Sample Special Education Form: R1



REFERRAL FORM

SPECIAL EDUCATION AND RELATED SERVICES

Form R-1 (Rev. 7/06)

COLFAX SCHOOL DISTRICT

□ Initial □ Reevaluation

|Name of child(Last, first, middle) |Date of birth |Grade |School |

| | | | |

|Anna Erickson |1/18/2005 |3 |Colfax |

|Name of parent or legal guardian |Address (Street, city, state, zip) |

| | |

|Aryn Erickson |N7904 730th Street. Colfax, WI 54730 |

|Telephone area/no. |Person making referral/title |Date parent notified of intent to refer |

| | | |

|(715)308-0864 | | |

| |Ms. Doering/General Education Teacher |06/26/2013 |

|Method of notifying parent of intent to refer |Is an interpreter needed? |

| | |

|□ Conference (□ Phone call □ Written |□ Yes □ No |

|Parent’s or adult student’s native language or other primary mode of communication if other than English (specify): |

| |

|Child’s native language or other primary mode of communication if other than English (specify): |

Date of receipt of referral by school district/LEA (July 1st, 2013)

(Note: the date the district receives the referral begins the 15 business day timeline in which to complete the review of existing information and notify the parents of whether additional assessments are needed.)

State reason you believe this child has a disability (impairment and a need for special education) - such as academic and non-academic performance and medical information; any special programs, services, interventions used to address this student’s needs and the results of those interventions, etc.

Anna has difficulties with speech-sound use. She continues to produce errors on speech sounds that are not typical for a child her age including /l/ and /r/ in the initial position of words. The teacher understands approximately 60% of what Anna says. Peers report even less intelligibility. This is evidenced by their hesitation to interact with Anna. Academically, Anna avoids contributing during large and small group activities. She is at her best interacting one-on-one with the teacher, Ms. Doering. It has been observed that Anna is becoming increasingly frustrated with her speech-sound errors and the impact on social communications and academics.

Ms. Doering made modifications to the classroom to facilitate participation in the classroom. Modifications included increased small group work. Ms. Doering also avoided direct questions at Anna to decrease pressure demands in the classroom. Even with these efforts, Anna is not making gains within the classroom.

If the child is transitioning from a Birth to 3 Early Intervention Program, and the district was invited by the designated lead agency to participate in the transition planning meeting, document the date of the meeting and who attended for the LEA or explain why the LEA did not attend:

□ N/A

INITIAL EVALUATION: NOTICE AND

CONSENT REGARDING NEED TO

CONDUCT ADDITIONAL ASSESSMENTS

Form IE-3 (Rev. 10/06)

COLFAX SCHOOL DISTRICT

[If you need this notice in a different language or communicated in a different way, or have

questions about this notice, please contact Ms. Meyer at Colfax Interpretation Services.]

Dear Ms. Erickson Date July 3rd, 2013

Previously you were notified of the school district’s intent to evaluate your child to determine whether he/she has a disability (impairment and need for special education). The individualized education program (IEP) team is responsible for this evaluation. You are a participant on the IEP team. The IEP team considered the following existing evaluation assessments, procedures, records or reports:

None. No existing evaluation reports.

The IEP team has determined that additional assessments or other evaluation materials are needed to determine whether your child has a disability.

□ You participated in making this decision on July 1st in the following way: Providing content and stating concerns over the phone

□ You did not participate in making this decision and the school district made 3 attempts to involve you as follows:

The school district needs your written consent (permission) before it can administer assessments or other evaluation materials to your child. With your consent the following assessments or other evaluation materials will be administered.

|Areas to be evaluated |Description of assessments and other evaluation materials and |Name of evaluator, |

| |titles, if known |if known |

| |Goldman Fristoe-Test of Articulation 2 |Ms. Demcak |

|Speech Sound Use | | |

|Speech Sample |Informal Assessment of Conversational Sample. Speech with be |Ms. Demcak |

| |analyzed. | |

|Academic Skills |Work Samples from Curriculum |Ms. Doering |

|(Math, Spelling, Writing) | | |

Other evaluation options considered, if any, and reasons rejected and a description of any other factors relevant to the proposed evaluation of this child:

