Central Committee of Special Education Dr. Mary Pauly Kim ...

Buffalo Public Schools Dr. Pamela C. Brown, Ed.D. Superintendent

Central Committee of Special Education Dr. Mary Pauly

Assistant Superintendent of Curriculum, Assessment & Leadership

Kim Curtin Director of Special Education

Buffalo Public Schools Dr. Pamela C. Brown, Ed.D. Central Committee of Special Education Superintendent Dr. Mary Pauly

Assistant Superintendent of Curriculum, Assessment & Leadership Kim Curtin

Director of Special Education

33 Ash Street, Buffalo, New York 14204 (716) 816-4746 – Fax (716) 816-3974

REV. 5/12/14

CSE NON-PUBLIC SCHOOLS ORGANIZATIONAL CHART 2014-2015 Kyle Morrison

Supervisor of Special Education Email – [email protected]

Central 3 Central 4 Central 8 Chairperson: Angela Bumbalo Chairperson: Dawn Haring Chairperson: Karen Smith Phone: 816-4704 Phone: 816-4703 Phone: 816-4701 Email: [email protected] Email: dharing@buffaloschoolsorg Email: [email protected] Psychologist: Marla Mis Psychologist: Kristen Litz Psychologist: AnnMarie Barrett Phone: 816-4705 Phone: 816-4703 Phone: 816-4702 Email: [email protected] Email: [email protected] Email: [email protected]

Schools Schools Schools

Canisius Nativity of Miguel Middle School Buffalo Seminary Nichols Catholic Academy Elmwood Franklin Our Lady of Black Rock St. Mark Greater Refuge Rainbow K Mount Mercy Universal School Notre Dame Nardin-Elementary and High School St. Tabernacle Nardin Montessori Bishop-Timon Westminster Early Childhood St. Joe’s University St. John Christian Academy Our Lady of Hope Home Schooling




(716) 816-4746 – Fax (716) 816-3974 Revised 4/15/14

Students new to Buffalo District enrolling in Nonpublic Schools

• The Central Committee on Special Education Placement Office must be made aware of all students with disabilities entering Nonpublic Schools for the very first time from out of district or out of state.

• Parent Completes ALL Forms: Transfer Student Information Sheet Student Racial & Ethnic Identification Form Request for Student Records Home Language Questionnaire Parent Consent Form Parental Consent for Medicaid Funding Copy of most current IEP

• Forward completed packet to:

Central Committee on Special Education Placement Office 33 Ash Street, Room 201

Buffalo, NY 14204





Revised 4/15/14

Transfer Student Information Sheet

Date: Start Date: Student Name: Student’s DOB: Grade: Address: City: Zip Code: Phone#: Emergency#: Email:

Student lives with: Name: Relationship to student:

If student is NOT living with parent, is the parent(s) still the legal guardian? YES NO If YES: Parent(s) names:

Address: Phone #: Emergency #:

Last School attended: District: Phone#: Fax: Address: City: Zip Code: School official to contact: Number:

Has the student ever attended the Buffalo Public Schools? YES NO

Was the student a special education student in the Buffalo Public Schools? YES NO

BUFFALO PUBLIC SCHOOLS STUDENT RACIAL AND ETHNIC IDENTIFICATION ESCUELAS PÚBLICAS DE BUFFALO IDENTIFICACIÓN ÉTNICA Y RACIAL DEL ESTUDIANTE

To the Parent/Guardian: The BUFFALO PUBLIC SCHOOL DISTRICT has adopted a policy which requires the collection and recording of the ethnic identity of students in the BUFFALO PUBLIC SCHOOL DISTRICT in accordance with the federal categories and definitions. The information will be used to: - Plan educational programs and make sure that they are readily available to all students. - Analyze differences in academic performance, attendance and completion of school. - Report information to the State and Federal Education Departments. We need your help in order to accomplish this task. Please review the Racial/Ethnic definitions on the back of this page. Put a check (√) in the box for the category or categories which best describe your child. The BUFFALO PUBLIC SCHOOL DISTRICT wishes to assure you that this information will be kept secure and confidential in accordance with all State and Federal student privacy laws and regulations. If the information requested is not provided on this form on behalf of your child, a student records officer from the school or district will be required to identify the group to which the student appears to belong, identifies with, or is regarded in the community as belonging. Thank you for your cooperation. Padre/Encargado: El DISTRITO DE LAS ESCUELAS PÚBLICAS DE BUFFALO requiere de acuerdo con la categoría y definición federal la colección y anotación de la identidad étnica de los estudiantes en el DISTRITO DE LAS ESCUELAS PÚBLICAS DE BUFFALO. La información se usará para: - Diseñar programas educativos y asegurarse que estos estén fácilmente disponibles a todos los estudiantes. - Analizar las diferencias entre el desarrollo académico, asistencia y cumplimiento académico. - Comunicar esta información a los Departamentos de Educación Federal y de Estado. Necesitamos su ayuda para poder llevar a cabo esta tarea. Por favor revise la definición Racial/Étnica en la parte de atrás de esta página. Marque (√) en el encasillado la(s) categoría(s) que mejor describe a su hijo(a). El DISTRITO DE LAS ESCUELAS PÚBLICAS DE BUFFALO desea asegurarle que esta información se mantendrá segura y confidencial de acuerdo con todas las leyes y regulaciones Federales y del Estado para la privacidad de los estudiantes. Si la información que le solicitamos no es completada en esta forma en nombre de su hijo(a), el oficial encargado de la escuela o distrito identificará el grupo en el cual el estudiante parece pertenecer, se identifica, o es considerado que pertenece en la comunidad. Gracias por su cooperación.

CONFIDENTIALITY PROCEDURES AND REGULATIONS PROCEDIMIENTOS Y REGLAS SOBRE LA CONFIDENCIALIDAD

To School Staff: This form will be filed in the student's permanent record as confidential information.

To the Parent/Guardian: The information which you have provided on this form is confidential. It is protected by the Confidentiality Regulations cited below. Al Personal de la Escuela: Esta forma será archivada en el expediente permanente del estudiante como información confidencial.

Al Padre/Encargado: La información que usted ha dado en esta forma es confidencial. Esta protegida por las Reglas de Confidencialidad listada en la parte de abajo.

The Family Educational Rights and Privacy Act (1974) prohibits unauthorized access to student records and unauthorized release of any student record information identifiable by either student name or student identification number.

El Acto de Privacidad y de los Derechos Educacionales de las Familias (1974) prohíbe el acceso sin autorización al expediente del estudiante y la liberación de cualquier información sin autorización que puede identificar al estudiante por medio del nombre o su número de identificación.

Please complete the form on the reverse side of this page Por favor complete la parte de atrás de este formulario

Name of School: Nombre de la Escuela:

Grade Level: Grado:

All students between 5 and 21 years of age have the right to a free public education. Children may not be refused admission because of race, color, creed or national origin, sex, citizenship, handicapping condition, or immigration status.

