Notice Of Individual Evaluation/reevaluation Request Form

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NOTICE OF INDIVIDUAL EVALUATION/REEVALUATION REQUEST

Hancock County Schools

Student’s Full Name _________________________________

Date ________________________________

School ____________________________________________

DOB ________________________________

Parent(s)/Guardian(s) ________________________________

Grade _______________________________

Address ___________________________________________

WVEIS#______________________________

City/State __________________________________________

Telephone_____________________________

INITIAL

REEVALUATION

OTHER ___________________________

Dear Parent(s)/Adult Student:

Your permission is requested to conduct an evaluation to determine the student’s educational needs. If the student has been receiving

special education services, a reevaluation is required at least every three years or more frequently, if warranted. Upon completion of

the evaluation, a meeting will be scheduled to discuss the evaluation results.

This evaluation will be conducted by qualified professionals and will include the areas checked below. A written description of each

evaluation component is provided. The evaluation results will be used as the primary source to determine the student’s eligibility for

special education and related services and/or to adjust the student’s educational services.

Academic Information

Developmental Skills

Transition Assessments

Achievement

Health ______________

Functional Vocational Evaluation

Classroom Performance

Hearing

Vocational Aptitudes

Teacher Report

Information from the Parent

Interests/Preferences

Adaptive Skills

Intellectual Ability

Vision

Assistive Technology

Motor Skills

Orientation and Mobility

Behavioral Performance

Observation(s)

Other (specify below)

Functional Behavioral Assessment

Perceptual-Motor

_______________________________

Communication

Social Skills

______________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Procedural Safeguards Brochure explaining parent/student rights and the responsibilities of the county school district is enclosed

for an initial referral.

__________________________________________________

Signature

Date

I have read, or had read to me, the above Notice of Individual Evaluation/Reevaluation Request regarding the

student. I understand the contents and implications of this notice and have been advised of my rights.

Check one:

I give permission to evaluate/reevaluate.

* REQUIRED *

I wish to schedule a conference before I decide.

Do not evaluate/reevaluate the student.