□ None

Following the administration of these assessments or other evaluation materials the IEP team will meet to review the results of these assessments and other evaluation materials as well as other existing information available on your child, including information provided by you. Using the results of these assessments or other evaluation materials along with other available information, the IEP team will make a determination of whether your child has a disability including his or her educational needs. As a participant on the IEP team, you will be involved in this determination. Upon completion of the evaluation, the IEP team will prepare an evaluation report which will include documentation of your child’s eligibility for special education. You will be provided with a copy of the evaluation report. If the IEP team determines that your child is a child with a disability, the team will develop an IEP to meet your child’s needs and determine a placement to carry out the IEP. You will be provided with a notice of placement and a copy of your child’s IEP. If it is determined by the IEP team that your child does not have a disability, you will be provided with a notice of that finding.

If at any point during an IEP team meeting to determine your child’s eligibility for special education, develop an IEP, or determine a placement, you or other IEP team participants believe that additional time is needed to permit your meaningful involvement, additional time will be provided. This IEP team process may be concluded in one meeting or may require more than one meeting depending on individual circumstances

You and your child have protection under the procedural safeguards (rights) of special education law. Previously you received a copy of your procedural safeguard rights in a brochure about parent and child rights. If you would like another copy of this brochure, please contact the school district at the telephone number above. In addition to district staff, you may also contact Ms. Yanzick at 715-835-1023 if you have questions about your rights.

Sincerely,

(Insert signature here)

_____________________________________________________

Name and Title of District Contact Person

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PARENT CONSENT/PERMISSION TO ADMINISTER ASSESSMENTS AND

OTHER EVALUATION MATERIALS AS PART OF AN INITIAL EVALUATION

I understand the action proposed by the school district and

(please check appropriate box below, sign and date, and return one copy to the school district)

□ I give my consent for the school district to administer these assessments or other evaluation materials described in this notice to my child as part of an initial evaluation. I understand my consent is voluntary and may be revoked at any time before the administration of assessments or other evaluation materials.

□ I do not give my consent for the school district to administer these assessments or other evaluation materials described in this notice to my child as part of an initial evaluation. I understand that if I do not consent for the school district to administer these assessments or other evaluation materials, the school district may request mediation or initiate a due process hearing regarding whether those assessments or other evaluation materials should be administered.

(parent signature here) July 3rd, 2013

___________________________________________________ ____________________________

Signature of parent or legal guardian or adult student Date

EVALUATION REPORT

Form ER-1 (Rev. 10/06)

COLFAX SCHOOL DISTRICT

Name of Student Anna Erickson

TYPE OF EVALUATION: □ Initial □ Reevaluation

DATE ON WHICH ELIGIBILITY DETERMINATION WAS MADE 07/07/2013

(month/day/year)

THIS EVALUATION REPORT AND DETERMINATION OF ELIGIBILITY INCLUDES THE FOLLOWING (check all that apply)

□ Information from review of existing data □ Additional documentation required when

child is evaluated for a specific learning

disability

□ Information from assessments and other sources □ Documentation for determining Braille

needs for a child with a visual impairment

□ Determination of eligibility for special

education

INFORMATION FROM REVIEW OF EXISTING DATA

A. Summary of previous evaluations

None. Anna was not evaluated for special education referral prior to this current referral.

B. Information provided by parents

Ms. Erickson participated in an interview and attended the evaluation findings meetings. During the interview, Ms. Erickson reported that Anna's birth was unremarkable and all developmental milestones were met with the exception of her speech-sound errors. Anna was enrolled in Colfax Elementary School as a kindergartner and is presently attending there. She has not previously received speech services. Family and peers report low intelligibility in home and academic settings. Anna's social interactions have been decreasing as a result of peers having difficulty understanding her, and her social interactions continue to worsen. Anna struggles with production of /l/ and /r/ in the initial position of words.

C. Previous interventions and the effects of those interventions

Prior classroom modifications have been implemented; however, improvement has not been observed.

