Member School Forms

Below are descriptions of the forms a person may choose to download below.

 

Consent for Mutual Exchange of Confidential Information- This form is used when requesting or sending confidential information to or from other schools or agencies.

 

Consent to Invite Outside Agency- This is a form to be utilized by case managers when seeking input and involvement of outside service agencies. As confidentiality is always a priority, parental permission is necessary and is reflected by a signature on the form attached below. For those case managers planning Transition IEP meetings, please utilize the permission form in AIM instead.

 

New Student Special Education Information Form- Please use this form when a student is added to your program or to update information as it becomes necessary (i.e., address change, school change (to another in our Cooperative), etc.) Send a copy to the Cooperative Office.

 

Observation Guides- These samples may be used when doing classroom observation for possible placement or reevaluation.  Information from these forms should be included on the Evaluation Team Report and the Test and Observation Summary.  The form itself should be included in the student's file as part of the overall assessment information.

 

Parental Consent for Additional Evaluation- This form, linked below,  is intended for use for a student whose eligibility has already been determined and when assessments are being requested only to obtain information for the IEP team.
Be sure to use the state's Evaluation Plan form if the evaluation(s) you are proposing may result in determination of SPED eligibility or a change in eligibility through an ER.   Also, if your intention is to conduct observations and acquire data for the purposes of an FBA, use the Evaluation Plan instead.  If services for occupational and physical therapy are being requested, please use this form.

Pre-Referral Request for Problem Solving- Prior to making a school referral, school teams need to gather comprehensive information and attempt early interventions prior to making a formal referral for special education services. The form found below is meant to guide a team through the data gathering process.  Keep in mind that if a parent requests an evaluation, the parent's signature on the Evaluation Plan should be secured and faxed to the Cooperative Office for staffing.  Do not delay.  Do be sure to state on the Evaluation Plan that the reason for the referral is parental request.

 

Program Placement Procedure- Optional guide, but recommended to assist the Special Education teacher in following the Special Education process from referral to placement.  Use it as a guide or comprehensive check for each student.

 

Psychological Protocols- Case Managers, please place this guidance note in the front of each of your students' files as you file new evaluation report work that includes psychological tests.  Recall speech, OT, and PT protocols are filed in your hard copy special education file unique to each student.

 

Referral for Medical Evaluation- Please use this form when a student is being referred to a physician.  This form will help schools pinpoint areas of concern that a physician may need to know, so as to provide relevant information about the student to the school.

 

Special Education Confidential File Access Log- The Special Education Confidential File Access Log is to be attached to the outside of each student's special education folder.  The following individuals have access to student records: school personnel, including teachers, who the school has determined to have legitimate education interest; and federal, state and local educational authorities with legitimate educational interest. Individuals accessing the special education file must sign, date and give the reason(s) for obtaining access.

 

Student Exit Information Form- Please use the Student Exit Information Form found below when a child exits any special education services (moves, returns to regular education, graduates, etc). Kindly send a copy to the Cooperative Office to update our database.For guidance on the destruction of records please review the item below titled Special Education Exit Record.

 

Taylor School Medication Effectiveness Report- This form can be used to provide a prescribing physician information regarding a student's performance in school after taking a certain medication.

 

Woodcock Johnson IV Testing Service- The form below should be completed by a case manager when the testing service for administration of the Woodcock Johnson IV is being requested.  The case manager must secure administrative pre-approval.  There is a fee for this service.  Please call the Cooperative Office prior to making a request as the service is intermittent at this time.