OWENSBORO PUBLIC SCHOOLS
REFERRAL AND PLACEMENT PROCEDURAL CHECKLIST
Student’s Name: _____________________________ DOB: _____________ School: ____________________________
DATE COMPLETED
____/____/____
If student is not making adequate progress on research based interventions and the child is suspected of
having a disability, a referral (IC) is completed. The completed referral must include:
□ All personally identifying information at the top of the referral.
□ Areas of concern checked in the boxes.
□ Record review/educational history including preschool experience, absences, and all required
screenings.
□ Summary of research based interventions and progress monitoring.
____/____/____
After receipt of the referral document, the ARC Chairperson/Case Manager must:
□ Complete Determination of Student Representative (EC #3).
□ Determine ARC membership.
□ Assign Case Manager.
□ Send Meeting Notice (IC) providing at least 7 days notice prior to the meeting, unless the
parent and ARC Chairperson agree otherwise.
____/____/____
If ARC accepts the referral and parent is present, the ARC must:
□ Explain rights and give parent a copy of OPS Procedural Safeguards.
□ Document parents received the Procedural Safeguards (EC #5).
□ Discuss the reasons for the referral.
□ Discuss the areas to be evaluated, and obtain parent’s written permission to evaluate on the Consent
(IC). Print page 1 & 2 only.
□ Complete Conference Summary (IC).
____/____/____
If permission to evaluate is denied:
□ Obtain signature and check line #2 on Consent (IC).
□ Complete Conference Summary (IC).
□ Contact Director of Special Education.
____/____/____
ARC Chairperson/Case Manager receives all completed evaluations and reports, then must:
□ Make the report available to the ARC members.
□ Send Notice of Meeting (IC), providing at least 7 days notice prior to the meeting unless the parent
and ARC Chairperson agree otherwise.
____/____/____
Conduct the ARC Conference:
□ Offer rights and give additional explanation of OPS Procedural Safeguards.
□ Review the results of the evaluation.
□ Discuss the child’s eligibility for specially designed instruction; complete the appropriate Eligibility
Form (IC).
____/____/____
If the child is determined eligible and placement is proposed:
□ Obtain written permission for Specially Designed Instruction Consent (IC). Print page 3 only.
□ Develop the IEP
□ Complete Conference Summary (IC).
____/____/____
If the child is NOT eligible for services and/or placement is NOT proposed:
□ Complete Conference Summary (IC).
□ Consider 504 or discuss accommodations that may be helpful.
□ Place all documents in blue folder and file with cumulative folder.
____/____/____
If permission to place is denied:
□ Complete Conference Summary (IC).
□ Obtain signature on Consent noting denial of services (page 3) (IC).
□ Complete eligibility report.
□ Place all documents in blue folder and file with cumulative folder.
□ Contact the Director of Special Education.
July 2014