PINELLAS COUNTY SCHOOLS
ESE INFORMED NOTICE AND CONSENT FOR EVALUATION
Dear Parent of:
DOB:
Grade:
Date:
Note: Reference to disability are not applicable for students referred for gifted eligibility ONLY
School personnel have recommended that your child receive an individual evaluation. This evaluation is recommended to determine:
the educational needs of your child; whether your child has a disability; and whether, as a result of that disability, your child needs
special education and related services.
This evaluation is proposed based on your child’s current educational performance and/or developmental progress, a review of your
child’s records and information provided by you (e.g.: conference forms, problem solving worksheet, intervention data, etc.).
Any previous evaluation which were used as a basis for this proposal include:
None
Specify:
Other options which school personnel considered include the following:
Educational interventions in general education (refer to intervention plan, if applicable)
Poor/insufficient response
Response is questionable
Demonstrates a continued need for ongoing intensive support to progress
Progress Monitoring Plan (PMP)
504 evaluation and plan
Not applicable: student not enrolled in school
Parent request
Other:
These options were rejected, as they were not adequate to meet your child’s educational needs.
Other factors relevant to the proposed evaluation are:
None
Specify:
Suspected area(s) of Disability (select all that apply) :
C - Orthopedically Impaired
J – Emotional Behavioral Disability
F – Speech Impaired
K – Specific Learning Disability
G – Language Impaired
L - Gifted
H – Deaf or Hard of Hearing
M – Hospital Homebound
I – Visually Impaired
O – Dual Sensory Impaired
P – Autism Spectrum Disorder
S – Traumatic Brain Injured
T – Developmental Delay (only PreK)
V – Other Health Impaired
W – Intellectual Disability
You will be contacted to provide input during the assessment process. Based on your child’s needs, the assessment may address the
following skills: cognitive, academic, adaptive, social-emotional, behavior, communication, functional vision (requires documentation of
a medical eye examination), motor/sensory (Physical Therapy requires a prescription from a Florida physician). Specific evaluations
may include an audiological evaluation, a functional behavior assessment, assistive technology needs, a social-developmental history,
or a developmental assessment. Data collected through progress monitoring and review of records will also be part of this assessment.
Areas to be addressed:
Sensory (visual acuity, hearing)
Speech
Cognitive/Developmental
Social/Emotional
Academics
Medical
You will receive a copy of all evaluation reports. Your specific rights concerning this proposal are described in your Procedural
Safeguards. If you want additional information on the proposed evaluation, or need to request a copy of your Procedural Safeguards
please contact:
School Personnel Name/Title
School Name:
At telephone #
You may also contact the Exceptional Student Education Office for Pinellas County Schools at 727-588-6032
We must have your consent before we can conduct this evaluation. Please check the box to indicate your decision. Sign and
date the form.
YES, I consent to the proposed evaluation, I have received and understand the Procedural Safeguards provided
NO. I do not consent to the proposed evaluation. I have received and understand the Procedural Safeguards provided
Signature of Parent, Guardian, or Surrogate Parent:
Date:
________________________________________________
This form also serves to notify you that if your child is Medicaid eligible and is eligible for a program for students with disabilities,
Pinellas County Schools may bill Medicaid for education and other health related services.
PCS Form 2-105 (Rev. 10/13)
Review Date 10/14
White – Staffing Folder
Yellow – Parent/Guardian
Pink – Case Manager
Category Y
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PINELLAS COUNTY SCHOOLS ESE INFORMED NOTICE AND