FREDERICK COUNTY PUBLIC SCHOOLS PARENTAL CONSENT FOR EVALUATION & STATE REPORTING ‘School: Monocacy Elementary Date: 8/31/2016 ‘The Schoo! Individual Education Program (IEP} Team has recommended that your child, Jamal Giles be evaluated to obtain information that will ‘assist the school in educational planing. Ifyou agre to the proposed inital evaluation twill occur within 60 calendar days (Re-evaluation willbe ‘completed within 99 calendar days), Please refer to the MSDE “Procedural Safeguards/Parental Rights” booklet, page 4, under Evaluation for timeline information. The reason for this referrals —— 10 determine whether or not your child has an educational dsabilty that requires spacial education services X to determine progress since your chile’ lst education evaluation other, specty ‘The procedures/assessment instruments checked below are tobe used when evaluating your child: ES Assessor X Assessment for Reading, Mathematics, and/or Written Language (Woodcock-ohnson, Tests of Certified Special Education Teacher Achievement) X Psychological Assessment ~ may include one or more ofthe following types of assessments Centified Schoo! Psychologist + Cognitive/intellectual + Perceptual + Behavioral + Social/Emotional ‘+ Developmental/Adaptive © Memory/tearning ‘Other techniques atthe discretion ofthe psychologist Functional Behavioral Assessment X Speech-Language Assessment Speech/Language Pathologist Functional hearing assessment(may include Test of Auditory Comprehension) Itinerant Teacher ofthe Hearing impaired ‘Audiotogicl Functional vision assessment (may include Diagnostic Assessment Procedure for Visual Itinerant Teacher of the Visually Impaired Functioning) —— Occupational and/or Physical Therapy assessments (may Include Oral-Motor, Fine Motor, Visual Perceptual, Neuro-developmental, Gross Motor, Manual Muscle] Adapted Physical Education Assessment —— Transition Assessment (may include Briganee, Transition Behavior Scale, Enderle-Severson, Rating Scale) X Classroom Observation X Other, specify Adaptive Skills ‘School Psychologist Please see below for an explanation of your rights concerning your child's evaluation. If yau have any questions about the information contained in this letter, please call your chiles case maneger, Rose Kraft at the school240.236-1400, If you have any questions about the psychological ‘assessment, please call Rollo Jones School Psychologist, at240-236-4600. "eis important that you understand your rights with regard to your child's evaluation. You have the right to review the procedures/assessment Instruments used to assess your child's performance. Once the assessment is completed, you will receive, in writing, a copy of the assessment report. The report wil be maintained in’@ CONF!DENTIAL fle and wil nt be shared with persons or agencies, other than school systems and those ‘approved under Public Schoo! Laws, without your written authorization. A record will be kept ofthe persons you authorize to read the report with the date and purpose for which the review eccurred. This record willbe available to you at anytime. A aster file of psychological assessments willbe maintained a the Department of *sichological Services under the direct supervision ofthe Director for Special Education and Psychological Services. ( See other side ) SE2 Reveed 14/15,