BROWNSVILLE INDEPENDENT SCHOOL DISTRICT
RESPONSE TO INTERVENTION PROCESS
REFERRAL FOR CONSIDERATION OF A SPECIAL EDUCATION
FULL AND INDIVIDUAL INITIAL EVALUATION
RTI-15
Date:
The Brownsville ISD RtI core team of
(campus) is recommending that a full and
individual initial evaluation may be needed to determine if
, ID#
, DOB
may be
qualified student with a disability under the Individuals with Disabilities Education Act (IDEA) and
additionally, if qualified, to determine the types of programs and services needed to appropriately serve
this student.
A campus representative must secure the written permission of the parent, guardian or adult student
prior to the initiation of evaluation activities. At the time of referral, a campus representative must
provide the parent, guardian or adult student with a copy of the publications entitled An Explanation of
Rights and Procedural Safeguards of a Parent with a Child with Disabilities in School and the Guide to
the Admission, Review and Dismissal Process. Campus representative must also obtain a signed and
dated receipt from the parent, guardian or adult student indicating their receipt of the abovementioned publications.
NOTE: Within 10 school days of above referral date, the Special Education Referral Packet must be
completed, attached to this referral, and sent to the Director of Special Education. Attach the entire RtI
student folder with ALL data previously collected and submit to the appropriate campus personnel
before submitting to the Director of Special Education for review. The RtI Case Manager should retain
copies of the original referral, the student’s most current intervention plan, and behavior intervention
plan, if appropriate.
REMINDER: A referral to Special Education should be initiated after an appropriate period of
interventions with written documentation of minimal or no progress. In addition, the RtI core team
must feel that the student may have a disability (one of 13 eligibility categories) and is in need of special
education and related aids or services.
SIGNATURES OF RTI CORE TEAM MEMBERS CONCURRING:
___________________________
___________________________
___________________________
Campus Principal/Designee
RtI Case Manager
Regular Education Instructor
**The purpose of this form is to provide a vehicle for communication and documentation between the Brownsville ISD RtI core team and the
Special Education Department of Brownsville Independent School District
August-2013