APPENDIX C

SAMPLE PRIOR NOTICES
School-Age

Preschool
and
DOCUMENTATION OF DETERMINATION OF ELIGIBILITY FOR STUDENTS SUSPECTED OF HAVING A LEARNING DISABILITY

 

SAMPLE PRIOR NOTICE - Initial Evaluation
School-Age Student

Dear___________________:
Description of the proposed action.
Explanation.
Other options considered.
On January 14, 2000, I received a referral to the Committee on Special Education for an initial evaluation of your child __________. This referral indicated that, even with additional general education supports (remedial reading and accommodations in test materials and curriculum materials), __________continues to demonstrate difficulties in the areas of reading and increasing behavior problems in the class. The school proposes to conduct an initial evaluation to determine if __________has a disability that may qualify him for special education services. In reviewing this referral, the school considered a referral to the Section 504 Committee but rejected that option based on the ongoing reports of _______’s difficulties despite the provision of other general education supports and services.
Purpose of the proposed evaluation.
How the proposed evaluation will be used.
The initial step in the special education process is to conduct an individual evaluation of your child. This will consist of a variety of tests and assessments provided at no cost to you to determine if ________is eligible to receive special education services and, if so, to develop an appropriate individualized education program (IEP) for him. As discussed with you and other members of the Committee on Special Education (CSE), the evaluation will consist of the following tests and assessments:
Description of each proposed evaluation.
  • An individual psychological evaluation to assess such areas as development, organization, memory, learning, behavior and other personality characteristics.

  • A physical examination to assess physical or medical factors (such as vision or hearing).

  • A social history, which is a report of information about the student, his family and his environment which may be influencing performance in school.

  • An observation of the student in his current classroom program.

  • Other assessments particular to this student:

  • A reading assessment (This assessment was conducted in November 1999 and therefore will not be repeated but will be considered as part of the initial evaluation.) We will not repeat this assessment unless you feel it is necessary.

  • A functional behavioral assessment to determine why the student may be engaging in certain behaviors in school.

Right to request a test or assessment.
Right to share evaluation information.
You have the right to request a test or assessment as part of this evaluation. In addition, if you have any evaluation information on your son that you would like considered in this process, please submit it to me. Any evaluation information that you submit will be considered by the CSE as part of its evaluation.
Request for consent. In order for the school to conduct this evaluation, we need your written consent. A copy of the "Consent for Initial Evaluation" is attached.
Statement regarding procedural safeguards notice and sources for the parents to contact.

Attached is a copy of the Procedural Safeguards Notice that explains your rights regarding the special education process. Also attached is a copy of the Parent Guide to Special Education. If you have any questions in understanding your rights or the special education process you may contact the following individuals for assistance:

Mrs. Jones Special Education Director
333-3333

Mr. Casey Training Specialist
456-6789

If you have any question regarding this notice or request for consent, please feel free to contact me. Upon your request, we will arrange a meeting to discuss the proposed evaluation and any concerns or questions you might have. Otherwise, please return the enclosed consent for evaluation form to me at the earliest possible time so that we can address your son’s learning needs in a timely manner.

 

Sincerely,

Mr. Administrator

Attachments
- Consent for Initial Evaluation
- Parent Guide to Special Education
- Procedural Safeguard Notice

 

SAMPLE PRIOR NOTICE- Initial Evaluation
Preschool Student

Dear_________________:
Explanation for proposed action. On January 14, 2000, I received from you a referral to the Committee on Preschool Special Education (CPSE) for an initial evaluation of your daughter, _______________.
Purpose
Description of proposed.
The initial step in the preschool special education process is to conduct an individual evaluation of ______. The proposed evaluation will be of no cost to you and will used to determine if _____ is eligible to receive preschool special education services and, if so, to develop an appropriate individualized education program (IEP) for her. As previously discussed with you, the evaluation will minimally consist of the following tests and assessments:
Description of each evaluation proposed.
  • An individual psychological evaluation to assess developmental, cognitive, learning, behavioral and other personality characteristics.

  • A physical examination to assess any relevant physical or medical factors (such as vision or hearing).

  • A social history, which is a report of information about the student, her family and her environment which may be influencing performance in school.

