ANNUAL REVIEW DOCUMENT CHECKLIST
REQUIRED FOR EACH FILE AT CLOSE-OUT
Student: _____________________________ Grade 11-12:_________ Disability(ies)__________________
Caseworker:___________________ District: ___M1 ____M2 ____M7 School: ______________________
Related Services: ____ speech ___ OT ___ PT ___ ABT ___ Nursing ___Counseling ____ vision
___ hearing ____ mobility ____ transportation ____Other (specify) __________________
Supplementary: ___ transportation ___ Nursing ____Other (specify)_________________________
Extended School Year : ___ yes ___ no Reason________________________________________________
If “Yes”, what is area of need: _______________ Confirmed by (assessment):__________________________
DOCUMENT CHECK
ALL STUDENTS
 Letters (2) of invitation EXCENT with contact dates
for follow up and phone conferences and details of
reason for meeting
 Conference summary District and(Prior written
notice)EXCENT to detail all determinations
 Medicaid Form (District)
 IEP signed by AT LEAST regular ed (must be the
child’s teacher) , special ed and LEA and any related
services providers (EXCENT)
 Esy eligibility form (EXCENT)
 PH12/attendance notification (district) for school
secretary
 Final Progress Report (EXCENT)
 MAPS/Testview Profile – copy of ACES/functional
 Follow-up letter if parent was not at meeting FROM
EXCENT
STUDENT WHO WILL BE 13 OR OLDER AT
ANY TIME DURING THE 11-12 YEAR
 13-A checklist signed off by school team (NSTTAC)
 Evidence the student invited to the meeting (letter)
(EXCENT)
 Evidence an outside agency was invited
to the meeting if funding postgraduate(EXCENT)
Permission from parent/student to invite agency
(District)
 Notification of rights for students who will
be 17 or older during the coming year (District)
STUDENTS WITH RELATED SERVICES
 Related service provider was at meeting
 Related Services Referral form (District)
 Related Services present levels/copy of evaluation
(District)
 Related Service goals and objectives (EXCENT)
 Related Services Med. Necessity (District)
STUDENT WITH BEHAVIORAL PROBLEMS




New FBA (EXCENT)
NEW BIP (EXCENT)
Counseling addressed in IEP (EXCENT)
Interventions attempted during the year and the
results of those interventions- PLOP section
(EXCENT)
GRADUATING STUDENTS
 If getting diploma - everything in the “all students”
section except IEP, Medicaid and PH12
 Information on if transition plan has been
accomplished and student’s goals in conf summary
(District) or PWN (EXCENT)
 Exit Survey - if given (State)
 Summary of Performance (District)
 If no diploma and not 21 must have all documents as
if coming back. Listed as drop-out.
 If getting certificate of attendance – district letter
regarding return
ANY EVALUAITON/REEVALUATION
INCLUDING: 3 YR RE-EVAL, CHANGE OF
PLACEMENT (LRE TIME), CONSIDERATION
FOR NEW RELATED SERVICE OR
SUSPECTED NEW DISABILITY OR SPED OR
RELATED SERVICE DISMISSAL
 Must discussed with the district prior to the meeting
 Prior Written Notice of re-eval for eligibility/change
in services in letter(EXCENT)
 PWN of all changes and determination after meeting
(Excent)
 Documentation to support change- grades, etc.
 Re-evaluation review (Data Review for Evaluation)
must indicate exactly what disability is suspected in
last section- e.g., data required would be “full scale
evaluation for learning disability” (EXCENT)
 Permission to evaluate (EXCENT) DO NOT HAVE
THIS DATED AND SIGNED UNLESS ALL
OTHER DOCUMENTS ARE PRESENT.
 Multidispl team report containing results of
evaluation (EXCENT)
 All forms current (sp/v/hearing, etc)
 An indication on the conference summary/pwn that
the team requests a re-evaluation of the student and
WHY. (EXCENT OR district)
FOR STUDENTS WHO ARE TO GET ESY
 ESY Plan / addendum
CLEARED BY _______________________ Date________