Record Of Parental Request For Re-Evaluation Language Or Speech Impaired (50 Day Timeline) Form
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1South Bend Community School Corporation
Special Education Services
Record of Parental Request for Re-Evaluation
Language or Speech Impaired (50 Day Timeline)
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 re-evaluation for my child,
____________________, DOB: _____________________.
_____ I suspect that my child may have a disability different than or in addition to language and/or
speech impairment. (Please note the suspected disability___________________)
_____Additional information is needed to inform the Case Conference Committee of my child’s
special education needs (language and/or speech impairment). Describe specifically:
________________________________________________________________________
______________________________________________________________________________
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.
____I suspect that my child is no longer eligible for special education services under language
and/or speech impaired. I understand that my child will be re-evaluated prior to the next Annual
Case Conference.
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 oversee the completion of the LI/SI Classroom Teacher Report.
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 (speech-language 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
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