Vineland Ii Report Template by gfa18637

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									                                      Alachua County Public Schools, 620 East University Avenue, Gainesville, FL 32601
                                                      Exceptional Student Education
                                         INFORMED NOTICE AND CONSENT FOR INITIAL PLACEMENT

Student Name:                                                                                                    Today's Date:
Student #:                                                             School:                                                               Grade:
Date of Birth:                                   Sex:                   Race:                Primary Language at Home
Parent/Guardian Name:
Parent/Guardian Address:
Parent/Guardian Home Phone:                                                               Work Phone:
Your child is eligible for special education and services. In order to meet your child’s educational needs we are proposing placement
in the special education program(s):
You were invited to participate as a member of the Individual Education Plan (IEP) team that made this proposal based upon a review
of your child’s performance on the following evaluation procedures, tests, and/or records:
Intellectual Evaluations:                            Behavioral/Projective Tests:                           Speech Tests:
      Wechsler Intelligence Scale for Children           Behavior Assessment System for Children                 Goldman-Fristoe Test of Articulation
      Stanford-Binet Intelligence Scale                  Human Figure Drawing                                    Assessment of Phonological Processes
      Nagliari Nonverbal Abilities Test                  House-Tree-Person                                       Photo-Articulation Test
      Reynolds Intellectual Assessment Scales            Piers-Harris Children’s Self-Concept Scale              Oral-Peripheral Exam
      Kaufman Assessment Battery for Children            Child Behavior Checklist                                Conversational Speech Sample
      Differential Abilities Scale                       Battelle Developmental Inventory                        Other:
      Battelle Developmental Inventory                   Other:                                             Language Tests:
      Other:                                         Adaptive Scales:                                           Preschool Language Scale
Process Tests:                                           Vineland Adaptive Behavior Scales                      Test of Language Development-Primary
     Woodcock-Johnson Cognitive                          Comprehensive Test of Adaptive Behavior                Test of Language Development-Intermediate
     Bender Visual-Motor Gestalt Test                    Developmental Profile-2                                Expressive One-Word Picture Vocabulary
     Visual Motor Integration Test                       Battelle Developmental Inventory                       Oral and Written Language Scales
     Other:                                              Other:                                                 Clinical Evaluation of Language
     Other:                                          Academic Assessments:                                      Fundamentals
Physical/Occupational Therapy Assessments:               Kaufman Test of Ed. Achievement-II                     Battelle Developmental Inventory
     Occupational Therapy Evaluation                     Woodcock-Johnson Achievement                           Other:
     Physical Therapy Evaluation                         Peabody Individual Achievement Test                Other:
     Criteria for Educational Relevant Therapy           Wechsler Individual Achievement Test                    Checklist of Gifted Characteristics
                                                         Kaufman Survey of Early Academic Skills                 Student Interest Survey
                                                         Other:                                                  Medical Information
                                                                                                                 Social/Developmental History
The team developed an IEP on                            (date) to meet your child’s special education and service needs. (A copy of the
plan is being provided to you.) The education program placement options for implementing the plan are described below. Each
option was considered by the team and the recommended option is identified by an “x.”
a.        Regular Class (more than 79% with non-disabled)                 d.          Separate Day School
b.        Resource room (more than 40%, but less than or equal to         e.          Hospital/Homebound
          79% with non-disabled)                                          f.          Residential School
c.        Special Class (less or equal to 40% with non-disabled)          g.          Other
The other placement options were rejected by the committee because they:
      Did not provide the least restrictive environment for your child.
      Did not provide the amount of individual or small group instruction required by your child.
      Did not provide the amount of academic challenge required by your child.
Any other factors relevant to the placement option recommendation include:

Your written consent for the recommended initial placement is required prior to implementation of the plan for your child. Upon
consent for the initial placement, you will receive written notice if any placement change is recommended in the future. As
parent(s)/guardian(s) of a child with a disability you have protections under the procedural safeguards of the Individuals with
Disabilities Education Act (IDEA) and Rule 6A-6.03311, FAC, Procedural Safeguards for Students with Disabilities or Rule 6A-
6.03313, FAC, Procedural Safeguards for Exceptional Students Who Are Gifted. The document describing these rights, Summary of
Procedural Safeguards, has been provided to you and is also available on the School Board website at Should you
want additional copies of the Procedural Safeguards or additional information about your rights, you may contact:
                      name                                   title                                    location                               phone
                      name                                   title                                    location                               phone

                                                                     Placement Consent
     Yes, I consent to the educational placement proposed for my child.
     No, I do not give my consent to the educational placement for my child.     _________________________________________________
                                                                                 Signature of Parent or Guardian                                          Date

Form No. ESE 056.007 - Informed Notice and Consent for Initial Placement/ESE                                                 Distribution:   __School/Principal
Revised Date: 11/14/05                                                                                                                       __ESE

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