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					SEO 6A WEST FARGO PUBLIC SCHOOLS SPECIAL EDUCATION UNIT
Integrated Written Assessment Report Initial Evaluation
STUDENT: AGE: GENDER: SCHOOL: PARENT: BIRTHDATE: GRADE: ETHNIC BACKGROUND: DATE OF REPORT:

Reason for referral:

Background information:

(see Student Profile for additional information)

Parent Input: Relevant Medical Information:

Observational information:

Assessment Summary:

Determination of Disability:

Non-Discriminatory procedures: The process, procedures, and instruments used in this assessment considered ’s culture, environment, sensory characteristics, and economic situation and were/were not found to be influential in the determination of a disability.

Impact of disability on education: Recommendations:
[ ] Check here that the multidisciplinary team has considered that the child’s disability is not due to lack of appropriate instruction in reading or math and/or limited English proficiency. [ ] Check here that the child’s parents, or the student if at the age of majority, received a copy of this Integrated Written Report on _______________________. Date 1

Signatures of team members indicating agreement:

Parent

Parent

Special Education Teacher

Administrator

General Education Teacher

Statement of disagreement if applicable:

2


				
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posted:12/30/2009
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