Form
RS36
Request for Integrated Assessment for an Education
Health and Care Plan
Under Section 36 of the Children and Families Act 2014
INCLUDED WITH THIS FORM
Family Conversation (separate form)
Medical Questionnaire (separate form)
Child's views (separate form)
Professionals reports (less than 6 months
old)
PLEASE TICK
Before completing the request form, have you read the LA's Criteria for Integrated
Needs Assessment and accompanying Guidance to completion to this form so that
you are able to say yes to the following points?
1. Have you considered if the child meets the needs criteria in relation to the four
categories of need – for example, for a child who is experiencing difficulties with
Cognition and Learning, are they functioning at levels indicated in the table on page 17
of the Criteria for Assessment. Please tick as appropriate:
YES
2. Have you illustrated through a Provision Map * or similar document all of the following:

Advice from external agencies – e.g. EPS / SaLT/Other?
YES

Advice implemented over at least 2 terms?
YES

Types of teaching approaches used?
YES

Strategies used have been reviewed and the reviews clearly show a lack of progress.
YES
3. Are you able to illustrate full use of School's delegated resources to the maximum level
together with evidence that the child needs a level of support in excess of Schools
£10,000 of provision to enable adequate progress to be made?
YES
V 4 Sept 2014
*If you are unsure about Provision Maps you can ask for training via Irene Punt or discuss with visiting Specialist staff.
What is the main reason that you are asking for this Integrated Assessment? (Please
note you are not required to complete this if you are responding to a Parental Request for
Assessment)
V 4 Sept 2014
Directorate of Children’s Services
Request for an Integrated Assessment
Under Section 36 of the Children and Families Act 2014
A request for an Integrated Assessment should not be made until the Guidance within the
SEN Code of Practice has been fully implemented and a graduated response applied to
meeting SEN. Requests should only be made in cases where the LA needs to determine
the special educational provision that a child or young person needs that is over and
above what is ordinarily available.
In any resulting Education Health and Social Care Plan this form will constitute all
or part of the Educational Advice.
1. General Details:
Surname:
Forename(s):
Date of birth:
Gender:
Placed in School Year (if appropriate) N R 1 2 3 4 5 6 7 8 9 10 11 12 13 14
In correct Year group?
Yes
Religion
No
Home Language(s)
Child’s Home Address
Postcode
Telephone Number
Please provide contact e-mail address for parents
Please
confirm
parents happy to be
contacted via e-mail.
Name of pre-school setting/school/college
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Page 1
Name of Parent(s)/Carer(s)
(including initials)
Relationship to child
Is the Child in Care to/Accommodated
by a Local Authority?
Yes
No
If so, state which Local Authority:
Name and contact details for social worker
Name and address of people with parental responsibility if different from above:
Postcode
Please indicate who has discussed this request for assessment with the people
with parental responsibility:
Did these people give their permission
for the request to be made?
Yes
No
Date on which discussed:
RS36 V4 Sept 14
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2.Background
Previous Schools (including pre-school settings if appropriate)
Name of school/setting
Dates attended
Details of recent attendance record over 3 terms (including present term)
Term
Possible
Actual
Details of any exclusions
Date of exclusion
No of days
Reason
Details of any medical condition which is relevant to the child’s special educational
Needs (please ensure medical questionnaire completed)
RS36 V4 Sept 14
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3. Levels of Attainment and progress overtime. (for pre-school
children see EYFS levels in section below)
MANDATORY
National Curriculum Attainments
Subject
Last
Key
SATs
Stage
results
Year
Teacher Assessment now
EYFS, P or
NC Level
English: Speaking & Listening
English: Reading
English: Writing
Maths
Please attach individual print out of most recent SATs results if appropriate
NB the Code “W” should only be used for cases of EAL.
Please use P Scales
Reasoning and Ability Tests (if available)
Name of test
Chronological Age
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Age equivalent
Standardised Score
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PROGRESS OVER TIME – MANDATORY
EYFS Profile (only applicable for children up to Reception)
Area
P S E& D
Phy development
Com and Language
Literacy
Maths
Und of World
Exp Arts and Design
Attainment on Entry
Attainment Mid Year
Attainment End of Year
P / National Curriculum levels (please use EYFS box to reflect previous levels if applicable)
