Professional Documents
Culture Documents
Dear ______________________________________:
Others invited to attend with knowledge of the student and/or for Post-Secondary Transition Planning.
Name Position/Affiliation
____________________________________________ ______________________________________
____________________________________________ ______________________________________
____________________________________________ ______________________________________
____________________________________________ ______________________________________
____________________________________________ ______________________________________
Sincerely,
Signature: ______________________________________________________________
Enclosures: Form 1
January 1, 2013
Special Education Evaluation Plan and Report – Cover Page
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
B. Questions:
Answers:
1) ______________________________________ ____________________________________
2) ______________________________________ ____________________________________
3) ______________________________________ ____________________________________
4) ______________________________________ ____________________________________
5) ______________________________________ ____________________________________
Does the Evaluation and Planning Team conclude that the student met the disability determination
in the area of _______________________________________? Yes No
At least one basic skill must be determined to have an adverse effect on educational performance using
a minimum of three of the six individual measures of school performance. A student is not found to
have an adverse effect if one basic skill is identified using only three similar measures of school
performance (i.e. three reading comprehension scores from three versions of individually administered
achievement tests).
All six measures of school performance must be reviewed until either three measures are determined to
meet the adverse effect criteria or at least four of the measures are determined not to have met the
adverse effect criteria. (Documentation is required whenever any of the six individual school
performance measures may not be applicable due to the student’s age or grade level.)
No single school performance measure can be required to prove adverse effect. For example, even if the
student does not demonstrate an adverse effect from a review of an individually administered
achievement test, the student can be determined to have an adverse effect if at least three of the other
five school performance measures meet the adverse effect criteria.
Basic Skill Area(s): Basic Reading Skills Reading Comprehension Reading Fluency (SLD only)
Motor Skills Mathematics Calculation Mathematics Reasoning
Written Expression Listening Comprehension Oral Expression
The documentation requirement for this section is the one basic skill and a minimum of three school performance
measures. However, if the student has additional educational or functional needs they MUST be addressed in the
needs section of this Evaluation Report. Once a student has been found eligible in one adverse effect basic skill
category, their additional special education services may be offered based upon the needs of the student or the
appropriateness of other standard supports available within their school. In addition, if a student is found not to
have an adverse effect in any one of the basic skills assessed, it would be necessary to document each additional
basic skill area to prove ineligibility.
Assessment Areas/Evaluation Procedure Professional or Team Role Responsible
1) ______________________________________ ____________________________________
2) ______________________________________ ____________________________________
3) ______________________________________ ____________________________________
4) ______________________________________ ____________________________________
5) ______________________________________ ____________________________________
Measure 1 Yes
Above
Individually
administered
No
Summarize discussion related to any individual factors
nationally-normed Below
achievement test
observed during testing that impacted these results. N/A
Results:
Measure 2
Yes
Normed group- Above
administered No
Summarize discussion related to any individual factors
achievement tests or Below
normed curriculum- observed during testing that impacted these results. N/A
based measures
Results:
Measure 3 Yes
Above
Grades or other
measures of
No
Describe how the student’s functional skills affect grades or
educational Below
proficiency
other measures of educational performance. N/A
Measure 4 Yes
Above
Curriculum-based
such as benchmark
No
Describe how the student’s functional skills affect progress in
assessments or Below
progress monitoring
the general education curriculum for their grade level. N/A
Results:
Measure 5 Yes
Above
Criterion- No
Describe how the student’s functional skills affect progress in
referenced Below
assessments the general education curriculum for their grade level. N/A
Results:
Measure 6
Yes
Other measures of Above
school performance
(Student work
No
Describe how the student’s functional skills affect grades or
samples, classroom Below
observations or
other measures of educational performance. N/A
portfolios)
Does the Evaluation and Planning Team conclude that the student met the adverse effect requirement in three (3)
out of six (6) measures for one basic skill area? Yes No
1. What accommodations and modifications, if any, are necessary for the student to demonstrate
progress within the general education (including early childhood) curriculum?
2. In what areas does the student require specially designed instruction that cannot be provided
through the educational support system, or through the standard instructional conditions,
supplementary aids and services within the school?