D. Current classroom-based, local or state assessments

(Teachers provide assessment scores and information on grade/classroom performance)...

E. Current classroom-based observations

Anna was observed in the classroom by Ms. Demcak. During this observation, Ms. Demcak reported that Anna had limited social interactions with peers. The social interactions observed demonstrated Anna's poor speech intelligibility during a 25-minute activity. After several attempts to interact with others and being ignored, Anna disengaged from the activity and began to work independently.

F. Observations by teachers and related service providers

Teacher reports speech-sound use errors. She continues to produce speech sound errors on /l/ and /r/ in the initial position of words (Teacher would add in a more detailed description).

INFORMATION FROM ASSESSMENTS AND OTHER SOURCES

In determining whether the student has a disability (impairment and need for special education) document consideration of other information including individual assessments, aptitude and achievement tests, independent and outside evaluations, teacher recommendations and information about the student’s physical condition, social or cultural background and adaptive behavior.

This is where the lead IEP team member would consolidate information from the following professionals:

Ms. Demcak (SLP): information would include results of the GFTA-2, informal classroom observation and speech sample analysis.

Ms. Doering (GE Teacher): reports and recommendations, teacher interview

There are no concerns relating to Anna's physical condition. Her social and cultural background is distinct to this area. Adaptive behaviors have been noted, including participation avoidance after several unsuccessful interactions with peers, family members, and teachers.

If assessments or other evaluation materials were not administered in accordance with the instructions provided by the publisher or producer of the assessments describe the extent to which there were variations in administration from standard conditions such as qualifications of the evaluator or methods of assessment administration including the language or other mode of communication that was used in assessing the student. □ N/A

DETERMINATION OF ELIGIBILITY FOR SPECIAL EDUCATION

A. This student meets the criteria for one or more of the following impairments:

Check all that apply:

□ Autism □ Orthopedically Impaired

□ Cognitive Disability □ Other Health Impairment

□ Emotional Behavioral Disability □ Speech or Language Impairment

□ Hearing Impairment □ Traumatic Brain Injury

□ Specific Learning Disability □ Visual Impairment (complete ER-3, “Determining

(complete ER-2, “Additional Braille Needs”)

documentation required for □ Significant Developmental Delay (first consider

specific learning disabilities”) other areas as the primary disability)

□ None found (complete C. below)

B. For each impairment identified, document how the student meets the criteria:

Anna met the criteria for a speech impairment. On a formal assessment, Anna fell more than 1.75 standard deviations below the mean. Anna consistently made speech errors on /l/ and /r/ sounds. Teacher reports that her errors are consistent in the classroom and have a negative impact on academic performance. Peers become frustrated due to Anna's low speech intelligibility. Anna is persistent, but beginning to show increased frustration.

C. Were impairments considered and rejected? □ Yes □ No

(If yes, document which one(s) and how the student did not meet the criteria)

D. By reason of the impairment(s) identified, does this student need or continue to need special education?

□ Yes □ No (In order for the IEP team to determine that the student needs special education, the IEP team must answer “yes” to question 1 AND list needs under 2b and/or 3 below)

|□ Yes |Does the student have needs that cannot be met in regular education as structured? |

| |(If yes, list the needs below. Use reverse side or attach additional pages if needed) |

| | |

| |It is not part of the third grade curriculum to work on speech sounds, such as /l/ and /r/. It is expected that 8-year-old students |

| |to have mastered these sounds. Anna would benefit from one-on-one and/or small group instruction. This instruction would include |

| |production practice for age expected speech sounds. Prior attempts at teacher modifications were not effective; therefore, |

| |one-on-one and/or small group instruction is warranted. Without remediation, we would predict further educational difficulties. |

| | |

| | |

|□ No |(If no, there is no need for special education). |

|□ Yes |Are there modifications that can be made in the regular education program to allow the student access to general education |

| |curriculum and to meet the educational standards that apply to all students? (Consider adaptation of content, methodology and/or |