2 years ago
Yr Group
P/NC Level
1 year ago
Yr Group
6 months ago
P/NC Level
Yr Group
Now
P/NC Level
Yr Group
P/NC Level
Reading
Writing
Number
Science
ndardised test results . * St Sc = Standardised Score
Skill tested
Test Used
2 years ago
Age equivalent
St Sc
1 year ago
Age
equivalent
St Sc
Now
Age
Equivalent
St Sc
Reading accuracy
Reading comprehension
Spelling
Numeracy
Other
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4. Strengths
Describe the pupil’s strengths/talents from first hand experience of the pupil in the teaching situation:
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5. Essential Evidence
Under which of the following categories does the pupil’s special educational needs match
the criteria as defined in the Children’s Services Directorate’s Criteria for integrated
needs assessment document.
Please indicate the priority need
Communication and interaction
Social, mental and emotional
health
Cognition and learning
Sensory and/or physical
Given all the data and information presented in the above sections please give a detailed
account below of the evidence that the child, despite the above interventions, meets the
criteria for integrated needs assessment. You will need to have close regard to the Criteria
for Integrated Assessment document which describes the essential and specific criteria for
each area of need. You need only provide information about the areas of need where you
have ticked the above boxes. Please use headings from the relevant sections of the
Criteria document and write a brief narrative under each making close reference to the
bullet points listed under them
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Essential
3. and specific Evidence continued
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6. Strategies and Approaches
Please give a brief account of strategies used in the "Assess, Plan, Review, Do" Cycle please
indicate where these have been as a result of involvement of external agency involvement
Action taken to address SEN
including in-class, small group
and individual support
What was the effect of this intervention e.g.
educational outcomes, learning gains
Assess,
Plan, Do,
review Cycle
One
Assess,
Plan, Do,
review Cycle
Two
Indicate
where
external
professional
advice
implemented
Provide brief chronology of reviews undertaken: PLEASE ENSURE THAT ALL INDIVIDUAL
PROVISION MAPS/REVIEWS ARE INCLUDED WITH THIS SUBMISSION AND CROSSREFERENCED AND PAGINATED
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Details of any Pupil Premium
Please detail any Pupil Premium received for this Pupil, how this funding has been
used and the outcomes.
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MANDATORY
7. Current allocated Resources/Provision from Notional SEN Budget A critical aspect in our decision making
is how you have made provision at school, using your notional SEN Budget and how you have adapted over time to secure
progress. We also suggest that you attach a copy of the pupil's timetable showing when support is allocated to them.
INTERVENTIONS
What is the provision –
e.g. TA support in
class/ specific
intervention or
programme?
How long and how
often is the
intervention- e.g. TA
support in class (attach
timetable) or specific 6
week intervention to
support literacy
How did the
intervention meet the
child's needs?
Was the intervention
individual or in a group
(if in a group, what was
the size?)
Who provided the
intervention? (Class
teacher, SENCO, TA?)
What was achieved?
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MANDATORY 8
Name of Agency
Please provide details of support currently provided by other agencies.
Nature of support
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9 The Way Forward PLEASE NOTE – THIS NEED NOT BE COMPLETED IN THE CASE OF PARENTAL
REQUESTS WHERE YOU FEEL YOU ARE MEETING NEEDS FROM NOTIONAL SEN FUNDING.
You are making this request for assessment on the basis that something additional to, or different from, what is happening now needs
to happen that cannot be provided within your SEN Budget. What, therefore is the school's view of what an EHC Plan would bring:
Outcome
Support required to meet
outcome – please detail
interventions required - eg
a speech and language
therapy programme
Frequency of
intervention/support – eg
30 mins daily
Who will provide the
support? – eg
classteacher/TA etc
Resources required – eg
Teaching assistant time/
Classteacher time/
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RS36 V4 September 14
Signed:
Headteacher/Member of Senior Leadership Team (please specify)
Date:
This form should be returned to:
SEN Services Administrative Officer,
Inclusion and Assessment (SEN)
Learning and Achievement
Children's Services
County Hall
Spetchley Road
Worcester
WR5 2NP
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