Date rec’d by
SOUTH BEND COMMUNITY SCHOOL CORPORATION
certified
Special Education Department,
personnel
215 South St.Joseph St., South Bend, IN 46601
____________
574-283-8130
REFERRAL FOR RE-EVALUATION (Grades 7-12)
All referrals must be screened by school personnel for completeness. Incomplete referrals will be returned to
obtain necessary information.
If required, the case conference is to be conducted within 50 instructional days of the date the written consent is
received by school personnel. See information on the Consent page to assist in determining the need for a case
conference within 50 school days. If required, please schedule a date/time below.
**The case conference committee meeting has been scheduled for:
(Date)_________________ (Time)_____________________(Location)______________________
**This conference must be scheduled at the time of this referral. Be sure to inform all CC members
immediately. A formal Notice of Case Conference must still be sent prior to the scheduled CC.
This referral has been reviewed for completeness: _____________________________________________
Principal Signature required
*FOR OFFICE USE ONLY*
Sections Complete:
Attachments
________________
___ __________________________
___ Academic Record/Test Record
Date rec’d-certified personnel:
50 instructional days:__________________
Rec’d in office:_______________________
Assigned to: _________________________________
Student
Birth Date
Age ________
Student ID #_____________ STN# ______________________ Ethnic Code ___________ Sex: M
F
Parent/Guardian Name _____________________________________________________________________
Street Address ___________________________________________________________________________
City
State
Zip
Phone ______________
School (Attending)
Home School (if different)___________________________
If private/parochial school, provide school’s address ________________________________ Zip __________
Phone # _________________________
Teacher___________________________________ Grade __________
Home Room No._______________
(Full Name)
If kindergarten: Full Day
AM
PM _______
Referral Source ____________________________ Contact person at school __________________________
(Name and title)
Rev. 9/09