| |delivery of instruction.) |

| |If yes, |

| |a) List modifications that do not require special education. (Use reverse side of page or attach additional pages if needed) |

| | |

| |Teacher will systematically pair Anna with suitable peers to promote positive interactions, encouragement, and engagement. |

| | |

| |Teacher will increase one-on-one interactions in order to present speech production models and feedback. |

| | |

| |Teacher will increase the amount of time class is conducted in small groups. |

| | |

| | |

| |b) List modifications that require special education. (Use reverse side of page or attach additional pages if needed) |

| | |

| |Anna would benefit from individual and/or small group instruction for /l/ and /r/. This would provide Anna with speech sound |

|□ No |production instruction and practice. Ms. Demcak will consult with Anna's general education teacher on a weekly basis to foster |

| |generalization to the classroom setting. |

| | |

| |(If no, go to question 3). |

|□ Yes |Are there additions or modification that the child needs which are not provided through the general education curriculum? (Consider|

| |replacement content, expanded core curriculum, and/or other supports.) |

| |(If yes, list below. Use reverse side of page or attach additional pages if needed) |

| | |

| | |

| | |

|□ No | |

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EVALUATION REPORT AND IEP COVER SHEET

Form I-3 (Rev. 10/06)

|Name of Student |DOB |Sex |Grade |

| | | | |

|Anna Erickson | | | |

| Parent or Legal Guardian |Telephone (area/number) |

| | |

|District of Residence |Current District of Placement |Race/Ethnic (if parent chooses to identify) |

| | | |

|Address |For students transferring between public agencies: |

| |IEP reviewed and adopted by ________________________________________________ |

| |On _____________________________________________ |

| |For students transferring between public agencies: |

| |Evaluation report reviewed and adopted by _____________________________________ |

| |On _____________________________________________ |

PURPOSE OF MEETING (Check all that apply):

□ Evaluation including determination of eligibility □ Initial or annual IEP development

□ IEP review/revision □ Develop a statement of transition goals and services (required for students age 14 and older, or younger if appropriate)

□ Placement □ Manifestation determination

□ Alternate assessment □ Determine setting for services during disciplinary change in placement

□ Other: _____________________________ □ Other: _____________________________

If a purpose of this meeting is IEP development, review, and/or revision related to the academic, developmental and functional needs of the child, the IEP team considered the results of:

Initial or most recent evaluation □ Yes □ Not applicable

Statewide assessments □ Yes □ Not applicable

District-wide assessments □ Yes □ Not applicable

Date of Meeting: August 15, 2013

(month/day/year)

IEP Team Participants Attending or Participating by Alternate Means in the Meeting:

|Parent/Guardian |Regular education teacher/title: |Regular education teacher/title: |

|Aryn Erickson |Ms. Doering/3rd Grade Teacher | |

|Student (if appropriate): |Special education teacher/title: |Special education teacher/title: |

|LEA Representative/Title: |Other: |Other: |

| |Ms. Demcak/SLP | |

|Other: |Other: |Other: |

If the parent did not attend or participate in the meeting by other means and did not agree to the time and place of the IEP team meeting, document 3 efforts to involve the parents:

INDIVIDUALIZED EDUCATION PROGRAM: PRESENT LEVEL

OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Form I-4 (Rev. 10/06)

Name of Student Anna Erickson

Describe the student’s strengths and the concerns of the parents about the student’s education.

Anna is pleasant and interactive third grade girl. She enjoys reading and playing outside during recess. She demonstrates strengths in reading, math, and art. Parent and teacher concerns include speech intelligibility and speech-sound production. Anna is displaying increased frustration with interactions due to peers ostracizing her during group work.

Describe the student’s present level of academic achievement and functional performance including how the student’s disability affects his or her involvement and progress in the general education curriculum. For preschool children, describe how the disability affects involvement in age-appropriate activities. (Note: Present level of performance must include information that corresponds with each annual goal)

Anna performs within normal limits in the following subjects: reading, math, and art. Anna's speech sound difficulties impact her performance due to decreased social interaction with peers and teachers during large and small group activities. Her GFTA-2 score was >1.75 standard deviations below the mean. Anna is judged to be 60% intelligible.

Will the student be involved full-time in the general education curriculum or, for preschoolers, in age-appropriate activities? □ Yes □ No

(If no, describe the extent to which the student will not be involved full-time in the general curriculum or, for preschoolers, in age-appropriate activities)

The student will participate in an alternate or replacement curriculum that is aligned with alternate achievement standards in: (check all that apply)

___ Reading ___ Math ___ Language Arts ____ Science ____ Social Studies

___ Other (specify):

SPECIAL FACTORS After consideration for special factors (behavior, limited English proficiency, Braille needs, communication needs including deaf/hard of hearing, and assistive technology), is there a need in any of the areas?

□ Yes □ No (If yes or student has a visual impairment, attach I-5, “Special Factors” page)

INDIVIDUALIZED EDUCATION PROGRAM

SPECIAL FACTORS

Form I-5 (Rev. 7/06)

Note: For any need(s) identified below, there must be a statement of the service(s) to meet that need (including amount/frequency, location, and duration) on the “Program Summary” page (I-9).

Name of Student Anna Erickson

A. Does the student’s behavior impede his/her learning or that of others? □ Yes □ No

(If yes, include the positive behavioral interventions, strategies, and supports to address that behavior)

B. Is the student an English Language Learner? □ Yes □ No

(If yes, include the language needs that relate to this IEP)

C. If visually impaired, does the student need instruction in Braille or the use of Braille?

□ Yes □ No □ Cannot be determined at this time

(If yes, include Braille needs; if no or cannot be determined, attach ER-3, “Determining Braille Needs” from the latest evaluation/reevaluation)

D. Does the student have communication needs that could impede his/her learning? □ Yes □ No

(If yes, include communication needs)

{If yes and the student is deaf or hard of hearing, identify the communication needs including (a) the student’s language; (b) opportunities for direct communication with peers and professional personnel in the student’s language and communication mode; and, (c) academic level and full range of needs including opportunities for direct instruction in the student’s language and communicative mode}:

Anna requires opportunities for direct instruction of speech sounds through one-on-one and small group instruction.

E. Does the student need assistive technology services or devices? □ Yes □ No

{If yes, specify particular device(s) and service(s)}

INDIVIDUALIZED EDUCATION PROGRAM

ANNUAL GOAL

Form I-6 (Rev. 10/06)

Name of Student Anna Erickson

Measurable annual academic or functional goal to enable the student to be involved in and progress in the general education curriculum, and to meet other educational needs that result from the student’s disability. (Note: present levels of academic achievement and functional performance must include information that corresponds with each annual goal)

Upon review: □ Goal met □ Goal not met

LTO 1: Anna will produce the phoneme /l/ in the word-initial position with 70% accuracy during conversational speech.

Benchmark 1: Anna will produce the phoneme /l/ in the word-initial position while practicing 3rd grade spelling words with 80% accuracy across one month (i.e., 8 practice sessions).

Benchmark 2: Anna will produce the phoneme /l/ in the word-initial position while reading 3rd grade leveled readers with 80% accuracy across one month (i.e., 8 practice sessions).

Benchmark 3: Anna will produce the phoneme /l/ in the word-initial position of words with 70% accuracy during conversational speech given clinician prompts and cues across one month (i.e., 8 practice sessions).

LTO 1: Anna will produce the phoneme /r/ in the word-initial position with 70% accuracy during conversational speech.

Benchmark 1: Anna will independently produce the phoneme /r/ in the word-initial position while practicing 3rd grade spelling words with 80% accuracy across one month (i.e., 8 practice sessions).

Benchmark 2: Anna will independently produce the phoneme /r/ in the word-initial position while reading 3rd grade leveled readers with 80% accuracy across one month (i.e., 8 practice sessions).

Benchmark 3: Anna will produce the phoneme /r/ in the initial position of words with 70% accuracy during conversational speech given clinician prompts and cues across one month (i.e., 8 practice sessions).

