• PRESCHOOL REQUEST FOR EVALUATION

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  • Student Information:

  • Gender*
  • Date of Birth
     - -
  •  -
  •  -
  • Request made by:*
  • Date request was received by the school:*
     - -
  • How was request made?*
  • Request for evaluation was:*
  • Date the school's decision notice was sent to parent:*
     - -
  • Date school received consent signature:*
     - -
  • Have you personally verified that the parent consent has been EasyFaxed into IIEP and is in the student's file?*

  • Click this link to view the GJCS compliance calendar.

  • Timeline?*

  • 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 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 TC compliance calendar.

  • Click this link to view the PERRY compliance calendar.

  • Click this link to view the PIKE compliance calendar.

  • Compliance Date*
     - -
  • First Steps Transition Referral Date(This is the date used for EV)*
     - -
  • First Steps Compliance Date (50 Day timeline AND prior to 3rd Birthday)
     - -
  • Suspected Disabilities*
  • Who needs to be involved?*

  • Speech/Language/OT Medicaid Referral Form

  • Please enter more specific information about how you want the individual(s) to be involved in the evaluation.  No email addresses needed unless specifically prompted for.

  • Reports MUST be uploaded by:

  • Date Reports must be uploaded by:*
     - -
  • Should be Empty: