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					                            Secondary Mild/Moderate Program
                                      CHECKLIST
                        Contemplating Change of Placement/Program

RSP to SDC or SDC to RSP! After discussing at SERT with School Psychologist, submit this
checklist with all pertinent documentation to School Psychologist, who will then consult with the
Program Coordinator. As per our Director, if the last full evaluation was over one year ago, the
student will need to be formally assessed. The extent of the assessment is determined on a case
by case basis.

Student ________________________________ Age ____ Date of Birth _______________________

School Site _____________________________ Grade ___ Case Carrier ______________________

___ Printout student information page from Zangle

___ Printout attendance from Zangle

___ Printout discipline history from Zangle

___ Printout of OARS

___ Copy of latest IEP/BSP – Date of last evaluation: ____________________

___ Retained in grade(s) ____ and ____

___ LEP overall level is ____ according to CELDT dated _________________

___ Student can read at the ____ grade level and comprehend at the ____ grade level

___ Student’s math calculation is at the ____ grade level and applied problems at the ____ grade level

___ Student’s writing ability is at the ____ grade level

___ Formal assessment results from school psychologist

___ Informal assessment result from special education teacher

___ Test Variations/Accommodations (as per IEP): Regular and Special education teachers need to
    provide work samples indicating how they were accommodated/modified and the result.

___ Anticipated Date of IEP is _______________________________________


Outcome: _________________________________________________________________________
__________________________________________________________________________________

January 2010 FUSD Contemplating Change of Placement Form

				
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