Docstoc

Medical Orthopedic Assessment Form - Excel

Document Sample
Medical Orthopedic Assessment Form - Excel Powered By Docstoc
					                                           Complete this form online, print, district sign and return to: Intake Specialist at
                                                             Northwest Regional Program
                                                             5825 NE Ray Circle, Hillsboro, Oregon 97124                                     Last Revised 04/17/08


                       Request for Regional Services and/or Evaluation for Eligibility
Please type and fill in all fields of this form:

Referring Agency / Person:                                Medical            Parent          District Team
                                                                                                                                                 Date

Last Name of Student                                 First Name                       MI                           Gender               Date of Birth

                                                                                                                                         Family Requires a
                                                                                   OR                                                    District Translator
Home Address                                                City                  State                                 Zip
                                                                                                                                                               1
                                                                                                                                        Select Language
Parent/Guardian                                     Home Phone                        Work Phone                Cell Phone
                                                                                                                                              District Provided

Parent/Guardian                                     Home Phone                        Work Phone                Cell Phone
                                                                                                                                               Consent to Bill for
                                                                                                                                              Interpreter Services


 Attending School/Placement                         Home School                  Grade
and/or EI/ECSE Placement


   Attending School District                       Resident District                       County                             Spec Ed Director



     Contact Person Name                                  Position                         Phone                        Fax



         Contact Address                            Contact Email                          Current Sp Ed Eligibilities                    Current Date of IEP/IFSP



                 SSID #                                              Signature of Spec Ed Director


                                                   Request for Assistance with Eligibility Determination
                              A copy of the "Consent for Evaluation" form signed by a parent/guardian is REQUIRED for NWRP to
                     participate in eligibility determination. (No action will be taken on this request unless it is accompanied
                     by signed consent for evaluation form).

Eligibility assistance with:                                                     This is an Initial Eligibility

                Autism                       Deaf/Hard of Hearing                                     Vision
              Supporting documents                  Supporting documents                             Supporting Documents required,
            required, see instructions              required, see instructions                       see instructions on page 2
        on page 2                                   on page 2




                           Request for Services
                                                    (Supporting documents required, see instructions on page 2)                             This is an EI/ECSE student


                Autism                       Deaf/Hard of Hearing                                   Orthopedic                                     Vision
         Is this a Move-in?                    Is this a Move-in?                                Is this a Move-in?                                  Is this a Move-in?
         Eligibility attached                  Eligibility attached,                             Eligibility attached                                Eligibility attached
                                               see page 2

Regional Use:                                                                                                District Use:
Office Use:                                                                                                  Initials of person submitting to Regional:
                            Intake                 Date                               Assigned To:
                                                                                                             Date Received              Date Sent to Regional
SSS.RS.3011
                                                                   Supporting Documents



                             Autism Services                                                                      Vision Services

The following is to be completed by the district and must accompany a             The following is to be completed by the district and must accompany a Request
Request for Assistance with Eligibility Determination:                            for Assistance with Eligibility Determination:

    Copy of the Signed Consent for Evaluation for:                                    Signed Eye Report from an ophthalmologist or optometrist
        - Three observations                                                          Copy of the Signed Consent for Evaluation listing:
        - File review                                                                               - Functional Vision Assessment
        - Developmental profile
                                                                                  The following is to be attached to a Request for Services for a student who has
(Note: for Initial Early Intervention (EI) eligibility determinations the first   moved into the district with a current Vision eligibility:
observation may occur during the evaluation meeting where the Permission to
Evaluate is received.)                                                                Eligibility Statement
                                                                                      Signed Eye Report from an ophthalmologist or optometrist
The following is to be completed by the district prior to the initial                 Functional Vision Report
eligibility determination meeting:                                                    Current IEP or IFSP
                                                                                      Previous Evaluation Reports and assessment information
    Physician's Statement
    Functional Communication Assessment
    Other testing as determined by evaluation planning team

The following is to be attached to a Request for Services for a student
who has moved into the district with a current ASD eligibility:

    Eligibility Statement
    Signed Medical Statement
    Current IEP or IFSP
    Previous Evaluation Reports and assessment information



                          Deaf/Hard-of-Hearing                                                                Orthopedic Services

The following is to be completed by the district and must accompany a
Request for Assistance with Eligibility Determination:                            The following information must accompany a Request for Services:

    Copy of the Signed Consent for Evaluation for:                                   Copy of the Signed Consent for Evaluation
         - Classroom observation                                                     Copy of current cover page for IFSP or IEP (NWRP services to be added,
         - File review                                                                when eligible)
    Two failed hearing screenings or a current audiological assessment               Verification of diagnosis (A physician's statement or medical report
                                                                                      which includes diagnosis. Must have physician's signature.)
The following is to be completed by the district prior to the initial                Statement of Eligibility
eligibility determination meeting:                                                                   - Orthopedic Impairment (70)
                                                                                  Ages 0-2 Years Old
    Physician's Statement                                                                       Standardized scores
                                                                                            Results page of test protocol with standardized scores
The following is to be attached to a Request for Services for a student           Ages 3-21 Years Old
who has moved into the district with a current HI eligibility:                               OREST (3-21 years old)

    Eligibility Statement
    Signed Medical Statement
    Current IEP or IFSP
    Current Audiological Evaluation Report



SSS.RS.3011
English
Hebrew
Japanese
Korean
Mandarin
Russian
Sign Language
Spanish
Vietnamese

				
DOCUMENT INFO
Description: Medical Orthopedic Assessment Form document sample