CCJS - NOREE Updated 08/2025

Notification of Request for Educational Evaluation
Upon the M-team deciding on an educational evaluation due to a request from a parent or school personnel, fax immediately to 765-514-0075 and provide a copy of this notification to your school psychologist.

A COPY OF PROCEDURAL SAFEGUARDS IS TO BE GIVEN TO PARENTS WHEN SENDING THE NOTICE OF CONSENT TO THE PARENTS. FAX RECEIPT OF PROCEDURAL SAFEGUARDS CHECKLIST WITH THIS DOCUMENT.

Revised 08/2025
Student First Name*
Student Last Name*
Middle Initial
STN*
Grade*
What is the student's gender?*

MaleFemale?
Birth date*

MonthDayYear
Date
Age*
School of Residence*
What is the student's race?*

White/CaucasianBlack AmericanAmerican Indian or Alaskan NativePacific IslanderAsianMultiracial
What is the student's ethnicity?*

HispanicNot Hispanic
School Attending*
Primary Language*
Guardian(s) Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Zip
Homeless*

YN
Home Phone
Work Phone
Cell Phone*
Emergency Contact Phone*
Email Address
example@example.com
Custody:*

Natural ParentsMaternal Parent OnlyWard of StateCourtDCSDMSPaternal Parent OnlyFoster ParentAdopted
Teacher's Name/s:*
Teacher's Email*
Request Made By:*

ParentM-TeamSchool Personnel
Request Made via*

PhoneIn PersonWriting
If School Personnel, please enter your title:
Date request was received by school*

MonthDayYear
Starts the 10 school day timeline
Proposed Disability*
Anticipated Teacher of Record for IEP
Principal Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Notification of Request for Educational Evaluation