Files.dcs.tn.gov



|[pic] |Tennessee Department of Children’s Services |

| |Parent Response To Educational Placement |

Date:      

TO:      

Name of Parent, Guardian, or Surrogate

RE:      

Name of Student

On      , A Individual Education Plan Team Meeting, in which you were given the opportunity to participate, was held. During the meeting an Individual Educational Program was prepared for your child. After other possibilities were considered, the plan described below was recommended. The reason(s) for recommending the plan are stated below also:

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A description of each evaluation procedure, test record, and other report(s) factor(s) used in making the determination to recommend the plan are as follows:

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It is important for you to be aware of the following:

1. You have access to all school records, files and reports pertaining to your child, including results of the formal assessment and how the findings are used. You can request that records be amended.

2. You have the option to give or refuse program recommendations for your child.

3. You have the option to get an outside evaluation of your child, if you are not satisfied with the results of our assessment.

4. You have the right to request that this program be reviewed by the IEP Team at any time.

5. You have the right to request that the recommended program be reviewed by appropriate school administrators, if you do not agree with the program.

6. You have the right to an interpreter/translator, if you do not speak English.

7. You have a right to a hearing if efforts to resolve a difference of opinion regarding the education of your child cannot be resolved in informal meetings. After a hearing, you can have a verbatim record of the hearing and written findings and decision. If you disagree with the results, you may take the matter to court.

Parent Response to Educational Placement

Special Education Options

The following are the options considered in making special education decisions. The options considered are checked below. An explanation is given for options considered and rejected;

The regular program with additional support services. An aide or attendant helps the regular teacher. Special equipment or supplies may be provided for the student.

The regular program with a consulting teacher assisting the regular teacher who provides the special program.

The regular program with a special education teacher working with the student in the regular class-room.

The regular program with a speech and/or language teacher who works with the student outside the classroom.

The regular program with a special education teacher teaching the student in a resource room part of the day.

The regular or special school program combined with services of an outside public or private agency.

A full time program of instruction in a special education class in the regular school.

A special day school providing services needed by the student.

A residential facility for the student whose needs cannot be met in a day school or regular school special education class.

Home or hospital instruction for a student who cannot attend school either on a regular or temporary basis.

OTHER OPTIONS AND CONSIDERATIONS (Please print clearly);

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Parent Response To Educational Placement

You must return this page, within five days of its receipt, to the address listed on page one. Before returning it you must:

1. Check one of the spaces provided below.

2. Sign your name in the provided space.

3. Write the date on which you signed.

IF YOU FAIL TO RETURN THIS PAGE PROPERLY COMPLETED, YOUR CONSENT TO THE PROPOSED PROGRAM FOR YOUR CHILD WILL BE PRESUMED.

I understand my rights and agree to the recommended education program for my child.

I would like additional information about the recommended program for my child.

I do not consent to the recommended education program for my child.

The Department of Children’s Services has made me (us)aware of the proposed special educational services and I ( we) wish to decline these services for my( our)child and wish for him/her to participate in the regular education program.

I will request a formal hearing.

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Signature of Parent/Guardian/Surrogate Date

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