SPED REFUSAL Sample Form by ePHG87dN

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									                                                    NOTICE OF REFUSAL
                                      Notice of refusal to provide services in regard to identification,
                                       evaluation, placement, or free appropriate public education.
                                 John H. Wood Jr. Public Charter District
                  Campus:


         Student's Name:

                      SSN:                                                                 Local ID:

            Date of Birth:

          Action Refused:         Full and Individual Evaluation                                 Parent request for additional evaluation

                                  Parent request to change criteria                              Parent request to change instructional setting

                                  Establish eligibility for SPED Services                        Parent request to provide related service(s)

                                  Other:

    Why Action Refused:           No documented educational need                                 Student does not meet eligibility criteria

                                  Testing already completed                                      Current testing received

                                  Testing does not support a different criteria                  Parent request that testing not be conducted

                                  Related service not necessary for student to benefit           Lack of educational opportunity (excessive absences or
                                  educationally                                                  numerous school changes)
                                  Current IEP, instructional modifications, and review of previous educational efforts support the student's present
                                  instructional setting
                                  Other:

   Documented Basis for           Report card(s)                                                 Status reports from teachers
              Refusal:
                                  Standardized test scores (cum folder)                          Medical/social history (parent information)

                                  Parent comments                                                Behavior rating scales (school and parent)

                                  Previous evaluation(s)                                         Information from previous school district

                                  Attendance records

                                  Other:

Other Factors Relevant to         No modifications indicated on report card                      Hearing/vision screening
                 Refusal:
                                  See accompanying letter for further explanation

                                  Other:

   Your rights were explained to you when you were/your child was initially referred for special education evaluation. Federal regulations require that
   parents and adult students be provided a full explanation of all procedural safeguards (rights) in their native language or other mode of
   communication upon initial referral for evaluation, each notification of an ARD meeting, upon reevaluation, upon receipt of a request for due process,
   and upon a manifestation determination review, or if a removal is contemplated that constitutes a change in placement. Another copy of the
   procedural safeguards (rights) is attached to this form.

   To obtain assistance in understanding this notice, please contact either the school staff person named below or a source external to the school district
   (see the last page of Explanation of Procedural Safeguards for external telephone numbers).

    School Staff Contact:

     Telephone Number:

   My signature below indicates I have received this notice of refusal.
   Parent, Guardian, Surrogate Parent, or Adult Student Signature:                                                                     Date:


   Interpreter Signature (if applicable):                                                                                              Date:



   Note: If the refusal occurs at an ARD meeting, the parent/adult student must be given a copy of this notice immediately.

								
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