3. If the student is experiencing educational difficulty in a basic skill area, but does not qualify for
special education under adverse effect or need, what additional information needs to be provided as
part of the referral to the Section 504 Team or Educational Support Team?
Answers:
D. Does the team conclude that the student has a need for special education services? Yes No
Based upon the results of this Evaluation Plan and Report, the Evaluation and Planning Team has
determined that:
_________________________________________________________________
(Student/Child’s Name)
meets or continues to meet the special education eligibility requirements under the disability
category(ies):
____________________________________________________
____________________________________________________
OR
did not meet or did not continue to meet the special education eligibility requirements. The reason(s)
for determining this ineligibility is/are:
Reminder: If a child/student has a documented disability but does not demonstrate either an adverse effect
or a need for special education services, they must be referred to their building principal who then ensures
that a 504 Team reviews the student/child’s eligibility and supports.
___________________________________________________________
Enclosures:
Dear ______________________________________:
On _____/_____/_____ we had a meeting or a discussion about a special education evaluation plan. The school
district plans to evaluate:
_________________________________________________
Student/Child’s Name
_________________________________________________________________________________________.
Enclosed you will find an Evaluation Plan (Form 2) and appropriate Parental Rights sections. Included in the
Plan are the questions to be answered in order for us to determine eligibility for special education services and/or
an appropriate education program. The enclosed Plan indicates:
we have agreed to determine eligibility, or continued eligibility, for special education services by conducting
new testing or by using other evaluation methods (such as a classroom observation). We must, therefore, have
your written consent to begin this evaluation. Please complete and return the enclosed “Consent for A
Special Education Evaluation” (Form 3a). If this is an initial evaluation, we have 60 calendar days from the
date we receive this written consent form to complete the evaluation.
we have agreed to determine eligibility, or continued eligibility, for special education services by reviewing
existing educational records. If this is a re-determination of eligibility, you have the right to request new
testing be done. We are required to give you this Notice before we begin the review of the records. If this is an
initial evaluation we have 60 days from the date we have sent you this notice to complete the record review.
OR
We have agreed there is a need to obtain additional information through new testing or other evaluation
methods. In order to complete this testing we are asking for your written consent. (Attach documentation
identifying the evaluations to be completed.) Please complete and return the enclosed “Consent for A
Special Education Evaluation” (Form 3a).
If you have any questions or would like to discuss this further, please contact me:
by phone at : _______________________________________
Sincerely,
Signature: _____________________________________
January 1, 2013
Consent for A Special Education Evaluation
The evaluation process and my parental rights have been explained to me. I understand that giving my consent is
voluntary and may be revoked at any time. If I do choose to withdraw my consent, I understand this withdrawal
will not apply to any testing that may have already been completed.
________________________________________________________ ________________________
Signature of the Parent/Guardian/Surrogate/Adult Student Date
I understand that not granting my consent is voluntary and that I may change my decision at any time. If I do not
grant this consent to determine whether there is an eligibility for an individual education program, I understand
that should my child (or myself) be involved in a major disciplinary situation my child (or myself) would not
receive the protections available only to those students with a disability or suspected of having a disability and
are in the process of being evaluated.
________________________________________________________ ________________________
Signature of the Parent/Guardian/Surrogate/Adult Student Date
If this is an evaluation to determine if a student continues to be eligible for special education services, my
failure to respond to this request for consent will result in the school district proceeding with the special
education evaluation as described in the Evaluation Plan.
