Revised JP 1-4
Student Profile and Decision
REFERRAL STATUS
Supplemental Request by IEP Team
Create
Academic/Behavior Intervention Team (ABIT)
Mandated Re-evaluation/Disabled Student (1)
Update
Specially Requested Re-eval. By IEP Team
Initial Evaluation
JEFFERSON PARISH PUBLIC SCHOOL SYSTEM
Student Name: (Last) _______________________ (Suffix) ___ (First) _________________ (Middle) _____DOB: Click here to enter a date.
Student #________________________ Grade: Not Enrolled Ethnic Group: Choose an item. School: ____________________
Has student previously received an Individual Evaluation? ☐ No ☐ Yes If YES, Date of Eval.: Click here to enter a date.
Primary Exceptionality: _____________________
Secondary Except: _____________________
Is student currently receiving Special Education Services? ☐No ☐ Yes If YES, Date of most recent IEP:
Click here to enter a date.
If, YES, List Direct and Related Services from IEP: ___________________________________
SECTION 2 PARENT/GUARDIAN/SURROGATE INFORMATION:
Name: (Last)
Address: (No. & Street)
(City)
Telephone Numbers: (Home)
(Alternate Phone)
SECTION 3 Reason for Referral:
☐Reading Difficulties
☐ Social/Behavior Problems
☐Other Academic Difficulties
☐Court Ordered Evaluation
SECTION 4 Screening Request
☐Vision/ Hearing
☐Asst, Tech
☐Language/ Speech
(Suffix)
(First)
(Mid.)
(State)
(Work)
E-mail:
☐Communication Difficulties
☒ Visual Difficulties
☐ Parent Request
☐ Court Ordered Referral to (ABIT)
☐Motor
☐ Social Emotional
☐Health
Section 5
DECISION ABIT Entry Date: Click here to enter a date.
ABIT Decision:
☐ No further action at this time
☐ Tier 2 Intervention
☐ Individual Tier 3 Intervention (Required PAP Staff)
☐ Data suggest adequate progress continue with
Tier 3 Intervention
☐ Recommend Individual Evaluation
☐ Refer to outside agency, (Name of Agency: ________
☐Section 504 Eligibility Evaluation
☐ Other: ________________
☐ Hearing Difficulties
☐ Gifted
☐ Motor Difficulties
☐ Other (Specify)
(Zip)
(Emergency)
☐ Mathematic Difficulties
☐ Talented
☐ Health Problems
☐ Sensory
Areas of concern: _____________
☐Educational
_________________________
☐ Dominant language
IEP Team Decision
☐ Specially Requested Reevaluation
☐ Change of Classification (COC)
☐ Supplemental Evaluation
☐ Appropriate Placement (RAP)
☐ Other: ________________
Summary:____________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Section 6
ABIT Decision Date: Click here to enter a date.
ABIT Chairperson (Principal or ODR): ______________________________
Referring Teacher___ _____________________________________________
ABIT Team Member: ____________________________________________
ABIT Team Member Regular Education Teacher: ________________________________________
SPOE: ______________________ __________________________________ (Educational Diagnostician, SWEC, or School Psychologist only;
needed for IE, COC, Supplemental Evaluation requests)
Parent/Guardian/Surrogate/Student (if age of majority): ____________________________________
FORM COMPLETED BY: _______________________________________
COPIES TO:
_
Sp. Ed. Data Entry
_
Pupil Appraisal
_
Area Office
_
Cumulative Folder
Revised JP 1-4