DOUGLAS COUNTY SCHOOLS PROGRAM FOR EXCEPTIONAL CHILDREN

Revised 07/2016

RE-EVALUATION REQUEST FOR ____________________________________________ PROGRAM (All items must be completed in order for this referral to be processed; incomplete referrals will be returned to the school.)

Name: __________________________________________ DOB: ____________ Age: ____ Sex: M F

School: _______________________________ Grade: __________ Teacher: _____________________________

Father’s Name: _____________________________________________ Occupation: _______________________

Mother’s Name: ____________________________________________ Occupation: _______________________

Child lives with: Mother Father Stepmother Stepfather Other: ____________________________

Special Education Programs: (list all) ______________________________________________________________

Date Consent for Reevaluation signed: ________________ (attach RDM form)

Vision test passed ________ Wears glasses: Y N Hearing test passed ________ (attach H&V) (date) (date)

Current grade level estimates:Reading: _______ Writing: _______ Spelling: _______ Math: _______ Science: _______ SS: _______

MOST RECENT TEST DATA:

CURRENT GROUP TEST DATA (such as GA Milestones, CRCT, CAT, ITBS, etc.): ______________________________ ____________________________________________________________________________________________

Date

__________________________________________________

Assessment (List by name such as Standford-Binet, WISC-IV, Vineland, etc.)

1. _______________________________2. _______________________________3. _______________________________4. _______________________________5. _______________________________

Significant behavior characteristics: _______________________________________________________________

_____________________________________________________________________________________________

Significant physical limitations: ___________________________________________________________________

_____________________________________________________________________________________________

How does child react to teacher and to discipline? ___________________________________________________

_____________________________________________________________________________________________

How does child get along with peers? ______________________________________________________________

_____________________________________________________________________________________________

Reason for placement and other weaknesses: _______________________________________________________

_____________________________________________________________________________________________

Child's strengths: ______________________________________________________________________________

_____________________________________________________________________________________________

List any other outside services currently received: ____________________________________________________

_____________________________________________________________________________________________

Special Education Teacher: ______________________________________ Date: ___________________

Scores

______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________

PEC-01B