If you have any questions or would like to discuss this further, please contact me:
by phone at : _______________________________________
or write to me at: _______________________________________________________________
Sincerely,
Signature: __________________________________________________
Dear _________________________________________________:
We are in the process of completing an initial comprehensive special education evaluation for:
_____________________________________________________________________
Although we expected to complete this evaluation by _____/_____/_____, we find that we are unable to meet
this deadline. This delay is due to the following exceptional circumstance(s):
If you have any questions or would like to discuss this further, please contact me:
by phone at : _______________________________________
or write to me at: _______________________________________________________________
Sincerely,
Signature: _____________________________________
Form 4
January 1, 2013
Individualized Education Program (IEP)
School District: ___________________________________________ Annual Meeting Date: ____/____/____
IEP Case Manager: ____________________________________Effective date of Revision : ____/____/____
Next 3-year Re-evaluation Date: ____/____/____ Next Annual Review Date: ____/____/____
Name:
Name:
Name:
Name:
Name:
Name:
Name:
*Including individuals for Part C Early Intervention or Post-Secondary Transition Planning
Form 5: Individualized Education Program (August 1, 2013)
Individualized Education Program
Present Levels of Educational and Functional Performance
Student Name: _______________________________________________ IEP Meeting Date: ____/____/____
This section should provide a concise overview of student’s current skills and serve as the basis of the student’s program for
the upcoming year. Describe the student’s present levels of educational performance including the student’s functional
performance, abilities, acquired skills and strengths relative to standards and/or grade level expectations. Briefly
highlight how the disability affects the student’s involvement and progress in the general curriculum or, for preschool children,
participation in age appropriate activities. As appropriate, address the following areas.
DISABILITY/IMPACT ON STUDENT LEARNING:(Identify the disability and areas of impact, e.g academic, social-
emotional, behavioral)
OTHER CONSIDERATIONS: (Areas to consider that could enhance the child’s education: safety/health; future, opportunity
for additional student or family input, mobility, transportation, disability awareness, self-advocacy needs)
Progress Review Dates Code: A – Achieved the goal/objective as written; S – Sufficient progress on objective is being made; likely to achieve this goal; E – Emerging progress on the
objective, continuing to work towards the goal; N – Objective/goal not yet introduced
Form 5: Individualized Education Program (August 1, 2013)
IEP for _________________________________________________ IEP Meeting Date: _____/_____/_____
Progress Review Dates Code: A – Achieved the goal/objective as written; S – Sufficient progress on objective is being made; likely to achieve this goal; E – Emerging progress on the
objective, continuing to work towards the goal; N – Objective/goal not yet introduced
Age Appropriate Transition Assessments performed (State the assessment and date, then identify the
student’s preferences, interests, strengths and needs then link that information to post secondary goals.) See
NSTTAC case studies for specific examples.
Definitions-
Measurable Post Secondary Goals- A post secondary goal is a statement of the desired outcome for the
student after leaving high school.
Measurable Annual Transition Goals- Goals that address the skills that the student will be focusing on
during the life of the annual IEP in order for the student to reach his/her post secondary goals.
Annual Transition Goal(s) for Education and Training (Required): Progress Review Dates
Example- Given direct instruction in the high school Business Math course and
10-31 11-5 3-30 6-22
guided practice, student will (a) use an adding machine, and (b) create
spreadsheets using money management software with 85% accuracy throughout
the Spring semester of this IEP.
List Transition Services related to Education and Training: Examples- job shadow experiences, visit college campus,
meet with student support office at college
List Transition Services related to Employment: Examples-social skills training, on the job safety instruction, community
based instructional experiences, work based instruction
Independent Living (as appropriate)
Post Secondary Goal(s) for Independent Living: Example- After graduating high school, student will travel to and from
work using the public transportation system with time-limited supports of a job coach or transition service provider.
List Transition Services related to Independent Living: Examples-social skills training, travel training, community
based instructional experiences
Course(s) of Study: A description of coursework to achieve the student’s desired post-school goals, from
the student’s current to anticipated exit year. Requirement: List the course(s) of study needed to assist the
student in reaching his/her post secondary goals or attach a list of courses. Course of study may also be listed in a
narrative format.
Describe the Coordinated Interagency Linkages and Responsibilities (services provided or paid for from
another agency and a timeline for completion):
If the student will be reaching age 17 during the duration of this IEP, he/she and their parents must have
been notified, in writing, that parental rights will transfer to the student upon reaching the age of 18. □ Yes
If not completed in writing, please specify how they were notified:
Document the alternative credit courses/programming necessary for the student to complete their
graduation requirements.
Grade Graduation Requirements Details as to why the student can not Alternative Course
School Year Level the student can not master master the requirements Or Activity/Credits
Given
Student’s cognitive level prevents
him from accessing the curriculum Life Skills Math/
2010-2011 10 Algebra I in a timely manner. 0.5 credits
When credits are being offered through a Multi-year Plan, this page must be signed by the
superintendent or his designee.
