Form 22a - State Selpa Iep Template - E Assessment Plan

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Student Name _____________________
Date of Birth ___/___/________
IEP Date ___/___/________
To parent/guardian of ____________________________________________________
Date ___/___/_________
District _________________________________________
School ________________________________________
Grade __________________________________________
Date of Birth ___/___/_______
Primary Language _________________________________
English proficiency/CELDT Level _____________________
The district proposes to assess your child to determine his/her eligibility for special education services or continued eligibility and present levels
of academic performance and functional achievement. Your child will be assessed in all areas of suspected disability as needed.* To meet your
child’s individual education needs, this assessment will consist of an evaluation in only the areas checked by the local educational agency
(LEA)/district. *Tests conducted pursuant to these assessments may include, but are not limited to classroom observations, rating scales, one-
on-one testing or some other types or combination of tests.
Evaluation Area
Examiner Title
Academic Achievement These tests measure reading, spelling, arithmetic, oral
and written language skills, and/or general knowledge
Health Health information and testing is gathered to determine how your child's
health affects school performance
Intellectual Development These tests measure how well your child thinks,
remembers, and solves problems.
Language/Speech Communication Development These tests measure your child's
ability to understand and use language and speak clearly and appropriately.
Motor Development These tests measure how well your child coordinates body
movements in small and large muscle activities. Perceptual skills may also be
Social/Emotional These scales will indicate how your child feels about
him/herself, gets along with others, takes care of personal needs at home, school
and in the community.
Adaptive/Behavior These scales indicator how your child takes care of personal
needs at home, school and in the community.
Post-Secondary Transition Age appropriate transition assessments related to
training, education, employment and where appropriate independent living skills.
Other _____________________________________________________
Alternative Means of Assessment (Describe alternative methods of assessing the
child, if applicable) ___________________________________________________
I consent to the assessment. I understand that the results will be kept confidential and that I will be invited to attend the IEP
team meeting to discuss the results. I also understand that no special education services will be provided to my child without my
written consent.
I do not consent to the proposed assessment described above.
I would like the following assessment information to be considered by the IEP team ________________________________
Adult Student
Address _________________________________________________
Phone number _____________________
Comments ______________________________________________________________________________________________
NOTE Prior Written Notice attached if this is an initial evaluation.
Date Received by District/LEA ____/____/______
Revised 07/2013
Form 22A


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