Todos los estudiantes entre los 5 y 21 años de edad tienen el derecho a una educación pública gratuita. Los estudiantes no pueden dejar de ser matriculados por causa de la raza, color, credo u origen nacional, sexo, ciudadanía, incapacidad, o estatus de inmigrante.

Date of Birth (Month/Day/Year): Fecha de Nacimiento (Mes/Día/Año): / /

Student Name: Last, First, Middle: Nombre del Estudiante: Apellido, Primer y Segundo Nombre:

DIRECTIONS TO PARENT/GUARDIAN/INSTRUCCIONES A LOS PADRES/ENCARGADOS

BLACK: A person having origins in any of the black racial groups of Africa NEGRO: Una persona que tiene cualquier origen con los grupos raciales negros de África

WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East BLANCO: Una persona que tiene cualquier origen con personas originales de Europa, África del Norte, o el Oriente Medio

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. NATIVO DE HAWAII O OTRAS ISLAS PACIFÍCAS: Una persona que tiene cualquier origen con personas originales de Hawai, Guam, Samoa, o otras Islas Pacíficas

ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. ASIÁTICO: Una persona que tiene cualquier origen con personas originales del Sudeste de Asia, o el subcontinente de India, incluyendo por ejemplo, Cambodia, China, India, Japón, Korea, Malasia, Pakistán, las Islas Filipinas, Thailand y Vietnam.

________________________________________________________________ Signature of Parent/Guardián/Other/Firma del Padre/Encargado/Otro

______________________ Date/Fecha

AMERICAN INDIAN OR ALASKA NATIVE: A person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition. e.g. Cherokee, Mohawk, Inuit. INDIO AMERICANO O NATIVO DE ALASKA: Una persona que tiene cualquier origen con personas originales de Norte America y quien mantiene identificación cultural por medio de una afiliación indígena o reconocimiento de la comunidad. ej. Cherokee, Mohawk, Inuit.

School District Student Identification Number: Número de Identificación del Estudiante del Distrito

PLEASE ANSWER QUESTIONS (1) and (2). PLEASE READ THEM BEFORE YOU RESPOND. [For question (1) Check (√) the box that best describes your child.] Check (√) only ONE box.

POR FAVOR CONTESTE LAS PREGUNTAS (1) y (2). POR FAVOR LEA ANTES DE CONTESTAR. [Para preguntas (1) Marque (√) el encasillado que mejor describe a su hijo(a)] Marque (√) sólo UN encasillado.

Other (Specify)/Otro (Especifíque): _________________________

Mother/Madre Father/Padre

Guardian/Encargado

BUFFALO PUBLIC SCHOOLS STUDENT RACIAL AND ETHNIC IDENTIFICATION ESCUELAS PÚBLICAS DE BUFFALO IDENTIFICACIÓN ÉTNICA Y RACIAL DEL ESTUDIANTE

1. Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race. ¿Es el estudiante Hispano, Latino, o de Origen Español? Hispano, Latino, o origen Español significa una persona que es Cubana, Mexicana, Puertorriqueña, de Centro y Sur América, o de otra cultura o origen Español, sin importar la raza.

YES, Hispanic/SÍ, Hispano

NO, not Hispanic/NO, no Hispano

2. Select one or more races from the following five racial groups [For question (2) Check (√) all groups that apply to your child; check (√) at least ONE box.]:

Seleccione una o más razas de los siguientes cinco grupos raciales [Para preguntas (2) Marque (√) todo grupo que le aplica a su hijo(a), marque (√) por lo menos UN encasillado.]:

Relationship to Student (please check one box below)/Relación con el Estudiante (por favor marque sólo un encasillado):





Revised 4/16/14

REQUEST FOR STUDENT RECORDS

The student, indicated below, has transferred to the Buffalo City Schools District. The Federal Education Rights and Privacy Act, states, School districts may release student record to another school or school system without parent consent. 34CFR§99.31(A)(1). Thank you.

Please provide the following information to assist us with appropriate school assignment for this student and mail or fax to:

33 Ash Street, Buffalo, NY 14201 Rm. 201 or fax: 816-3977

ATTN: _____________________________________________

Cumulative Record / Transcripts

• IEP

• Psychological

• Social History

• Related Services

• Education Evaluations

• Discharge Recommendations

ESL/Bilingual Services

School Suspensions / Expulsion / Disciplinary Records

504 / ADA

Birth Certificate / Immunization and Health Records

Parent / Guardian, please complete this section:

Students Name: Grade: DOB: Parent Signature:

The University of the State of New York • The State Education Department • Office of Bilingual EducationAlbany, New York 12234

Home Language Questionnaire (HLQ)TO BE COMPLETED BY SCHOOL PERSONNEL

DISTRICT Please print or type clearly

SCHOOL GRADE

STUDENT NAME

DATE OF BIRTH

STUDENT IDENTIFICATION NUMBER

COUNTRY OF BIRTH / ANCESTRY

NUMBER OF YEARS ENROLLED IN SCHOOL OUTSIDE THE U.S.

NAME/POSITION OF SCHOOL PERSONNEL COMPLETING THIS SECTION

DETERMINATION: ❏ Possible LEP

❏ English Proficient

Dear Parent or Guardian:

In order to provide your child with the

best possible education, we need to

determine how well he or she under-

stands, speaks, reads and writes

English. Your assistance in answering

these questions is greatly appreciated.

Thank You

(✔ boxes that apply)

1. What language(s) is spoken in the student’s ❏ English ❏ Other __________________________________home or residence? specify

2. What language(s) are spoken most of the time ❏ English ❏ Other __________________________________to the student, in the home or residence? specify

3. What language(s) does the student understand? ❏ English ❏ Other __________________________________specify

4. What language(s) does the student speak? ❏ English ❏ Other __________________________________specify

5. What language(s) does the student read? ❏ English ❏ Other _______________ ❏ Does Not Readspecify

6. What language(s) does the student write? ❏ English ❏ Other _______________ ❏ Does Not Writespecify

7. In your opinion, how well does the student understand, speak, read and write English?

_________________________________________________ ____________________________________________________Signature of Parent/Guardian/Other Date HLQ (2/00) 99-337 PM

Month: Day: Year:

Month: Day: Year:

Very well Only a little Not at all

Understands English ❏ ❏ ❏

Speaks English ❏ ❏ ❏

Reads English ❏ ❏ ❏

Writes English ❏ ❏ ❏

(✔ Marque las casillas que aplican)

1. ¿Qué idioma(s) se habla en el hogar ❏ Inglés ❏ Español ❏ Otro ___________________________o residencia del estudiante? (Especifique cuál)

2. ¿En qué idioma(s) se le habla al estudiante ❏ Inglés ❏ Español ❏ Otro ___________________________la mayor parte del tiempo (Especifique cuál)

en el hogar o residencia?3. ¿Qué idioma(s) entiende el estudiante? ❏ Inglés ❏ Español ❏ Otro ___________________________

(Especifique cuál)

4. ¿Qué idioma(s) habla el estudiante? ❏ Inglés ❏ Español ❏ Otro ___________________________(Especifique cuál)

5. ¿En qué idioma(s) lee el estudiante? ❏ Inglés ❏ Español ❏ Otro _____________ ❏ No lee

(Qué idioma)

6. ¿En qué idioma(s) escribe el estudiante? ❏ Inglés ❏ Español ❏ Otro _____________ ❏ No escribe

(Qué idioma)

7. ¿En su opinión, qué tan bien el estudiante entiende, habla, lee y escribe inglés?