______________________________________ _____/_____/_____
Superintendent or Designee Signature Date
Parental Consent to Bill Medicaid: For parents and legal guardians who have signed a Release of Information form, the
school district is authorized to bill Medicaid for the services listed in this Individualized Education Program and to release any
necessary special education records to a physician/nurse practitioner in order for them to reach a determination that the services
are medically necessary. Release of information is also granted to Agency of Education and Human Services personnel charged
with processing Medicaid billing for those IEP services that are also considered medical services under Vermont Medicaid
rules. This consent will remain in effect until consent is revoked or until the student reaches the age of 18 (at which time
consent must be obtained from the student) or when the student graduates. Refusal to consent does not affect the school
district’s responsibility to provide these services to the student at no cost to the family. I understand that I may revoke consent
at any time and when I revoke consent it will apply to billing for any services from that date forward.
Form 5: Individualized Education Program (August 1, 2013)
Individualized Education Program
Educational Environment/Placement, Accommodations/Modifications for Assessments
Student Name: _____________________________________________ IEP Meeting Date: ____/____/____
If the student cannot participate full-time with non-disabled children in the general education class,
extracurricular or other non-academic activities explain why full participation is not possible:
The general characteristics of the student/child’s educational environment/placement (check one, ages 6-21):
Inside regular class at least 80% of the time Inside regular class 40% to 79% of the time
Inside regular class less than 40% of the time Separate day school – public or private
Residential facility Homebound/Hospital
Identify other accommodations, modifications, or supplementary aids (such as extended time, assistive
technology, peer tutors) and services needed for the student:
Materials which have met the National Instructional Materials Accessibility Standards for print
disabilities.
Identify the program modifications or supports that will be provided for school personnel and parents to
implement the IEP:
Other Options Considered (include reasons why they were not included):
Initiation and Duration of the IEP: Initiation and Duration of Extended Year Services:
Name:
Name:
Name:
*With parental consent, include individuals from CIS/Early Intervention if child is transitioning from EI services to EEE at age 3
MEDICAL History: (physical, hearing, vision, CDC report, etc.) Briefly describe how the child’s disability or medical condition affects
his/her access to and participation in age appropriate activities.
Child STRENGTHS: Consider child’s strengths across the three early childhood outcome (ECO) areas:
Child CONCERNS: Consider child’s concerns across the three early childhood outcome (ECO) areas:
Child NEEDS: (consider and prioritize the necessary supports in order for the child to access and participate in age appropriate activities within a
regular early childhood setting with his/her same-age peers and/or within their home environment.)
OTHER CONSIDERATIONS: (safety/health; school district partnerships with community-based early childhood programs (Act 62);,functional
behavior assessment (FBA)*; private early childhood programs; home-visiting; community-based child and family resources (Children’s Integrated Services;,
transportation; disability awareness; advocacy needs, etc)
Early Childhood Outcomes Considering the child strengths, concerns and needs complete an ECO culminating statement for each of the
three Early Childhood Outcome areas. ECO reporting is required upon entry and exit of EEE services.
ECO A. Social-emotional skills and relationships: ∇ ECO B. Acquisition & use of knowledge and skills: ∇ ECO C. Take action to meet needs: ∇
*Foundations for Early Learning (FEL) Functional Behavior Assessment Forms can be located on-line at www._______
Please check one or more of the domain areas that you are addressing within this outcome area:
social/emotional adaptive communication fine/gross motor cognitive skills
Current functional ability: (Consider how the child uses discrete skills (as stated above) ‘ in order to’ or ‘ so that’ it is meaningful, intentional and functional within the context of everyday
activities, routines and transitions. Focus on the child’s engagement, approaches to learning and independence in developmentally appropriate activities across a variety of settings.)
Short-term Objectives, Benchmarks, Evaluation Procedures and Personnel Responsible For review of this outcome/goal and progress monitoring data,
we, the team, have evidence that demonstrates the:
a)
Review 1 Review 2 Review 3 Review 4
Date: Date: Date: Date:
c)
For review of this outcome/goal and progress monitoring data,
we, the team, have evidence that demonstrates the:
Review 1 Review 2 Review 3 Review 4
Date: Date: Date: Date:
Comments:
ECO ∇
Developmental Domain∇
Service: Case Management
ECO ∇
Developmental Domain∇
Service:
ECO ∇
Developmental Domain∇
Service:
An explanation of the extent, if any, to which the preschooler will not participate with same age peers in a
regular early childhood setting:
The general characteristics of the child’s early childhood education environment/placement (ages 3-5):
Child is attending a regular early childhood program 10 or more hours per week.
□ and receives at least 50% of their special education services in the regular early childhood program
□ and receives at least 50% of their special education services in some other location
Child is attending a regular early childhood program less than 10 hours per week
□ and receives at least 50% of their special education services in the regular early childhood program
□ and receives at least 50% of their special education services in some other location
Child is not attending a regular early childhood program and receives special education services in:
□ a separate special class
□ a separate school
□ a residential facility
□ their home
□ the service provider’s location or another location
Identify environmental accommodations, curriculum modifications, supplementary aids, assistive technology etc.
that will support the child’s access to and participation in a regular early childhood setting and/or in age appropriate
activities.
Identify the program modifications, supports and training that will be provided for preschool personnel and family
to implement the IEP:
For VT AOE reporting purposes, the IEP team has For VT AOE reporting purposes, the IEP team has
determined that the child’s annual progress will be assessed determined that the child’s annual progress will be assessed
using the GOLD (required statewide PreK assessment using an alternative assessment measure e.g., Battelle
measurement) Developmental Inventory (BDI); Trans-disciplinary Play-
based Assessment (TPBA); Assessment, Evaluation and
Programming System (AEPS), etc.
4
Entry
3 year 1
year 2
2
Exit
0
ECO A ECO B ECO C
The authorized District staff has explained to the parent that there is no requirement to enter into this agreement.
________________________________________________ _____/_____/_____
Authorized District Staff – Printed Name Date
A. WHEN A DESIGNATED TEAM MEMBER WILL BE ABSENT FROM THE IEP MEETING
Member(s) not in attendance:
I agree for the identified Individualized Education Program (IEP) team member to not attend the meeting
scheduled on _____/_____/_____, in whole or in part, because the member’s area of curriculum or related
service is not being modified or discussed at this meeting.
I do not agree for an Individualized Education Program (IEP) member to not attend the meeting scheduled on
_____/_____/_____, in whole or in part, because the member’s area of curriculum or related service is not being
modified or discussed at this meeting. This meeting will be rescheduled for _____/_____/_____.
________________________________________________________ ________________________
Signature of the Parent/Guardian/Surrogate/Adult Student Date
________________________________________________________ ________________________
Signature of the Authorized District Staff Date
B. WHEN A DESIGNATED TEAM MEMBER WILL BE EXCUSED FROM THE IEP MEETING
Member(s) excused from the meeting:
I agree for the following Individualized Education Program (IEP) team member to be excused from the
meeting scheduled on _____/_____/_____, in whole or in part, despite the member’s area of curriculum or
related service being modified or discussed at this meeting. I understand this agreement requires the excused
member submit in writing to the Team their input into the development of the IEP prior to the meeting.
I do not agree for an Individualized Education Program (IEP) team member to be excused from the meeting
scheduled on _____/_____/_____, in whole or in part, because the member’s area of curriculum or related
service is being modified or discussed at this meeting. This meeting will be rescheduled for _____/_____/_____.
________________________________________________________ ________________________
Signature of the Parent/Guardian/Surrogate/Adult Student Date
________________________________________________________ ________________________
Signature of the Authorized District Staff Date
Form 5a
January 1, 2013
Agreement to Revise the IEP Between Annual Review Meetings
Local Education Agency_____________________________ Case Manager___________________________
Student Name _____________________ Date of Birth____/____/____ Child Count ID # ______________
If you have additional questions regarding this IEP revision, or would like to discuss this further, please contact
me by phone at: _________________________________ or write to me at:
Printed Name and Position:___________________________________________________________________
Mailing Address: ___________________________________________________________________________
Enclosures: Revised IEP pages (provided to Parents and IEP Team Members) Form 5b
August 1, 2013
Revision of the IEP Between Annual Review Meetings
Local Education Agency_____________________________ Case Manager___________________________
Student Name _____________________ Date of Birth____/____/____ Child Count ID # ______________
If you have additional questions regarding this IEP revision, or would like to discuss this further, please contact
me by phone at: _________________________________ or write to me at:
Printed Name and Position:___________________________________________________________________
Mailing Address: ___________________________________________________________________________
Enclosures: Revised IEP pages (provided to Parents and IEP Team Members) Form 5c
January 1, 2013
Consent for Initial Provision of Special Education Services
School District: _____________________________________________________ Date: _____/_____/_____
Dear ____________________________________________________:
In order for the initial special education and related services to begin, please review, check one of the
statements below, sign, and return this form to the school. (Use this Form for children and students ages
3-21 and use Form 6b for only those children transitioning from Part C, ages 0-3 years of age, to Part B
services.)
