Revised 10/99

Student's Name: Date of Birth: 
Date of Evaluation:
Parent /Guardian: Agency:


Address: Contact person:
County of Residence: School District:


This reporting form provides a summary of the findings of the evaluation which includes a detailed statement of the child's individual needs. As a result of Chapter 474 of he Laws of 1996, the evaluator may no longer recommend the general type, frequency and duration of special services and programs needed nor address the manner in which the special services and programs can be provided in the least restrictive environment.

Please indicate the individually administered evaluation measures used, including the result of the observation of the child and the findings pertinent to the following domains. Incorporate the strengths of the child and the characteristics relating to the suspected disability. This summary and the documentation of the evaluation results are to be transmitted to all the members of the Committee on Preschool Special Education (CPSE) and to the Municipality representative. Before meeting with the parent, the CPSE must transmit a copy of this evaluation summary report to the parent. The summary report must be transmitted in English, and when necessary, in the dominant language or other mode of communication of the parent.

1. Cognitive



2. Social/Emotional



3.Motor Development



4.Language and Communicative



5.Adaptive/Functional Behavioral Assessment



Please indicate the date the evaluation results, including this summary report, were sent to the Committee on Preschool Special Education and the Municipality Representative: ___________________________________