The University of the State of New York • The State Education Department • Office of Bilingual EducationAlbany, New York 12234

CUESTIONARIO SOBRE EL IDIOMA QUE SE HABLA EN EL HOGAR(“Home Language Questionnaire, HLQ”) – Spanish

PARA SER COMPLETADO POR EL PERSONAL ESCOLAR(TO BE COMPLETED BY SCHOOL PERSONNEL)

DISTRITO IMPRIMA O ESCRIBA CLARAMENTE (District) (Please print or type Clearly)

ESCUELA GRADO (School) (Grade)

NOMBRE DEL ESTUDIANTE (Student Name)

FECHA DE NACIMIENTO (Date Of Birth)

NUMERO DE IDENTIFICACION DEL ESTUDIANTE (Student Identification Number)

PAIS NATAL O ASCENDENCIA (Country of Birth/Ancestry)

NUMERO DE AÑOS MATRICULADO EN ESCUELA(S) FUERA DE LOS E.U. (Number of years enrolled in school outside the U.S.)

NOMBRE/POSICIÓN DEL PERSONAL ESCOLAR LLENANDO ESTA SECCION (Name/Position School Personnel Completing This Section)

DETERMINACIÓN: ❏ Posiblemente LEP (Possibly LEP)❏ Dominante en Inglés (English Proficient)

Estimado Padre/Madre o Guardián:

Para poder ofrecer a su hijo(a) la mejor

educación posible, necesitamos

determinar cuán efectivamente él o ella

entiende, habla, lee y escribe el idioma

inglés. Su ayuda será apreciada si

contesta estas preguntas.

Gracias.

Muy bien Un poco Nada

Entiende Inglés ❏ ❏ ❏

Habla Inglés ❏ ❏ ❏

Lee Inglés ❏ ❏ ❏

Escribe Inglés ❏ ❏ ❏

_________________________________________________ ____________________________________________________Firma del Padre/Madre/Guardián/Otro Fecha (Signature of Parent/Guardian/Other) (Date)

HLQ (2/00) 99-337 PM

Mes: Día: Año: (Month) (Day) (Year)

Mes: Día: Año: (Month) (Day) (Year)

(Determination)





Revised 4/15/14

PARENT CONSENT FORM

Date: Parent/Legal Guardian of: DOB:

I give my consent for initial placement of my child in Special Education program/services.

I do not agree to the delivery of Special Education services for my child as recommended on the Individualized Education Program (IEP).

Date: Signature: Relationship to Student:

Please Note: Your child will not be placed in a Special Education program without your consent. If you agree with this recommendation, please complete and return to:

If you disagree, no further action will be taken and your child will not be placed into the recommended Special Education program.

33 Ash Street, Buffalo, New York 14204 (716) 816-4746 ♦ Fax (716) 816-3974

“Putting children and families first, to ensure high academic achievement for all.”

Buffalo Public Schools Dr. Pamela C. Brown, Ed.D. . Superintendent

Buffalo Public Schools

Notice Concerning Our receipt of Public Health Insurance Funds

And Your Related Rights.

No Action is Required by You.

We are required to provide you with an annual reminder of your rights related to this District’s receipt of funds through the State Medicaid Program. This money, received through the New York Department of Health helps support services provided to all children. To receive this funding we are required to file claims with the State Medicaid Program for some of the health care service we provide our students. This includes services such as nursing, physical therapy, occupational therapy, psychological counseling, and speech therapy. The information is provided electronically through processes prescribed by the Federal and State governments. It contains information like service code, date of service, and duration. No information is provided without the voluntary consent of the student’s parent or guardian and they can withdraw their consent at any time. Regardless of whether or not the public insurance program pays for these services, or whether or not the parent allows us to bill, these services are provided free of charge to parents for a long as the student needs them. Should you have any questions, wish to consent to our seeking this funding, or wish to withdraw consent you have already granted please contact: Nina Blumlein Director [email protected]

mailto:[email protected]�

Buffalo City School District Committee on Special Education

School 12 33 Ash St.

Buffalo, NY 14204 (716) 816-3976

TERMS, RIGHTS AND RESPONSIBILITIES

PARENTAL CONSENT FOR RELEASE OF EDUCATIONAL INFORMATION FOR MEDICAID FUNDING

By signing this application, I understand and confirm that:

• I have been fully informed in my native language or other mode of communication that the granting of my consent to share information for the purpose of obtaining Medicaid reimbursement for the services provided per my child’s individualized education program (IEP) is voluntary and may be revoked at any time and that if I revoke my consent, it does not negate (undo) an action that occurred after my consent was given and before my consent was revoked.

• If I refuse consent to allow use of Medicaid insurance to pay for special education services, the school district must still provide all required special education services at no cost to me.

• The use of Medicaid insurance for special education services will not decrease the available lifetime coverage, increase premiums or lead to the discontinuation of benefits, result in my family paying for services required for my child outside of school that would otherwise be covered by the Medicaid program or otherwise diminish my family’s insured benefits under the Medicaid program.

• I will not incur an out-of-pocket expense such as payment of a deductible or co-pay amount.

I, _______________________________________________, (Print name of parent or person in parental relationship) as parent/guardian of: _______________________________ (Name of student)

DOB: ________________________(Date of birth of student) give permission to the public agency (school district, municipality or Medicaid provider) to use Medicaid to pay for IEP services and to such public agency and to each approved private special education school or provider who provides IEP services to my child to disclose information regarding diagnosis and procedure codes for billing Medicaid for services described in my child’s IEP and for evaluations in relation to the services; and in the event of an audit, documentation required to support services reimbursed by Medicaid from my child’s educational records to local, State and federal agency representatives for the sole purpose of claiming Medicaid reimbursement for covered health-related support services for each service and for each school year in which service is provided as recommended in my child’s IEP if my child is or becomes Medicaid-eligible.

I give my consent voluntarily and understand that I may withdraw that consent at any time. I also understand that my child’s entitlement to a free appropriate public education (FAPE) is in no way dependant on my granting consent.