I give my consent for all initial services in the IEP to begin. Should you change your mind prior to the start
of these initial IEP services, you must notify your school contact (shown below) so that services will not
commence. If you wish to revoke your consent after the initial IEP services have begun, revocation of
consent shall be in writing, on Form 6a provided by the LEA or in any other written form, and should
indicate the date of revocation.
I do not give my consent for any of the initial IEP services to begin. I understand should my child be
involved in a major disciplinary situation my child would not receive the special education protections
available only to students with a disability or suspected of having a disability. (Please be aware that if you
refuse all IEP services, the school may attempt to resolve the matter through an informal meeting with you,
or by requesting mediation, a re-evaluation, or a review of existing data to determine if your child is not
eligible for IEP services.)
I do not give my consent to the initial IEP services to begin. However, due to the current home schooling
status, or our decision to place our child in an independent school, we may be seeking some initial special
education services through a service plan with the school district or supervisory union. We understand the
district or supervisory union is not required to provide such special education services and that any or all
services may be limited to the amount of federal monies currently available to serve this population of
students.
If you have any questions regarding this consent form, please contact me:
by calling _____________________________
January 1, 2013
Revocation of Consent for Provision of Special Education Services
I hereby revoke my consent for the provision of special education and related services.
I understand that once I revoke consent for my child to receive special education and related services, my child is
considered a general education student and my parental rights in special education will end.
I understand that should my child be involved in a major disciplinary situation my child would not receive the special
education protections available only to students with a disability or suspected of having a disability.
I understand that after I revoke consent for my child, the school district is not required to amend my child's records to
remove any references to my child's receipt of special education and related services.
I understand that after revoking consent for my child, I maintain the right to subsequently request an initial evaluation
to determine if my child is a child with a disability who needs special education and related services.
This is to provide you with written notice that the school district has received your revocation of consent for special
education and related services for your child. In response, the school district will take the following action(s):
your child will no longer be identified as having a disability under the Individuals with Disabilities Education Act (IDEA)
your child’s educational placement will be changed to ____________________
The district will have no authority to provide, and will not provide, special education and related services to your child
August 1, 2013 1
Vermont Agency of Education
Form 6B
Dear ____________________________________________________ ,
Your child’s Children’s Integrated Service/Early Intervention (CIS/EI) Part C program has notified the
local school district/local education agency (LEA) that your child may be potentially eligible for Part B
Early Childhood Special Education services when your child turns 3 years old. The school district
team will use the following eligibility criteria as well as evidence presented by the CIS/EI team during
the 90 day transition meeting, to determine your child’s eligibility to receive Early Childhood Special
Education and related services.
Evidence The LEA will review, consider and determine your child’s eligibility to receive
Part B/Early Childhood Special Education services based on the following
evidence:
1. Please check the state approved all domain assessment tool that was used to determine 25% delay:
Assessment, Evaluation, and Programming System (AEPS)
Infant-Toddler Developmental Assessment (IDA)
Hawaii Early Learning Profile (HELP)
Trans-Disciplinary Play-based Assessment (TPBA)
Tool(s) used, in addition to the state approved tools listed above, may provide evidence in
support of a 25% delay in specific domain areas (e.g., speech/articulation, gross motor, etc.)
