School Building Level Committee Minutes - Initial Meeting Template
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SBLC 4A
ACADIA PARISH SCHOOL BOARD
SCHOOL BUILDING LEVEL COMMITTEE MINUTES - INITIAL MEETING
Student: __________________________________________ School: _____________________________________
Referred By: _______________________________________ Position: ____________________________________
Meeting Date: _____/_____/_____
Presenting Concern: _______________________________________________
Signatures and Positions of Committee Members Present:
_______________________/______________________
______________________/_____________________
_______________________/______________________
______________________/_____________________
_______________________/______________________
______________________/_____________________
Teacher Input:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________________________________________
NOTE: If speech (articulation, voice, or fluency) is only concern, teacher input should state how the problem interferes in the
educational setting.
Parent Input (Concerns, Expectations, Attempts to Solve, Strengths, Etc.):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Decision:
1. ____________ Conduct no further action at this time.
2. ____________ Conduct interventions. (Teacher:______________________ Dates:____________)
3. ____________ Refer to appropriate committee for 504/Dyslexia evaluation.
4. ____________ Refer to pupil appraisal for support services.
5. ____________ Refer to pupil appraisal for individual evaluation.
If decision is #3 or #5 indicate on SBLC 2A and obtain principal signature.
Anticipated Date of Next Meeting (if needed):
________/________/________
Provide Copies To: Special Education Office
School
Parent
Revised 7/2000 - form4a.vjm
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