• Request for Re-evaluation

  • Demographics

  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Grade Level*

  • Corporation & School

  • Corporation*
  • GJCS School*
  • SWD School*
  • NED School*
  • SED School*
  • NS School*
  • SS School*
  • CA School*
  • TC School*
  • Perry Central School*
  • Pike County School*

  • Referral Information

  • Request made by:*
  • Date of Referral*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Request for evaluation was:*
  • Date the school's decision notice was sent to parent:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Consent & Timeline

  • Was parent consent obtained?*
  • Have you personally verified that the parent consent has been EasyFaxed/SmartScanned into IIEP and is in the student's file?*
  • Have you personally verified that multiple attempts to obtain parent signature have been properly documented in IIEP under parent communications?*
  • Consent Date? Please note: This must be a student school date.*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is this current Re-Eval looking at Speech or Language Only?*
  • Timeline?*

  • Evals due at next AR

  • Date of Last Annual Review?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Compliance Date (Upcoming AR)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Which current eligibility areas are you re-evaluating?*

  • 50 day eval

  • Reason for 50 day Eval?*

  • Click this link to view the GJCS compliance calendar.

  • Click this link to view the SWD compliance calendar.

  • Click this link to view the NED compliance calendar.

  • Click this link to view the SED compliance calendar.

  • Click this link to view the TC compliance calendar.

  • Click this link to view the NS compliance calendar.

  • Click this link to view the SS compliance calendar.

  • Click this link to view the CA compliance calendar.

  • Click this link to view the PERRY compliance calendar.

  • Click this link to view the PIKE compliance calendar.

  • 50 Day Compliance Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • NEW Suspected Eligibility Areas AND any Current Eligibility Areas being considered for dismissal*

  • 20 day eval

  • 20 Day Compliance Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • NEW Suspected Eligibility Areas AND any Current Eligibility Areas being considered for dismissal*

  • Team Planning

  • Who needs to be involved?*

  • Direction for Evaluator

    Please list specific involvement
  • Will an FBA be a part of this eval?*

  • Reports MUST be uploaded by:

  • Date reports must be uploaded by*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Speech/Language/OT/PT Medicaid Referral Form

  • Should be Empty: