Form Xed0202 - I01 Referred And/or Evaluated Status Form - St. Lucie County Data Input
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1St. Lucie County Data Input
I01 Referred and/or Evaluated Status Form
Student Name: ____________________________________ School:_______________
Student ID # : ____________________________________
Grade :_______________
*SECTION 1:
*I01 Referred and Pending Section
Submit this information to the School Data Specialist after the Psychologist/Speech Language Pathologist picks up the
completed referral. Retain white and yellow copies to Complete Section 2 or 3 at later date if applicable. Photocopy for
Referral Packet.
Student > Student Profile> ESE> Add Student to ESE
√ Work in Progress
Student Placement Status: R – Referred and pending evaluation
Type of Evaluation: Initial Evaluation
Referral Date: _________________________
Consent Date
Referral Reason: _______
A-Attention
B-Behavior
G-Gifted
H-Health
M-Math
P-Pre-K
R-Reading
S-Speech
SAVE
Guidance Counselor: _________________________________________________
Date: _____________
Evaluation Specialist: ________________________________________________
Date: _____________
School Data Specialist: _______________________________________________
Date: _____________
**SECTION 2:
** Evaluation Results Section
If student is found INELIGIBLE, complete this section and submit yellow to the School Data Specialist.
Student> Student Profile>ESE>Expand record> Expand ESE Details>Edit Initial Evaluation (WIP)
Uncheck Work in Progress
Student Placement Status: I – Evaluated and ineligible
Referral Date: Same as above
Evaluation Start: _____________________
First Test Given
Eligibility Determination: ____________________
Evaluation Completed: ___________________
Date of Staffing
Last Test Given
Referral Reason: Same as above
SAVE
SECTION 3:
*** Parent has Withdrawn consent
If parent has withdrawn consent prior to evaluation complete this section.
Delete referred and /or evaluated record - parent has withdrawn consent prior to evaluation.
Student> Student Profile>ESE>Expand record> Expand ESE Details>Delete Initial Evaluation (WIP)
Guidance Counselor: _______________________________________________
Date: _____________
Section 2 or 3
School Data Specialist: _____________________________________________
Date: ____________
Section 2 or 3
White:
Yellow:
Pink:
XED0202 Rev. 11/09
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