Form 22a - State Selpa Iep Template - E Assessment Plan
Download a blank fillable Form 22a - State Selpa Iep Template - E Assessment Plan in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 22a - State Selpa Iep Template - E Assessment Plan with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1STATE SELPA IEP TEMPLATE
ASSESSMENT PLAN
Student Name _____________________
Date of Birth ___/___/________
IEP Date ___/___/________
Initial
Annual
Triennial
Transition
Interim
Other_____________________________________________
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
measured.
________________________________
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 ________________________________
Signature__________________________________________________________________
___/___/______
Parent
Guardian
Surrogate
Adult Student
Date
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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business