Initial Evaluation Packet

Student Name: __________________________________

Grade: _____

ID: ___________

DOB: _____________

Teacher: _______________

Room: _____

Required Information
(or N/A)
BRING TO THE TIER III IAT MEETING (Refer or Refuse):
H_Student_Status Report (Chancery)
Response to Intervention Report (RTI/PGP Chancery)
Students Permanent Record Folder (for committee review)
Health Information Form with dates and results of vision & hearing
(nurse)
Classroom work samples showing strengths and weaknesses
Benchmark test scores (if available)
I-Station data (if reading referral)
Behavior documentation (if area of concern)
Copy of Permanent Record Card
Copy of Report Cards (last three years, if available)
Copy of Home Language Survey
Copy of Stanford/Aprenda printouts
Copy of TAKS and/or STAAR printouts
Copy of High Frequency Word Evaluation results
Copy of TPRI reports
For LEP students:
Copy of LEP folder (with oral language proficiency test results
and LPAC recommendations)
Copy of TELPAS printouts
TO COMPLETE AT THE IAT MEETING:
Referral for Disability Evaluation Form
Notice of Refusal to Test (if referral is denied)
Record of Communication with Parents Form
PARENT COMPLETES DURING OR AFTER THE IAT MEETING:
Notice of Full and Individual Evaluation Test Description
Consent for Full and Individual Evaluation
Receipt of Procedural Safeguards

Sociological Data Form

Private Evaluation Waiver (if needed)
Consent for Release of Medical Information (if OHI or OI referral)
Speech survey(s) for language/articulation/fluency (if SI referral)
TEACHER COMPLETES DURING OR AFTER THE IAT MEETING:
Behavior Rating Scale
Language Rating Scale
I-Station (or other reading software) Student Summary Report
Behavior Documentation forms (if needed)
Speech survey(s) for language/articulation/fluency (if SI referral)
DESIGNATED PERSON ENTERS REFERRAL INFO INTO CHANCERY

Event
Written request for evaluation (if applicable)
Date of IAT (with 10 school days of written request)
Date of consent for evaluation
Date referral and consent entered into Chancery
Date evaluation specialist received folder
45 calendar days from consent

Date