Fillable Record Of Parental Request For Evaluation printable pdf download

SOUTH BEND COMMUNITY SCHOOL CORPORATION

SPECIAL EDUCATION DEPARTMENT

RECORD OF PARENTAL REQUEST FOR EVALUATION

(50 Day Timeline)

Student’s name: _________________________________ DOB: __________________________

School: ____________________ Grade: ___________

Teacher: ________________________

ID# _______________________ STN# _____________________________________________

Parent’s name: ________________________________

Phone: _________________________

Address:_______________________________________________________________________

__________________________________________________________________

Date of Request: _________________________

Certified Personnel* who received Request for Evaluation: _____________________________

How Request was received: _______________________________________________________

Suspected Disability (ies): ________________________________________________________

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 evaluation for my child, ____________________,

DOB: _____________________. I suspect that my child may have a disability 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, and the suspected disability. It is not necessary to have the parent

sign this form.

THIS COMPLETED FORM MUST BE IMMEDIATELY FORWARDED TO THE

ADMINISTRATIVE ASSISTANT (PC/IC)/Guidance Director (HS), who will distribute the

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 evaluation to determine if

the student is eligible for special education and related services.

The attached CLASSROOM TEACHER REPORT MUST be completed and returned it to the

school psychologist within 3 school days (due _________). This information will be used by the

psychologist 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.

* = principal, guidance counselor, teacher, psychologist, speech/language pathologist

Cc: Parent, Teacher, Cum, Psychologist/Sp.Ed. file, Principal

Record Of Parental Request For Evaluation

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