Signature: _________________________________ Date: ______________

TERMINOS, DERECHOS Y RESPONSABILIDADES

CONSENTIMIENTO DEL PADRE PARA LA DIVULGACIÓN DE INFORMACIÓN EDUCACIONAL PARA LA CUBERTURA POR EL MEDICAID

Por firmar la aplicación presente, yo entiendo y confirmo que:

• He sido informado/a completamente en mi idioma nativo o en algún otro modo de comunicación que al conceder mi consentimiento para la divulgación de información con el propósito de obtener reembolso del Medicaid para los servicios proveídos según el Programa Educativo Individualizado (PEI) de mi hijo/a es voluntario y puede ser revocado en cualquier momento y en caso tal de que yo revoque mi consentimiento, ello no niega (deshace) una acción que ocurrió después que mi consentimiento fue dado y antes que mi consentimiento fue revocado.

• Si yo rehúso mi consentimiento en permitir el uso del seguro Medicaid para el pago de los servicios de educación especial, el distrito escolar deberá proveer todos los servicios de educación especial a ningún costo a mi persona.

• El uso del seguro Medicaid para servicios de educación especial no disminuirá la cubertura disponible de por vida, ni aumentaran el costo del seguro, ni resultara en al descontinuación de beneficios, ni resultara en que mi familia tenga que pagar por los servicios requeridos para mi hijo/a fuera de la escuela que sería de lo contrario cubierto por el programa Medicaid o que de lo contrario disminuiría los beneficios de seguro de mi familia bajo el programa Medicaid.

• Yo no incurriré en gastos de mi bolsillo, tales como el pago de un deducible o una cantidad par un co-pago.

Yo, __________________________________________________, como padre/guardián de (Escriba en letra de molde el nombre del padre o persona en relación de padre)

___________________________________________________, (Escriba el nombre del niño/a en letra de molde)

doy permiso a la agencia pública (distrito escolar, municipio, o proveedor del Medicaid) a que usen el Medicaid para pagar por los servicios del PEI y a tal agencia pública y a cada escuela de educación especial privada aprobada o al proveedor que provea los servicios del PEI a mi hijo/a a divulgar la información concerniente al diagnosis y los códigos de procedimientos para el envío de la factura al Medicaid para los servicios descritos en el PEI de mi hijo/a y para las evaluaciones en relación a estos servicios; y en el evento de una auditoria, el requisito de documentación para el reembolso de los servicios de apoyo por el Medicaid de los archivos educacionales de mi hijo/a a los representantes locales, estatales y federales con el propósito único de reclamar el reembolso del Medicaid para los servicios de apoyo relacionados a la salud cubiertos para cada servicio y para cada año escolar en al cual el servicio fue proveído, según es recomendado en el PEI del mi hijo/a si es que mi hijo/a es elegible o llegase a ser elegible para el Medicaid. Doy mi consentimiento voluntariamente y entiendo que yo podre retirar mi consentimiento en cualquier momento. También entiendo que el derecho de mi hijo/a de recibir una Educación Pública Gratis y Apropiada (Free Appropriate Public Education – FAPE) en ninguna manera depende de que yo conceda mi consentimiento.

Firma: Fecha:

Edited 5/06/13 2

General Responsibilities

• Notify the CSE chairperson assigned to your school when a student with a

disability registers at your school.

• If a change in the recommended level of service is warranted, complete the request for a Committee on Special Education Meeting form (Amendment and rationale page) and return to your assigned chairperson.

• Review and forward Student Intervention Record or IEP Information Planning

Worksheet for Charter and Non-Public Schools (found in Reevaluation Three Year State Mandated section) to CSE two weeks prior to CSE meeting.

• For students age 12 and above, complete Level I Assessment and return to the

chairperson two weeks prior to the scheduled CSE meeting. • Ensure a meeting location is available in your school on the date of the CSE

meetings. Ensure the expected attendees have been informed about the date, time and location of the meetings.

• All meeting attendees should be prepared to discuss and contribute to the

development of the IEP.

• Follow Chapter 408 IEP Implementation Responsibility Checklist per regulations.

• Complete Post-Secondary Exit Summaries for graduating seniors. Form will be

given.

• Instruct parents to write a letter requesting services from the district by June 1st.

• Forward letter to Central CSE.





Revised 4/15/14

REQUEST FOR A COMMITTEE ON SPECIAL EDUCATION MEETING AMENDMENT

Student: School: Student ID: Date of Birth: Grade:

Parent/Guardian: Teacher/Counselor: Relationship to Student: Emergency Contact #:

Address: Mother’s Work #: Father’s Work #:

Home Phone# Language: REASON FOR CSE MEETING: (Please describe specific concerns.)

IF ABOVE ARE NOT APPLICABLE, THE BUILDING ADMINISTRATOR OR CENTRAL OFFICE SPECIAL EDUCATION ADMINISTRATOR IS TO ATTACH A RATIONALE STATEMENT JUSTIFYING THE ABSENCE OF EITHER THE EDUCATIONAL BENEFIT OR STUDENT INTERVENTION RECORD FORMS.

Signature: Title: Date:

Forward to District Representatives/CSE Chair Date

Return to Referring Teacher for More Data

Date

Building Administrator

Date Received

Central Office Special Education Administrator

Date Received

Forward to Related Service Director

Date

Date request for referral received by CSE/District Representative

Date





Revised 4/15/14

ATTACHMENT TO THE REQUEST FOR A CSE MEETING AMENDMENT

Student Name: I.D. #: School: Date Request:

What is the school proposing be amended on the student’s current IEP? (please be specific)

Why is the school requesting this amendment?

What records, reports, or other relevant information was used in the decision to request this amendment?

Were there any other options considered prior to requesting that the IEP be amended?

Is there any other relevant information that the CSE should be aware of?

CHAPTER 408

IEP IMPLEMENTATION RESPONSIBILITY CHECKLIST

Student: ID#: 900 Date Developed: ___/___/___ DOB: ___/___/___ Designated Lead Special Education Teacher or Service Provider:

(If incorrect, please indicate the correct name and return to the Placement Office at School #12, 33 Ash Street, Buffalo NY 14204)

Please be advised that a copy of a student’s IEP must remain confidential in accordance with applicable federal and state regulations, including the confidentiality provisions of IDEA and FERPA (Family Education Rights and Privacy Act). These laws prohibit the further disclosing of this IEP or the information contained within it to any other person without the written consent of the student’s parent/guardian, except as otherwise authorized under IDEA and FERPA.

*Inform/Receive IEP Signature Date Informed/Received 1.

2.

3.

4.

5.

6.

7.

8.

*Inform Only Signature Date Informed 9.

10.

11.

12.

13.

14.

15.

*Inform means that as a teacher or service provider for this student, you are aware of your responsibilities with the implementation of this student’s IEP

___/___/___ Signature of CSE member completing form Date Revised 2008-CC

Initial Referrals

Per 200.4 (a)(iv)(b)(2) of the Regulations of the Commissioner, the parent should be offered “the opportunity to meet to discuss the request for referral, and, as appropriate, the availability of appropriate general education support services for the student.” If the parent wishes to continue the referral process, parental consent for all evaluations will be obtained by the Central Committee on Special Education. Initial Referral According to New York state regulations (200.4): A written request for an initial referral submitted by persons other than the student or a judicial officer shall:

1. State the reason for the referral and include any test results, records or reports upon which the referral is based that may be in possession of the person making the referral.

2. Describe in writing, intervention services, programs or instructional methodologies used to remediate the student’s performance prior to the referral, including supplementary aids or support services provided for the purpose, or state the reason why no such attempts were made.

3. Describe the extent of parental contact or involvement prior to the referral. The Student Intervention Record must be fully completed and include research based documentation for each implemented intervention. The Request for Committee on Special Education Referral (Initial), should be sent to the Supervisor of Special Education, at School #12 with the following documents:

• Student Intervention Record with cover sheet • Copy of current physical exam • Home Language Questionnaire • Related service referral checklists (refer to Related Service section).

Buffalo Public Schools

REQUEST FOR A COMMITTEE ON SPECIAL EDUCATION INITIAL REFERRAL

Date of request: Requested by (name/title): Relationship to Student: Student Name: ____________ Student Number: Date of Birth: Sex: Dominant Language: Address: ZIP: Parent/Guardian: Phone: School: Grade: Teacher/Counselor: Student approved for ESL: Yes No Start Date: Proficient End Date: Parent’s Dominant Language: Interpreter Needed: Yes No REASON FOR REQUEST: (Please describe specific concerns.) FOR NEW REQUESTS/RE-REQUESTS:

• List previous programs, accommodations, and support services:

• Attach the Student Intervention Record and progress monitoring data. This should include specific information about what has been done to meet the student’s educational needs in his/her present setting.

IF ABOVE ARE NOT APPLICABLE, THE BUILDING ADMINISTRATOR IS TO ATTACH A RATIONALE STATEMENT JUSTIFYING THE ABSENCE OF PRE-REFERRAL INTERVENTIONS.

REVISED 4/24/14 2

FOR TRANSFER STUDENTS: Previous District: State: Previous Teacher/Counselor: Phone #: Previous Classification: Previous Services: BUILDING INTERVENTION TEAM: FOR OFFICE USE ONLY:

Date of receipt of request for referral Name and title of Administrator receiving request

Date of copy of request forwarded to Building or SE Administrator

Date Referral forwarded to CSE Chairperson Date received by CSE Chairperson

Name and title of person making Referral to CSE

Date parent notified of Referral

BPS COMMITTEE ON SPECIAL EDUCATION CHARTER/NON-PUBLIC SCHOOLS

Student Interventions Record

1

1. Student Information

Student Name: ID Number: DOB: Native Language: Address: Translation: YES NO Phone: Ethnicity: Gender: Male Female School: Teacher(s): Grade:

2. Parent/Guardian Information (If other than parent, indicate relationship below name)

Parent/Guardian: Parent/Guardian: Relationship: Relationship: Address: Address: City, State & Zip City, State & Zip Home Tel: Home Tel: Work Tel: Work Tel: Native Lang: Native Lang: Translation: Yes No Translation: Yes No

3. Referral Information

Area of Suspected Disability: Check and describe the specific reason(s) and/or situations that may indicate the presence of a disability.

Primary Considerations Secondary Considerations Educational Achievement Educational Achievement Social/Behavioral Social/Behavioral Physical Physical Other Other Describe in detail the reason for referral, attach minutes of building level team or additional sheets if necessary:

4. Background Information

Describe child’s educational, cultural and experiential background and how this may be affecting progress. This especially pertains to students new to the district and whose motive language is other than English. Regulations require that the determinant factor for eligibility for a child to have a disability cannot be the lack of appropriate instruction in reading or math or limited English proficiency.

Date completed:

Student Interventions Record (PLEASE COMPLETE ALL ITEMS)

2

Is absenteeism or lateness a problem? Yes No Has student ever been retained? Yes No

5. For Students whose language is other than English

How long has the student been going to school in the USA? Has the student ever received instruction in English as a Second Language? Yes No If yes, indicate test results with the dates and intensity of services provided:

6. Health Information (to be completed by the school nurse)

Are there any medical conditions which may be contributing to the student’s reason for referral? Yes No If yes please describe below: Indicate any medications the student is receiving: Date of Last Physical Examination: Signature of School Nurse:

7. Response to Intervention & Academic Intervention Services Previously Provided (to be completed by providers)

Interventions Implementation dates and progress information AIS - Reading Instruction Start Date: End Date: Remedial Reading Teacher Assessment: Response to Interventions Pre – test: SS %ile GE Post test: SS %ile GE AIS Math Start Date: End Date: Response to Interventions Teacher Assessment: Pre – test: SS %ile GE Post test:


3

Interventions Implementation dates and progress information SS %ile GE AIS Written Expression Start Date: End Date: Response to Interventions Teacher Assessment: Pre – test: SS %ile GE Post test: SS %ile GE AIS Listening Comprehension Start Date: End Date: Response to Interventions Teacher Assessment: Pre – test: SS %ile SS Post test: SS %ile SS

8. Other Interventions Attempted to Resolve Referral Concerns Interventions Implementation dates and progress information Alternative Programs Start Date: End Date: (e.g., summer school) Teacher: Comments on Progress: Speech Improvement Services Start Date: End Date: Therapist: Comments on Progress: Adjusted Assignments Start Date: End Date: Therapist: Comments on Progress: Schedule Adjustments Start Date: End Date: Therapist: Comments on Progress: Individualized Curriculum Start Date: End Date: based on Skills Therapist: Comments on Progress:


4

Alternative Approaches to Start Date: End Date: Learning Therapist: Comments on Progress: Suspension from School Start Date: End Date: Therapist: Comments on Progress: Counseling Start Date: End Date: Therapist: Comments on Progress: Other Consultation with: Principal/Assistant Principal Psychologist Social Worker Speech Therapist Guidance Counselor Special Ed Teacher Other: Additional Comments and Details:

9. Work Habits Always Usually Sometimes Rarely Completes Class Work Completes Homework Motivated to learn Attentive to task Can transition between activities Generalizes learning to new situations Works independently Frustrates easily Distractible Short attention span Inconsistent learning

10. Speech and Language Information Indicate any areas that appear problematic for the student: Articulation Dysfluencies (stuttering) Expressing self verbally Comprehension of basic information/vocabulary


5

Maintaining topic of relevancy Additional Concerns:

11. Indicate the Students Performance Levels Please describe levels of academic achievement (reading, math, and written language), learning characteristics, ability to function in classroom, and/or adaptive behavior skills. Include specific areas of strength and weakness. Attach

report cards, standardized test results and transcripts.

Reading Comprehension: Reading Decoding: Math Computation: Math Concepts/Applications: Written Language: Learning characteristics, Adaptive Behavior, Strengths and Weaknesses:


6

Please describe levels of social development. Include the quality of the student’s relationship with peers and adults, adjustment to school and community, and indicate any behaviors that interfere with the learning environment or may impede the student’s learning process. Attach Functional Behavioral Assessment (FBA) / Behavior Intervention Plan (BIP), if applicable. Please describe levels of physical development. Include the student’s motor and sensory development and any physical skills or limitation that may pertain to the learning process.

Targeted Essential Learning Outcome:

BEHAVIOR INTERVENTIONS SECTION

List all behavior modification techniques implemented AND provide all pertinent progress monitoring data (graphing and charting) in order to be in alignment with Response to Intervention (RTI). Here are some examples of behavior modification techniques:

• Classroom Monitoring: effective teaching practices, frequent monitoring, strict rules and regulations, social praise, etc.

• Pro-social behavior: positive and negative reinforcements, modeling of proc-social behavior, verbal instruction, role playing, etc.

• Moral education: moral science classes on real-life situations, imaginary situations and literature. Let students play different roles as a teacher, principal, parents, etc and participate in school administration.

• Social Problem Solving (SPS): direct teaching of SPS skills (i.e., alternate thinking, means-end thinking), dialoguing, self-instruction training, etc.


7

• Effective Communication Models: values explanation activities, active listening, importance of communication and interpersonal skills, training for students and teachers, etc.

How does this student’s academic skills or behavior compare to average students in your classroom? ** (for behavior attach pertinent data in terms of charting and graphing) 1. Which intervention have you applied to address this outcome? ***Additionally, list how a

baseline of data has been collected on ALL behavioral concerns (attach the data to this packet) List all behavioral factors in terms of a observable, and definable behavior.

Duration of Intervention: Begin Date

End Date

Frequency of assessing/measuring student response to this intervention: Person(s) responsible: State the measurable results. (Data must be attached):


8

2. Which intervention have you applied to address this outcome?


End Date




End Date



9



End Date

Frequency of assessing/measuring student response to this intervention: Person(s) responsible: State the measurable results. (Data must be attached): What would be the best day(s)/time(s) for someone to observe the student exhibiting the difficulty addressed by the interventions? (Please attach a copy of the student’s daily schedule.) Please attach the following: Student’s current report card Student attendance record Student schedule Student DIBELS data report Classroom DIBELS data Standardized Assessment reports (i.e. TerraNova, State Assessments) Any additional data (i.e. CORE Assessments from Multiple Measures, curriculum based

assessments) Behavior Plans Data (i.e. BPIS plans, Behavior Modification Plans, other behavior

reports)

Reevaluation

Parent and/or School Requested Reevaluation

The Student Intervention Record must be completed fully and include documentation for each implemented research based intervention. Send a completed Student Intervention Record with cover sheet, Request for Committee on Special Education Meeting, (Reevaluation) and any Related Service referral checklists to the Supervisor of Special Education, at School #12.

State Mandated Three Year Reevaluation According to New York State Regulations of the Commissioner of Education, 200.4 (b)(4), a student with a disability have a reevaluation at least once every three years, “except where the school district and the parent agree in writing that such reevaluation is unnecessary.” The following information should be sent to the CSE chairperson:

IEP Information Planning Worksheet for Charter/Non-Public Schools Report Card Attendance Record Reading Test Results/Running Records Standardized Test Results High School Credits/Transcripts Level I Assessment Related Service Progress Summaries Cumulative Record Card BIP Progress Monitoring Reports Discipline Records

The Student Intervention Record is required if the student is being considered for a change of classification or a more restrictive placement.

Revised 4/24/14

Buffalo Public Schools Special Education Department

Request for a COMMITTEE ON SPECIAL EDUCATION Meeting

REEVALUATION

Student: School: Student ID#:

Date of Birth: Grade:

Parent/Guardian: Teacher/Counselor:

Relationship to Student: Emergency Contact #:

Address: Mother’s Work #:

Father’s Work #:

Home Phone #: Language:

REASON FOR CSE MEETING: (Please describe specific concerns.)

Attach Student Intervention Record

IF ABOVE ARE NOT APPLICABLE, THE BUILDING ADMINISTRATOR OR CENTRAL OFFICE SPECIAL EDUCATION ADMINISTRATOR IS TO ATTACH A RATIONALE STATEMENT JUSTIFYING THE ABSENCE OF EITHER THE EDUCATIONAL BENEFIT OR STUDENT INTERVENTION RECORD FORMS. SIGNATURE: Title: Date:

Forward to District Representative/CSE Chair Date

Return to Referring Teacher for More Data Date Building Administrator Date Received Central Office Special Education Administrator Date Received Forward to Related Service Director Date Date request for referral received by CSE/District Representative Date

Revised 4/24/14

Buffalo City School District Special Education Department

ATTACHMENT TO THE REQUEST FOR A CSE MEETING

REEVALUATION

Student Name: I.D. #: School: Date Request: The school is requesting that the CSE conduct a reevaluation Why is the School requesting this reevaluation? What records, reports, or other relevant information was used in the decision to request this reevaluation? Where there any other options considered prior to requesting this reevaluation? Is there any other relevant information that the CSE should be aware of?

IEP INFORMATION PLANNING WORKSHEET FOR CHARTER & NON-PUBLIC SCHOOLS

Student Name: DOB: Address: Phone #: Cell #: Email: School: Grade: Teacher:

Please return this form (Fax: 816-3974 to appropriate chair) along with the following information/documents at least 2 weeks prior to scheduled meeting date:

Report Card Level 1 Vocational Assessment Attendance Record IEP Progress Reports Schedule Diagnostic Related Service Summaries Reading Test Results/Running Records Cumulative Record Card Standardized Test Results Discipline Reports High School Credits/Transcripts Behavior Intervention Plan Progress Monitoring Summer School Information

Please include statement reflecting CAN DO skill levels & abilities, progress, strengths, weaknesses, NEEDS, learning styles & modalities, and work habits.

• Reading o Strengths:

o Needs:

• Written Language o Strengths:

o Needs:

• Math o Strengths:

o Needs:

• Social/Emotional/Behavior (interests, strengths, difficulties, needs)

• Other Pertinent Information (i.e. work habits, task completion rate, learning modalities, attendance, additional diagnosis/health or medical information, etc.)

• Academic/Behavioral Interventions (including Start/End dates, Frequency, duration, setting, & Student Response: Progress Monitoring Data):

BPS COMMITTEE ON SPECIAL EDUCATION CHARTER/NON-PUBLIC SCHOOLS

Student Interventions Record

1

1. Student Information

Student Name: ID Number: DOB: Native Language: Address: Translation: YES NO Phone: Ethnicity: Gender: Male Female School: Teacher(s): Grade:

2. Parent/Guardian Information (If other than parent, indicate relationship below name)

Parent/Guardian: Parent/Guardian: Relationship: Relationship: Address: Address: City, State & Zip City, State & Zip Home Tel: Home Tel: Work Tel: Work Tel: Native Lang: Native Lang: Translation: Yes No Translation: Yes No

3. Referral Information

Area of Suspected Disability: Check and describe the specific reason(s) and/or situations that may indicate the presence of a disability.

