Record Of Parental Request For Evaluation Language Or Speech Impaired printable pdf download

South Bend Community School Corporation

Special Education Services

Record of Parental Request For Evaluation

Language or Speech Impaired

Student’s name: _________________________________ ID#:________________ STN#:___________________

School: ____________________ Grade: __________ Teacher: _______________________ DOB: ___________

Parent’s name: _______________________________________________________________________________

Address:____________________________________________________________________________________

_____________________________________________________________________________________

Request for Evaluation received by: ____Speech-language Pathologist ____ other Certified Personnel (specify):

____________________________________________________ Date of Request: _________________________

How Request was received: _____________________________________________________________________

Parent:

If the parent makes the Request for an evaluation in person at the school, please have the parent sign below.

I am requesting a multi-disciplinary team ___ language and/or ___ speech evaluation for my child,

____________________, DOB: _____________________. I suspect that my child may have a ___ language

___ speech impairment because ________________________________________________________________

___________________________________________________________________________________________

I understand that within 10 school days, I will receive Written Notice informing me whether the school proposes or

refuses to evaluate my child. At that time, if the school makes a recommendation to proceed with the evaluation, I

will be asked to provide written consent for this evaluation.

Parent Signature: ______________________________________

Date: ______________

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If the parent does not make the Request in person at the school, the certified personnel who received the Request

must document at the top of this page, his/her name and the date of the request. It is not necessary to have the

parent sign this form.

THIS COMPLETED FORM MUST BE IMMEDIATELY FORWARDED TO THE SPEECH-LANGUAGE

PATHOLOGIST, who will distribute the LI/SI Classroom Teacher Report and distribute copies of this page

to those on the CC list.

Date distributed to Teacher: ______________________________

Classroom Teacher:

The parent of the above named student has requested an educational- language and/or speech -evaluation to

determine if the student is eligible for special education and related services (therapy).

The attached LI/SI CLASSROOM TEACHER REPORT MUST be completed and returned to the speech-language

pathologist within 3 school days (due _________). This information will be used by the SLP to assist in

determining if the school will conduct the evaluation. The parent must be informed of this decision within 10 school

days of the Request.

Cc: Parent, Cum, Speech/language file

8/18/12

Record Of Parental Request For Evaluation Language Or Speech Impaired