St. Lucie Public Schools
Exceptional Student Education 772-429-4570
Notice/Consent for Reevaluation
Student:
ID#:
School:
D.O.B.
Race:
Reevaluation Date: ____/____/____
Special Medical Needs:
Glasses? ____Yes ____No
Other Medical Information:
Parent/Adult Student:
Address:
City, State, Zip:
Exceptionalities:
Hearing Difficulty? ___Yes ___No
Grade:
A reevaluation is proposed for your child. This process involves gathering and reviewing information about your child to assist the IEP team in determining
whether he/she needs is still a child with a disability and whether or not the child needs to continue in the special programs in which he/she is placed. The
evaluation procedures, test, records and reports used as a basis for the proposal to reevaluate included the following:
Previous Referrals
Medical Information
Sensory Screening
Academic Assessments
Academic Grades
Classroom Based Assessments
Other
Learning Abilities Assessment
Emotional Assessment
Psychological Reports
Pre-referral Information
Functional Behavior Assessment
Observations by Teachers and Related Services Providers
The reevaluation review team met on ___/___/___,
and was comprised of the following members:
ESE Director Designee:
Parent/Adult Student:
ESE Teacher:
Regular Education Teacher:
Evaluation Specialist:
Other:
Achievement Tests
Speech/Language Evaluations
Cumulative Folder
Intellectual Assessments
Parent Input
Assistive Technology Evaluation
Method of Parent Involvement in Review Process:
Phone Conference:
Attendance at Meeting:
Other:
By Whom:
Date:
Reevaluation Questions: The team has answered the following questions:
1. Is more information needed to determine if this is still a
student with a disability? ____Yes ____No
The IEP Team proposes the following actions for your
child based on review of the previous questions:
2. Is more information needed to determine the present levels
of performance? ____Yes ____No
3. Is more information needed to determine if the student still
needs ESE services? ____Yes ____No
4. Is more information needed to determine if there is a need
to modify the IEP or support participation in the general
curriculum? ____Yes ____No
5. Is more information needed to determine whether special
considerations e.g., communication or behavior, are
interfering with the student’s progress? ____Yes ____No
6. Is more information needed to determine appropriate
placement? ____Yes ____No
____ A three (3) year reevaluation
____ A more frequent reevaluation
____No additional data/evaluation/or assessment
recommended (refer to section at left)
____Further evaluation for consideration of additional
programs (Additional pre-referral/referral documents
must accompany reevaluation request)
If the IEP team concludes that no additional testing is necessary to
determine the child is still a child with a disability, please proceed by
completing the Reevaluation/Documentation Report Form XED 0072
The other options were rejected as it did not meet the needs of your child, or was not necessary at this time. The evaluator(s) will select specific tests based on
your child’s needs as specified below:
Check () area (s) recommended for reevaluation based on committee decision:
Intellectual
Emotional Assessment
OT Evaluation
Academic
Speech Evaluation
PT Evaluation
Process
Language Evaluation
Assistive Technology Evaluation
Adaptive Behavior
Orientation/Mobility Assessment
Medical Eye Exam
Social and Developmental History
Functional Behavioral Assessment
Audiological Evaluation
Career Inventory
Behavioral Observations
Functional Vision Assessment
Other:
Narrative
Progress Report
Other:
Vision
Hearing
If other factors were relevant to the proposal, they may have included:__________________________________________________________________________
Consent for Reevaluation
____Yes, I give permission for reevaluation and understand
my rights in regard to this evaluation.
____ No, I do not give permission for the reevaluation for the
following reasons: ________________________________
____ I request a conference before giving permission for the
reevaluation.
____________________________________________________
Signature
Date
Record of Contact Attempts: For office use only
1. ______________________________________________________________
(Date)
(Type)
(Results)
By:_____________________________________________________________
2. ______________________________________________________________
(Date)
(Type)
(Results)
By: _____________________________________________________________
As a parent of a student with a disability, or an adult student with a disability, you have certain protections under the attached procedural safeguards. For
further explanation of your rights, contact the school guidance counselor or ESE Chairperson.
I have received a copy of the procedural safeguards: Parent/Adult Student Initials_________________ Date: ____/____/____
White:
ESE Audit File
Canary: Parent/Adult Student
Pink: Evaluation Specialist
XED0046 1/07