St. Lucie Public Schools
Exceptional Student Education (772) 429-4570
Eligibility and Assignment Staffing
Student Name:
D.O.B. ___/___/___
Zone 1 2 3
Sex:
Race:
Language:
ID#:
Parent/Legal Guardian/Surrogate:
Address:
City:
State:
Home Telephone:
Business/Emergency Telephone:
Present School:
Regular Education:
ESE Program:
Grade:
Informed Notice of Eligibility, Ineligibility, Dismissal, Discontinuation, Change of Program Eligibility
The School Eligibility & Assignment committee met on ___/___/___to consider your child’s eligibility. This was the purpose of
the meeting and this notice explains why the committee proposes or refuses to take the actions listed.
 Has been evaluated and meets current criteria for initial assignment in Exceptional Student Education.
 Is an in-state/out-of-state (circle) transfer student and meets current criteria for assignment in Exceptional Student
Education.
 Meets current criteria for permanent placement in Exceptional Student Education.
 Has been reevaluated and is recommended for reassignment from ___________________________________program to
assignment in _______________________________________________program.
 Is already enrolled in ________________________________________program and has been evaluated and meets current
criteria for assignment in _____________________________________program.
 Has been evaluated and does not meet eligibility for an/another (circle) Exceptional Student Education program at this
time.
 Has been evaluated and is recommended for dismissal from the following Exceptional Student Education program (s):
___________________________________________________________
 Is already enrolled in ______________________program and has been evaluated and meets current criteria for
assignment in ____________________ as a related service.
 Current data reviewed and team recommends discontinuation from the following related service (s) ___________________
 Exceptional Student Education Program (s):
(List all eligible programs)
Evaluation Instruments Administered
Name of Instrument
Description
Date
Committee Members
ESE Director Designee:
Principal/Designee:
Parent:
Evaluation Specialist:
Translator/Interpreter:
ESE Teacher:
General Education Teacher:
Speech /Language Pathologist:
Guidance Counselor:
Other:
Eligibility Review
(Eligibility is based on ESE Director/designee review of evaluation data and the staffing committee’s recommendations.)
Reviewed
Comments:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
ESE Director/Designee Signature :
Date ____/____/___
Three year (3 yr.) Reevaluation Date: _____/_____/_____
A copy of all evaluation reports used to determine eligibility
for Exceptional Student Education will be provided to the
parent.
 Check the method used to provide reports
 Parent in attendance at meeting
 Mailed to parent (Date: ____/____/____)
 Delivered by authorized school personnel
As a parent, you have certain protections under the attached
procedural safeguards. For further explanation of your
rights, and copies, please contact the school counselor or ESE
Chairperson.
I have received a copy of the procedural safeguards and
understand them. Initials_________ Date: ___/___/___
Placement Recommendations
All of the following placement options were considered.
Final recommendation is indicated by checks:
 Regular Class
 Special Day School
 Resource Room
 Individual Instruction
 Separate Class
in a home or hospital
 Other:
(specify)____________
Other placements did not:



Provide the least restrictive environment
Provide the appropriate program
Other: ___________________________________________
Other factors relevant to this proposal may include: ____________
____________________________________________________
Parent Consent for Initial Placement
The district proposes to place your child as indicated on the individual educational plan. Consent for placement is required for the first time
the student is placed in an Exceptional Student Education Program.
I/We the undersigned parent (s)/guardian (s) of the above named student (1) agree to his/her assignment; (2) do not agree to his/her
assignment in the Exceptional Student Education program (s). I/We understand the Parent/Guardian consent is required before initial
assignment. As a parent of a student with a disability, you have certain protections under the attached procedural safeguards. For further
explanation of your rights, and copies, please contact the school counselor or ESE chairperson.
Parent/Guardian Signature:
I have received a copy of the procedural safeguards and understand them.
White: Cumulative File or ESE Audit File
Canary: Parent/Adult Student
Date: _____/_____/_____
Initials:
Date:
______/______/_______
XED0090 Rev. 11/11