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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