school signature of school administrator date received [district name] public schools referral to determine eli

School
Signature of School Administrator
Date Received
[DISTRICT NAME] PUBLIC SCHOOLS
REFERRAL TO DETERMINE ELIGIBILITY FOR SPECIAL EDUCATION AND RELATED
SERVICES
-------------------------------------------------------------------
Student:
DOB:
Age:
Grade:
Parent/Guardian:
Primary Lang: English
Other:
Address:
Referred by:
Referral Date:
Telephone:
Relationship to Child:
1. AREA(S) OF CONCERN:
Check major area(s) of concern, and briefly describe the child’s
behavior, or performance in each area checked. If you have identified
more than one area of concern, circle the area you consider to be the
highest priority.
Academic
Social/Emotional
Gross/Fine Motor
Activities of Daily Living
Health Related
Behavior
Communication
Other: (specify)
A.
Describe Specific Concerns:
B.
Describe Alternative Strategies Attempted and Outcome: (Use
additional pages if necessary.)
ED621
January 2006
Page 1 of 2
Student:
DOB:
2. Special Services History:
Are you aware of any special services provided for this child
now or in the past?
Yes
No
If Yes, describe the type, location, and provider of the service.
3. Other Relevant Information:
4. Parent Notification:
Has the parent/guardian been notified about your concerns
regarding this student?
Yes
No
If Yes, method of notification:
Date(s) parent/guardian was notified:
Signed:
Date:
(Signature of individual completing this form)
*Please note: The special education referral date immediately affords
the student and parent(s) all special education procedural safeguards.
This referral also “starts the clock” with respect to the timelines
specified in RCSA 10-76d-13(a)(1) and (2) which provide that “(1) The
individualized education program shall be implemented within
forty-five days of referral or notice, exclusive of the time required
to obtain parental consent. (2) In the case of a child whose
individualized education program calls for out-of-district or private
placement, the individualized education program shall be implemented
within sixty days of referral or notice, exclusive of the time
required to obtain parental consent.” If a parent communicates in
writing directly with a staff member that they wish to refer their
child for an evaluation to determine her/his eligibility for special
education services, the date the staff member receives this written
communication constitutes the date of referral. If a parent
communicates verbally with a staff member that they wish to refer
their child for an evaluation to determine her/his eligibility for
special education services, the staff member should provide the parent
with a copy of this referral form and, when necessary, assist the
parent in completing this form. It should be understood that, in all
instances, this is a referral for an evaluation to determine
eligibility for special education services. Actual eligibility for
special education services is determined by the PPT only after an
evaluation has been completed.
ED621
January 2006
Page 2 of 2

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