Primary Considerations Secondary Considerations Educational Achievement Educational Achievement Social/Behavioral Social/Behavioral Physical Physical Other Other Describe in detail the reason for referral, attach minutes of building level team or additional sheets if necessary:

4. Background Information

Describe child’s educational, cultural and experiential background and how this may be affecting progress. This especially pertains to students new to the district and whose motive language is other than English. Regulations require that the determinant factor for eligibility for a child to have a disability cannot be the lack of appropriate instruction in reading or math or limited English proficiency.

Date completed:


2

Is absenteeism or lateness a problem? Yes No Has student ever been retained? Yes No

5. For Students whose language is other than English

How long has the student been going to school in the USA? Has the student ever received instruction in English as a Second Language? Yes No If yes, indicate test results with the dates and intensity of services provided:

6. Health Information (to be completed by the school nurse)

Are there any medical conditions which may be contributing to the student’s reason for referral? Yes No If yes please describe below: Indicate any medications the student is receiving: Date of Last Physical Examination: Signature of School Nurse:

7. Response to Intervention & Academic Intervention Services Previously Provided (to be completed by providers)

Interventions Implementation dates and progress information AIS - Reading Instruction Start Date: End Date: Remedial Reading Teacher Assessment: Response to Interventions Pre – test: SS %ile GE Post test: SS %ile GE AIS Math Start Date: End Date: Response to Interventions Teacher Assessment: Pre – test: SS %ile GE Post test:


3

Interventions Implementation dates and progress information SS %ile GE AIS Written Expression Start Date: End Date: Response to Interventions Teacher Assessment: Pre – test: SS %ile GE Post test: SS %ile GE AIS Listening Comprehension Start Date: End Date: Response to Interventions Teacher Assessment: Pre – test: SS %ile SS Post test: SS %ile SS

8. Other Interventions Attempted to Resolve Referral Concerns Interventions Implementation dates and progress information Alternative Programs Start Date: End Date: (e.g., summer school) Teacher: Comments on Progress: Speech Improvement Services Start Date: End Date: Therapist: Comments on Progress: Adjusted Assignments Start Date: End Date: Therapist: Comments on Progress: Schedule Adjustments Start Date: End Date: Therapist: Comments on Progress: Individualized Curriculum Start Date: End Date: based on Skills Therapist: Comments on Progress:


4

Alternative Approaches to Start Date: End Date: Learning Therapist: Comments on Progress: Suspension from School Start Date: End Date: Therapist: Comments on Progress: Counseling Start Date: End Date: Therapist: Comments on Progress: Other Consultation with: Principal/Assistant Principal Psychologist Social Worker Speech Therapist Guidance Counselor Special Ed Teacher Other: Additional Comments and Details:

9. Work Habits Always Usually Sometimes Rarely Completes Class Work Completes Homework Motivated to learn Attentive to task Can transition between activities Generalizes learning to new situations Works independently Frustrates easily Distractible Short attention span Inconsistent learning

10. Speech and Language Information Indicate any areas that appear problematic for the student: Articulation Dysfluencies (stuttering) Expressing self verbally Comprehension of basic information/vocabulary


5

Maintaining topic of relevancy Additional Concerns:

11. Indicate the Students Performance Levels Please describe levels of academic achievement (reading, math, and written language), learning characteristics, ability to function in classroom, and/or adaptive behavior skills. Include specific areas of strength and weakness. Attach

report cards, standardized test results and transcripts.

Reading Comprehension: Reading Decoding: Math Computation: Math Concepts/Applications: Written Language: Learning characteristics, Adaptive Behavior, Strengths and Weaknesses:


6

Please describe levels of social development. Include the quality of the student’s relationship with peers and adults, adjustment to school and community, and indicate any behaviors that interfere with the learning environment or may impede the student’s learning process. Attach Functional Behavioral Assessment (FBA) / Behavior Intervention Plan (BIP), if applicable. Please describe levels of physical development. Include the student’s motor and sensory development and any physical skills or limitation that may pertain to the learning process.

Targeted Essential Learning Outcome:

BEHAVIOR INTERVENTIONS SECTION

List all behavior modification techniques implemented AND provide all pertinent progress monitoring data (graphing and charting) in order to be in alignment with Response to Intervention (RTI). Here are some examples of behavior modification techniques:

• Classroom Monitoring: effective teaching practices, frequent monitoring, strict rules and regulations, social praise, etc.

• Pro-social behavior: positive and negative reinforcements, modeling of proc-social behavior, verbal instruction, role playing, etc.

• Moral education: moral science classes on real-life situations, imaginary situations and literature. Let students play different roles as a teacher, principal, parents, etc and participate in school administration.

• Social Problem Solving (SPS): direct teaching of SPS skills (i.e., alternate thinking, means-end thinking), dialoguing, self-instruction training, etc.


7

• Effective Communication Models: values explanation activities, active listening, importance of communication and interpersonal skills, training for students and teachers, etc.

How does this student’s academic skills or behavior compare to average students in your classroom? ** (for behavior attach pertinent data in terms of charting and graphing) 1. Which intervention have you applied to address this outcome? ***Additionally, list how a

baseline of data has been collected on ALL behavioral concerns (attach the data to this packet) List all behavioral factors in terms of a observable, and definable behavior.


End Date



8



End Date




End Date



9



End Date

Frequency of assessing/measuring student response to this intervention: Person(s) responsible: State the measurable results. (Data must be attached): What would be the best day(s)/time(s) for someone to observe the student exhibiting the difficulty addressed by the interventions? (Please attach a copy of the student’s daily schedule.) Please attach the following: Student’s current report card Student attendance record Student schedule Student DIBELS data report Classroom DIBELS data Standardized Assessment reports (i.e. TerraNova, State Assessments) Any additional data (i.e. CORE Assessments from Multiple Measures, curriculum based

assessments) Behavior Plans Data (i.e. BPIS plans, Behavior Modification Plans, other behavior

reports)

Buffalo Public Schools Central Committee on Special Education Dr. Pamela C. Brown, Ed.D Mary C. Pauly, Ed.D Superintendent Assistant Superintendent

Curriculum, Instruction, and Leadership Kim Curtin Director of Special Education

33 Ash Street, Buffalo, New York 14204 (716) 816-4746 • Fax (716) 816-3974 Revised 2/4/14

Process for Vocational Assessments

• is the initial phase of a student’s transition plan that includes input from student, parent and teacher.

Level 1 Vocational Assessment:

• is a data gathering process that must be completed by age 12 and updated annually prior to the annual CSE meeting.

• is completed by the lead Special Education teacher who is responsible for bringing the completed document to the CSE meeting.