  • An observation of the ______ in her current day care program program.

  • Other assessments particular to this student:

  • A speech and language assessment to determine ______’s ability to understand and use language.

List of approved evaluators and procedures for selection. Attached is a list of schools approved to conduct evaluations of preschool students in this county and surrounding counties and the procedures you must follow to select one of the approved evaluators to conduct the individual evaluation on your child. The approved evaluator may suggest other assessments that may be appropriate for ______. If that is the case, you will be notified.
Right to request a test or assessment.
Right to share evaluation information.
You have the right to request a test or assessment as part of this evaluation. In addition, if you have any evaluation information on your daughter that you would like considered in this process, please submit it to the approved evaluator or to me. Any evaluation information that you submit will be considered by the CPSE in its review of evaluation information.
Request for consent.
Right to withhold consent.
In order for the school to proceed with this evaluation, we need your written consent. A copy of the "Consent for Initial Evaluation" is attached. If you do not consent to an initial evaluation of _____, no additional action will occur. Please note that by consenting to the initial evaluation of your daughter, you are not consenting for your child to receive special education services.
Statement regarding procedural safeguards. Attached is a copy of the Procedural Safeguards Notice that explains your rights regarding the special education process. Also attached is a copy of the Parent Guide to Special Education. If you have any questions in understanding your rights or the special education process you may contact the following individuals for assistance:
Sources to contact.

Mrs. Jones Special Education Director 333-3333

Early Childhood Direction Center 678-1234

If you have any question regarding this notice or request for consent, please feel free to contact me. Upon your request, we will arrange a meeting to discuss the proposed evaluation and any concerns or questions you might have. Otherwise, please return the enclosed consent for evaluation form to me at the earliest possible time so that we can address your daughter’s learning needs in a timely manner. I will schedule a meeting with you and other members of the CPSE to review the results of the evaluation within 30 school days of when I receive your written consent to conduct the individual evaluation.

 

Sincerely,

Ms. CPSE Director

 

Attachments:
- Consent for Initial Evaluation
- Procedural Safeguard Notice
- Parent Guide to Special Education
- List of Approved Evaluators and Procedures for Selection

 

 

DOCUMENTATION OF DETERMINATION OF
ELIGIBILITY FOR STUDENTS SUSPECTED OF HAVING A LEARNING DISABILITY

In addition to the prior notice requirements in Section 200.5(a) of the Regulations of the Commissioner, 34 CFR Section 300.543 requires that the CSE’s documentation of the determination of eligibility of a student suspected of having a learning disability include the following information:

The CSE has reviewed the individual evaluation results for _________________ which indicate that the student:

____

has a specific learning disability requiring special education services, demonstrated by a  severe discrepancy between achievement and ability.

____

does not have a specific learning disability.

This decision was based on the following evaluation procedures, tests, records and reports:

 

 

The relevant behavior noted during the observation of the student and the relationship of that behavior to the student’s academic functioning indicate:

 

 

The educationally relevant medical findings, if any, indicate:

 

 

The CSE has determined that environmental, cultural and/or economic disadvantage factors impact on the student’s learning problems as follows:

 

 

The findings of the evaluation indicated a severe discrepancy between achievement and the student's intellectual ability as specified below:

Oral expression:

_____________________________________________________________________

Listening comprehension:

_____________________________________________________________________

Written expression:

_____________________________________________________________________

Basic reading skill:

_____________________________________________________________________

Reading comprehension:

_____________________________________________________________________

Mathematics calculation:

_____________________________________________________________________

Mathematics reasoning:

_____________________________________________________________________

 

CSE Member Certification of the Determination of a Learning Disability:

(Each CSE member must certify in writing whether the report reflects his or her conclusion. If not, the team member must submit a separate statement presenting his or her conclusion)

Title Signature Agree Disagree
LEA Representative _____________________________ _____ _____
Parent of Student _____________________________ _____ _____
Regular Education Teacher _____________________________ _____ _____
Special Education Teacher _____________________________ _____ _____
School Psychologist _____________________________ _____ _____
Parent Member _____________________________ _____ _____
Others: Specify _____________________________ _____ _____
_____________________________ _____ _____
_____________________________ _____ _____

Date: ________________________