OR
2. The child has a diagnosed medical condition that may result in significant delays by the
child’s sixth birthday as evidenced by:
Written medical diagnosis from child’s pediatrician or family medical doctor, or
Medical report stating diagnosis from Child Development Clinic, or
Other, please specify __________________________________________________
N/A (Complete #1 to review evidence of 25% delay)
AND
3. Evidence that child received consistent CIS/EI services prior to their 3rd birthday:
It is important to consider that what constitutes consistency in service delivery may be
affected by family priorities and/or availability. The family has an active role in Early
Intervention and may be identified as the ‘who’* (as specified on the One Plan Child Outcome
page) to implement strategies and activities across routines of the day. The EI provider is
responsible for providing families with information, skills and support related to enhancing
the skill development of the child. [Vermont Special Education Rule §2360.5.1(23)(iii)]
LEA will consider the following One Plan/IFSP evidence:
One Plan/IFSP Service Grid:
Early intervention services listed
Frequency (number of days/sessions service is provided)
Length of time during each session
One Plan/IFSP Child Outcome page(s):
Outcome(s) identified
Listed strategies and activities designed to promote a child’s acquisition
of skills per outcome
Evidence of who* is implementing strategies/activities
Evidence of when and where strategies/activities occur
One Plan/IFSP Outcome Review (typically reported at six month intervals)
The most recent child progress update(s)
__________________________________________________________________________________________
Based on criteria for potential eligibility listed above and all evidence presented at the 90 Day
Transition Meeting, the Local Education Agency representative has determined that:
__________________________________________________________
(Child’s Name)
OR
does not meet the Part B/Early Childhood Special Education eligibility requirements.
The reason(s) for determining ineligibility is/are:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Parental Consent
If your child was determined eligible to receive Part B/Early Childhood Special Education Services, the school district
requires your written consent for your child’s placement in Part B and for the initial early childhood special education and
related services to begin when your child turns 3. Please review, check appropriate statements below, sign, and return this
form to the school.
Parent Consent for placement in IDEA Part B/Early Childhood Special Education Services:
My child is transitioning from Part C (birth to age 3) to Part B (ages 3 to 21) services and has met
eligibility criteria requirements as stated above. I give consent for my child’s placement under Part
B Early Childhood Special Education (age 3-5) and related services.
If you have any questions regarding this consent form, please contact:
Email: ____________@_______________._____
Sincerely,
Signature: ______________________________
Printed Name: __________________________ Position: _____________________________________
Dear _____________________________________________________:
This letter is to provide you with written notice that the school district refuses to initiate or change the:
The evaluation procedures, tests, records, reports and other factors upon which this decision was based were:
Other options, if any, that the district considered and reasons why those options were not chosen:
Sincerely,
Signature: __________________________________________________________________________
Printed Name/Position: _______________________________________________________________
Form 7
January 1, 2013
Prior Written Notice of Decision
Local Education Agency: __________________________________ Date Form Completed: ____/____/____
Student Name: ____________________________ DOB: ____/____/____Child Count ID#: ______________
Dear _______________________________:
The Local Education Agency (LEA) must, by law, provide you written notice whenever it:
Proposes to begin or change the identification, evaluation or educational placement of your child or the
provision of a free and appropriate public education to your child, AND/OR
Refuses to begin or change the identification, evaluation or educational placement of your child, or the
provision of a free and appropriate public education to your child.
This notice is sent to you for that purpose.
A description of the action(s) the LEA proposes or refuses to take:
A description of each evaluation procedure, assessment, record or report the LEA used in deciding to propose or
refuse the action(s):
Other options, if any, that the district considered, and the reasons why those options were not chosen:
A description of other reasons (if any) why the district is proposing or refusing the action(s):
The Effective Date of this proposal or refusal decision will be: _____/_____/_____.
Procedural Safeguards to Protect Parent Rights
Resources that you may contact for help in understanding the special education law are located at the back of the
Procedural Safeguards (Parental Rights) booklet put out by the Vermont Agency of Education:
To obtain a copy of your “Parental Rights in Special Education,” which describe your rights, including
procedural safeguard protections under special education law, or if you have any questions about this notice or
the Parental Rights, please contact me at: ______________ (Tel.) or write to me at:
January 1, 2013
Written Agreement Between Parents and District – Re-evaluations
School District______________________________________ Case Manager___________________________
Student Name ____________________ Date of Birth: ____/____/_____ Child Count ID # _____________
The authorized School District staff has explained to the Parent that he or she is not required to enter into this
agreement. Your child’s special education services will not be affected by entering into this agreement.