Procedures for measuring the student’s progress toward meeting the annual goal:

A baseline speech sample will be collected. The Speech-Language Pathologist will collect data on progress throughout therapy during each session. Ms. Demcak will consult with Ms. Doering and parents on a weekly basis.

Will the student participate in an alternate assessment aligned with alternate achievement standards for students with disabilities in any subject area? □ Yes □ No

(If yes, include benchmarks or short-term objectives for the student)

When will reports about the student’s progress toward meeting the annual goal be provided to parents?

Parents will be notified of Anna’s progress towards meeting the annual goal through an official report when report cards are issued. Parents will also be provided with weekly progress updates through phone contacts.

INDIVIDUALIZED EDUCATION PROGRAM:

SUMMARY

Form I-9 (Rev. 10/06)

Name of Student Anna Erickson

Projected beginning and ending date(s) of IEP services & modifications 09/02/2013 to 06/10/2014 (month/day/year) (month/day/year)

Physical education: □ Regular □ Specially designed

Vocational education: □ Regular □ Specially designed

Include a statement for each of I, II, III and IV below to allow the student (1) to advance appropriately toward attaining the annual goals; (2) to be involved and progress in the general education curriculum; (3) to be educated and participate with other students with and without disabilities to the extent appropriate, and (4) to participate in extracurricular and other nonacademic activities. Include frequency, location, & duration (if different from IEP beginning and ending dates).

| I. Special education |Frequency/ |Location |Duration |

| |Amount | | |

| | |Speech Room |School Year |

|Small-Group |30 minutes weekly | | |

| | | | |

| |30 minutes weekly |Speech Room | |

|Individualized Speech Therapy | | |School Year |

| | | | |

| |15 min weekly |Classroom | |

| | | | |

|Teacher Consultation with SLP |10 min weekly | |School Year |

| | |Phone Contact | |

| | | | |

| | | |School Year |

|SLP Consultation with Parents | | | |

| | | | |

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| | | | |

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| | | | |

II. Related services needed to benefit from special education including frequency, location, and duration (if different from IEP beginning and ending dates).

□ None needed to benefit from special education

Freq / Amt Location Duration

|□ Assistive Technology | | | |

|□ Audiology | | | |

|□ Counseling | | | |

|□ Educational Interpreting | | | |

|□ Medical Services for Diagnosis and Evaluation | | | |

|□ Occupational Therapy | | | |

|□ Orientation and Mobility (VI only) | | | |

|□ Physical Therapy | | | |

|□ Psychological Services | | | |

|□ Recreation | | | |

|□ Rehabilitation Counseling Services | | | |

|□ School Health Services | | | |

|□ School Nurse Services | | | |

|□ School Social Work Services | | | |

|□ Speech / Language | | | |

|□ Transportation | | | |

|□ Other: specify | | | |

|III. Supplementary aids and services: aids, services, and other |Freq / Amt |Location |Duration |

|supports provided to or on behalf of the student in regular education or| | | |

|other educational settings. | | | |

|□ Yes □ No (If yes, describe) | | | |

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|IV. Program modifications or supports for school personnel that will be | | | |

|provided. | | | |

|□ Yes □ No (If yes, describe) | | | |

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V. Participation in Regular Education Classes

□ The student will participate full-time with non-disabled peers in regular education classes, or for preschoolers, in age-appropriate settings.

□ The student will not participate full-time with non-disabled peers in regular education classes, or for preschoolers, in age-appropriate settings. (If you have indicated a location other than regular education classes or age-appropriate settings in the case of a preschooler in I, II, or III above, you must check this box and explain why full-time participation with non-disabled peers is not appropriate.)

I. Participation in Extracurricular and Nonacademic Activities

Will the student be able to participate in extracurricular and nonacademic activities with nondisabled students? □ Yes □ No

(If yes, include under I., II., III., and IV. any special education, related services, supplementary aids and services, and program modifications or supports necessary to assist the student. If no, describe the extent to which the student will not be involved in extracurricular and nonacademic activities with nondisabled students)

No assistance is necessary.

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For School District Use Only

Date school district received parent consent

______________________

(month/day/year)

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