Preschool Screening Procedures
Child's Name: _______________________________ Screening Date: _____________
Prior to Screening (mail to parents) (Screening Secretary)
Telephone Screening
Letter to parents with screening appointment
Developmental and Medical History
Authorization for Release of Records
Consent for Preschool Screening
Parental Concerns Checklist
Preschool Teacher/Daycare
Provider Questionnaire
Map of Wilkes
At and Following the Screening (Team)
Gather documents (in italics above) from parents (keep checklist to assure all have come in)
Complete documentation of screening results used to write Preschool Screening
Report
Determine who will complete assessment:
Evaluation Case Manager: ____________________
Prior to Evaluation (mail to parents) (Screening Secretary)
Copy of completed Preschool Screening Report
Complete Prior Written Notice for Special Education Referral for those referred for
evaluation; send original to parent and retain a copy for Special Ed file
Copy of Procedural Safeguards, dated October 2013
Prior to Evaluation (copies sent to all staff completing an assessment) (Screening Secretary)
Preschool Screening Report
Parental Concerns Checklist
Developmental and Medical History
Preschool Teacher/Daycare Provider Questionnaire
Authorizations for Release of Records
The following documents should be retained in PS Screen/Eval working file, and returned
to the EC Coordinator (Maria) upon completion of the evaluation:
 Consent for Preschool Screening
 Parental Concerns Checklist
 Preschool Teacher/Daycare Provider Questionnaire
 Authorizations for Release of Records
 Developmental and Medical History *
 Preschool Screening Report *
 Prior Written Notice for Special Education Referral *
*to be filed in Special Education file if evaluation is recommended
rev.01/14