1. education
2. special education

SRS Notice and Consent for Initial Evaluation Form
ü Upon receiving a referral, but prior to an evaluation, the special educator (typically the
school psychologist, although it may be the speech-language pathologist, case manager,
or related service provider) will complete this document and obtain parent signature in
order to receive permission to evaluate.
Steps for completing the Notice and Consent for Initial Evaluation Form:
PAGE 1:
1. On document, enter date of notice in the box located in the top corner.
2. Enter a narrative in queries 1-6 providing information relevant to the evaluation.
•
Explanation of why the district proposes to evaluate your child: List
academic or curricular areas where the student is experiencing difficulty (reading,
writing, math, etc.), social or emotional concerns, perceptual or motor concerns, or
concerns in the area of communication (speaking, understanding language, AAC/AT,
etc).
Ø Possible text box entries for school age students:
o
The student has been involved in the problem solving/intervention (SAT)
process for __________ (amount of time) and despite trying various
interventions and exploring all viable alternatives, data from the team indicates
that the student is not responding to intervention and still experiencing
difficulties in the area of ___________ (may include, but are not limited to areas
such as: academics, reading, math, written language, communication skills,
social and behavioral skills, speech/articulation skills, fine motor skills,
gross motor skills, vision, etc.).
Ø Possible text box entries for 0-5 year old students:
o
o
o
o
o
•
Due to a physician’s referral and concern with the child’s development.
Due to a parent concern regarding their child’s development
Due to an outside agency’s referral and concern with the child’s development.
Due to a referral from a day care provider concerned with the child’s
development.
Following a district-conducted screening
Any options the district considered: List the options considered by PLV prior to
making the referral (i.e. Student Assistance Team, Para-support, classroom
accommodations, Peer-tutoring, etc.)
Ø Possible text box entries for school age students:
o
o
o
o
o
o
Continue to serve in the general education classroom.
Continue Student Assistance Team/Problem Solving process
Investigate 504 process
Develop and use district accommodation and modification plan
Not to test
Monitor progress through parent/classroom teacher input
Ø Possible text box entries for 0-5 year old students:
o
o
o
o
Not to test
Continue with no special education services
Continue in current day care/preschool setting
Monitor progress through parent input
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SRS Notice and Consent for Initial Evaluation Form Continued…
•
Reasons why the above options were rejected: Provide a narrative describing
why the above options were not adequate (i.e. the student failed to make progress,
assessment scores failed to improve, student not responding to interventions, etc.)
Ø Possible text box entries for all students
o
o
o
o
o
o
o
o
•
Concern that the student has a disability
Needed additional information in the area of academic skills
Needed additional information in the area of behavior and social skills.
Needed additional information in the area of cognitive skills.
Needed additional information in the area of communication skills.
Needed additional information in the area of fine and gross motor skills.
Did not meet family’s needs.
Student failing to respond to intensive, documented interventions
This proposal is based on the evaluation procedures, tests, records, or
reports described below: Describe any evaluation information that led to the
proposal (i.e. District-wide assessment scores, parent or student report, classroom
teacher input, etc.)
Ø Possible text box entries for school age students:
o
o
o
o
o
o
Problem-solving Team/Student Assistance Team documentation
Classroom observations
Classroom testing and assessments
Guided reading level or class grades
Parent input
Report cards
Ø Possible text box entries for 0-5 year old students:
o
o
o
o
o
o
o
•
Early Childhood Parent Input Form
Early Childhood Team input/documentation
Parent request
Student observation in natural environment
Physician’s information
Outside agency information
Daycare provider information
Any other factors relevant to this proposal: Provide any additional information
relevant to the evaluation (i.e. parent report, physician report, court order, subpoena,
etc.) in this area. If none, write “None.”
•
The estimated amount of time for completing the MDT evaluation and
making the verification decision is: This section will always state “The MDT
will be completed within 45 school days from the date parental consent was
received.”
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SRS Notice and Consent for Initial Evaluation Form Continued…
PAGE 2:
3. Determine which components of the MDT the district proposes to evaluate the student on
and enter descriptions based on the following areas: (If the student will not be evaluated
in a particular area, type “Not necessary for this evaluation.”)
§
Academic: This area identifies the student’s strengths and weaknesses in
subject areas including pre-academic skills, math, reading, and written
language.
§
Intellectual: This area provides an indication of the student’s potential
functioning in an educational environment.
§
Perceptual and Motor: This area assesses muscle strength, perceptual
development, fine motor skills, motor development levels, neurological
involvement, balance and coordination, as well as posture and gait.
§
Social and Emotional: This area provides an indication of the student’s
social and emotional development as it pertains to the educational
environment.
§
Speech and Language: This area identifies the student’s ability to
communicate within his/her environment. Areas of evaluation might
include articulation, receptive and/or expressive language, fluency,
voice, and hearing.
§
Other: Additional areas might include vision, functional vision, hearing,
general health, vocational considerations or other factors which could
influence education and function.
4. Enter the name and phone number of Jane Byers (537-6222) or the contact information of
the case manager.
5. Complete the form by selecting SAVE after all pertinent information has been entered.
Print both pages (the second page is the BLANK parent signature form) and send home
to parents. Remember to include a copy of the Parental Rights document.
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SRS Notice and Consent for Initial Evaluation Form Continued…
PAGE 3:
6. Once written parent permission is obtained, the designated special educator will go
back into SRS and check the appropriate box—either parent “gave consent” or “did not
give consent.” If parents failed to give consent, be sure to list the reasons given.
7. Check the box that states “Parent signature is on file” and type in the date of receipt of
parent signature. Select SAVE, DONE, and FINALIZE. (This form should be
finalized at the building level, not at C.O.)
ü If parents DID give consent, all testing consented to may begin at this time.
ü Make 3 copies of the signed document.
o The original (with signatures in ink) must immediately be sent to the Central
Office special education file. The 45 days will begin upon receipt of parent
signature.
o Provide one copy to parents
o File one copy in the student’s working file (typically maintained by the case
manager)
o File one copy in the building CUM file.
**The FINALIZED copy (without ink signatures) DOES NOT need to be sent to the C.O.
ü Designated Special Services secretary will enter and maintain this information at the
district-level.
o For School Psychologists and SLPs: The secretary will create a new CO SPED
file and keep the consent for evaluation and SAT documents in the CO SPED
file.
ü Be aware of the timelines relevant to the evaluation process. This process must not
exceed 45 school days.
ü CO file MUST be signed out through the designated Special Services secretary.
*DID I REMEMBER TO…
ü Completely fill out, SAVE, and print the document?
ü Send a copy of the Parent’s Rights Document home with the Notice and Consent
document?
ü Obtain parent signature and note the date to begin 45 day count down?
ü Note info from signed copy (yes-consent/no-consent) on SRS and check “signature on
file” box?
ü FINALIZE THE DOCUMENT.
ü Send ONLY the original copy containing ink signature to Central Office along with
Problem-solving team/SAT documentation to begin the MDT process?
ü File additional copies in appropriate locations?
ü Inform MDT Team that testing has been consented to so that they may begin evaluating?
07/17/09