Notice of Action within First Steps Parental Rights by seNlo20V

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									                                                      NOTICE OF ACTION/CONSENT


Child Name                                                                                Date of Birth                              Date Completed


Prior Written Notice must be given to you, and consent obtained from you, before certain actions are taken. The
following is to inform you of the action(s) being proposed.
( ) Initial Evaluation/Assessment of the Child              ( ) Discontinue Service(s) at IFSP Team Request
( ) Initiation of Early Intervention Service(s)             ( ) Ongoing Assessment of the Child
( ) Change in Early Intervention Service(s)                 ( ) Initiation of Summer Services on Child’s Third Birthday
Reason for the action:




Parent Signature for Consent is required before the action(s) above can be initiated:

Initial Evaluation/Assessment of the Child                                       Consent                   Decline*
Ongoing Assessment of the Child                                                  Consent                   Decline*

Early Intervention Service(s)
____________________________________                                             Consent                   Decline*
____________________________________                                             Consent                   Decline*
____________________________________                                             Consent                   Decline*
____________________________________                                             Consent                   Decline*
____________________________________                                             Consent                   Decline*

*I am fully aware of the nature of the evaluation/assessment or services that are available and understand that my child
will not be able to receive the evaluation/assessment or services unless consent is given.

_____________________________________                                            _____________________________
Parent Signature                                                                 Date of Parent Signature

_____________________________________                                            ______________________________
Signature of agency representative                                               Date received by agency




A copy of the Parent’s Rights Statement is enclosed with this notice.

If you need assistance in understanding the provisions of the Parent’s Rights Statement, you may contact Special
Education Compliance, Department of Elementary and Secondary Education at (573) 751-0699 or (573) 751-0186 or via
e-mail at secompliance@dese.mo.gov.


The Department of Elementary and Secondary Education does not discriminate on the basis of race, color, religion, gender, national origin, age, or disability in its
programs and activities. Inquiries related to Department programs and to the location of services, activities, and facilities that are accessible by persons with
disabilities may be directed to the Jefferson State Office Building, Office of the General Counsel, Coordinator – Civil Rights Compliance (Title VI/Title IX/504/ADA/Age
Act), 6th Floor, 205 Jefferson Street, P.O. Box 480, Jefferson City, MO 65102-0480; telephone number 573-526-4757 or TTY 800-735-2966; fax number 573-522-4883;
email civilrights@dese.mo.gov.
                                                                                                                                                                 (July 2012)

								
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