_______________________________________________________ _____/_____/_____
Authorized District Staff Name – Title Date
____________________________________________________________
School Name
____________________________________________________ _____/_____/_____
Authorized District Staff Signature Date
____________________________________________________ _____/_____/_____
Parent/Guardian/Surrogate/Adult Student Signature Date
(The date of the parent signature will be considered the date from which the next triennial will be due.)
Note: Prior Written Notice about Evaluation/Consent for Evaluation is not required.
Form 8
January 1, 2013
Completion of An Evaluation of A Transfer Student
School District______________________________________ Case Manager___________________________
The authorized School District staff has explained to the Parent that he or she is not required to enter into this
agreement.
__________________________________________________ _____/_____/_____
Authorized District Staff Name - Title Date
_______________________________________________________
School Name
The 60 day evaluation timeline for completing an initial evaluation does not apply if:
The first school district initiates an evaluation of the student and the student moves into a second school
district after the 60 days starts but before the initial evaluation has been completed. If the new school
district is promptly seeking information from the previous district and promptly completing the
evaluation, the new school district and the Parent then have to agree that the initial evaluation will be
completed by a specific date that exceeds the original 60 day timeline.
We agree that the initial evaluation for this student will be completed by: ______/______/_______
Date
_________________________________________ _____/_____/_____
Parent/Guardian/Surrogate/Adult Student Signature Date
_________________________________________ _____/_____/_____
Authorized District Staff Signature Date
The three year reevaluation timeline for completing a triennial evaluation does not apply if:
The first school district initiates a reevaluation of the student and the student moves into a second school
district after the reevaluation starts but before the reevaluation has been completed. If the new school
district is promptly seeking information from the previous district and promptly completing the
evaluation, the new school district and the Parent then have to agree that the reevaluation will be
completed by a specific date that exceeds the three year anniversary date.
We agree that the reevaluation for this student will be completed by: ______/______/_______
Date
_________________________________________ _____/_____/_____
Parent Signature Date
_________________________________________ _____/_____/_____
Authorized District Staff Signature Date
Note: Prior Written Notice about Evaluation/Consent for Evaluation is not required.
Form 9
January 1, 2013
Written Affirmation of Consultation for Parentally Placed Private School Students
School District:_______________________________________________________ Date_____/_____/_____
1. Child Find
Students will be identified and referred by (check all that apply):
Screening Referral by private school teacher or administrators
Phone calls Surveys
Written Correspondence Notice in Public Places
Other
Parents, teachers and private school officials are notified of the child find process by (check all that apply):
Postings at private schools Postings in the community
Public announcements Other
Private school representatives are informed of the amount of Federal funds available and how this is determined
by (check all that apply):
3. Consultation Process
Timely and meaningful consultation was conducted in the following ways (check all that apply):
Meetings Phone Calls
Written Correspondence Surveys
Other
Consultation throughout the school year to ensure that parentally-placed private school students with disabilities
identified through the child find process can, when a services plan is offered, meaningfully participate in special
education and related services will be accomplished by (check all that apply):
Meetings Phone Calls
Written Correspondence Surveys
Other
Form 10
January 1, 2013
Written Affirmation of Consultation for Parentally Placed Private School Students - page 2
4. Determination of Services
The method and timeline for how, where and by whom special education and related services will be provided
and the types of services, including direct services and alternate delivery mechanisms:
LEA will review the following by ____/____/____ (date) in order to make determinations regarding services:
5. How services will be apportioned if funds are insufficient to serve all children and how and when these
decisions will be made:
LEA will make decisions regarding apportionment of funds by ____/____/____ (date) using the following
information:
Funds are not sufficient - No Funds are sufficient to allow the following to be provided:
services are to be provided As needed by each child through a services plan
Multiple services/consultation to the school
One service/consultation to the school
Other; described in an attachment
As a result of the consultation process, we agree.
____________________________________________ Date _____/_____/_____
Signature, LEA Representative
As a result of the consultation process I do not agree to the following services provided by the
___________________________________________ School District/Supervisory Union for parentally
placed students who are eligible for special education.
Form 10
January 1, 2013