public expense under applicable procedural safeguards. The district will maintain confidentiality of records and provide results and recommendations in a timely manner.

Parent/Guardian / Adult Student consents to proposed reevaluation assessments: Yes   No

Administrative Findings and Recommendations

Date of Determination:

Sign Now