• findings are reflected in the PLEP statement and used to develop post secondary transition outcomes.

It is one of the responsibilities of the Committee on Special Education (CSE) to review the data collected from the updated vocational assessments during each CSE meeting. Evidence

from this information should be reflected in both the PLEP and transition plan in the IEP document.

Level 1 Vocational Assessment Checklist

Select Level 1 Assessment from A or B

Complete the form with parent/guardian, teacher and student input.

There must be evidence that the Level I document has been updated yearly prior to the CSE meeting.

Use Level I to begin to examine educational programs and career options based on the students’ needs, preferences and abilities.

Hold the CSE meeting.

Use findings from Level I Assessment to complete PLEP statement and post secondary outcomes on IEP document.

Put completed Level I Assessment in student’s IEP folder held by the CSE Chair.




• is an optional career assessment to be used when the Level I is NOT sufficient to create a realistic transition plan.

Level II Vocational Assessment:

• is available on the subsequent pages

• is completed by the lead Special Education teacher which includes input from student, parent and teacher.

Level II Checklist


Complete Level II Assessment and Transition Questionnaire Summary Form.

Complete the form with parent/guardian, student, and teacher input.

Use Level II along with Level I to begin to examine educational programs and career options based on the students’ needs, preferences and abilities.


Use findings from Level I and Level II Assessments to complete PLEP statement and post secondary outcomes on IEP document.

Put completed Level II Assessment in student’s IEP folder held by the CSE Chair.

LEVEL I ASSESSMENT School Year 20 -20 Student: Date of Birth: Diploma Expectations: Regents IEP School: Anticipated Date of Graduation: Program: Cumulative Records Reviewed by: Date: Teacher: Interests/Preferences/Strengths:

POST HIGH SCHOOL VOCATIONAL PLANS Student

Interview Date: _______________________

Parent/Guardian Interview Date: _______________________

School Representative Teacher: ____________________________ Counselor: ___________________________ Other: _______________________________

Recommendations/Needs:

Referrals/Activities:

LEVEL I ASSESSMENT School Year 20 - 20

Student: Date of Birth:

School Attending: Program:

District: Counselor:

Teacher: Diploma Expectations: Regents IEP

Anticipated Date of Graduation:

Post-Secondary Goal

Student: What do you plan to be doing after finishing high school?

Parent: What would you like to see your child doing after completing his/her educational program?

Interests/Strengths/Preferences (hobbies/courses/work):

Things that you have tried but you don’t like:

Recommendations/Needs (if appropriate):


Signatures:

Student: Teacher:

Parent: Counselor:

Other:

Original: Permanent File Date of Interview: CSE Office Parent Teacher

Edited 5/06/13 5

Annual Reviews Annual Reviews will be conducted on or before the annual review date. Please refer to the IEP Information Planning Worksheet for Charter & Non-Public Schools for the required information. Send the completed sheet to the chairperson two weeks before the scheduled CSE meeting with the following:

• Report Card • Attendance Record • Reading Test Results/Running Records • Standardized Test Results • High School Credits/Transcripts • Level I Assessment • Related Service Progress Summaries • Cumulative Record Card

IEP INFORMATION PLANNING WORKSHEET FOR CHARTER & NON-PUBLIC SCHOOLS

Student Name: DOB: Address: Phone #: Cell #: Email: School: Grade: Teacher:

Please return this form (Fax: 816-3974 to appropriate chair) along with the following information/documents at least 2 weeks prior to scheduled meeting date:

Report Card Level 1 Vocational Assessment Attendance Record IEP Progress Reports Schedule Diagnostic Related Service Summaries Reading Test Results/Running Records Cumulative Record Card Standardized Test Results Discipline Reports High School Credits/Transcripts Behavior Intervention Plan Progress Monitoring Summer School Information

Please include statement reflecting CAN DO skill levels & abilities, progress, strengths, weaknesses, NEEDS, learning styles & modalities, and work habits.

• Reading o Strengths:

o Needs:

• Written Language o Strengths:

o Needs:

• Math o Strengths:

o Needs:

• Social/Emotional/Behavior (interests, strengths, difficulties, needs)

• Other Pertinent Information (i.e. work habits, task completion rate, learning modalities, attendance, additional diagnosis/health or medical information, etc.)

• Academic/Behavioral Interventions (including Start/End dates, Frequency, duration, setting, & Student Response: Progress Monitoring Data):




Process for Vocational Assessments

• is the initial phase of a student’s transition plan that includes input from student, parent and teacher.

Level 1 Vocational Assessment:

• is a data gathering process that must be completed by age 12 and updated annually prior to the annual CSE meeting.

• is completed by the lead Special Education teacher who is responsible for bringing the completed document to the CSE meeting.

• findings are reflected in the PLEP statement and used to develop post secondary transition outcomes.

It is one of the responsibilities of the Committee on Special Education (CSE) to review the data collected from the updated vocational assessments during each CSE meeting. Evidence

from this information should be reflected in both the PLEP and transition plan in the IEP document.

Level 1 Vocational Assessment Checklist

Select Level 1 Assessment from A or B

Complete the form with parent/guardian, teacher and student input.


Use Level I to begin to examine educational programs and career options based on the students’ needs, preferences and abilities.


Use findings from Level I Assessment to complete PLEP statement and post secondary outcomes on IEP document.

Put completed Level I Assessment in student’s IEP folder held by the CSE Chair.




• is an optional career assessment to be used when the Level I is NOT sufficient to create a realistic transition plan.

Level II Vocational Assessment:

• is available on the subsequent pages

• is completed by the lead Special Education teacher which includes input from student, parent and teacher.

Level II Checklist


Complete Level II Assessment and Transition Questionnaire Summary Form.

Complete the form with parent/guardian, student, and teacher input.

Use Level II along with Level I to begin to examine educational programs and career options based on the students’ needs, preferences and abilities.


Use findings from Level I and Level II Assessments to complete PLEP statement and post secondary outcomes on IEP document.

Put completed Level II Assessment in student’s IEP folder held by the CSE Chair.

LEVEL I ASSESSMENT School Year 20 -20 Student: Date of Birth: Diploma Expectations: Regents IEP School: Anticipated Date of Graduation: Program: Cumulative Records Reviewed by: Date: Teacher: Interests/Preferences/Strengths:

POST HIGH SCHOOL VOCATIONAL PLANS Student

Interview Date: _______________________

Parent/Guardian Interview Date: _______________________

School Representative Teacher: ____________________________ Counselor: ___________________________ Other: _______________________________

Recommendations/Needs:


LEVEL I ASSESSMENT School Year 20 - 20

Student: Date of Birth:

School Attending: Program:

District: Counselor:

Teacher: Diploma Expectations: Regents IEP

Anticipated Date of Graduation:

Post-Secondary Goal

Student: What do you plan to be doing after finishing high school?

Parent: What would you like to see your child doing after completing his/her educational program?

Interests/Strengths/Preferences (hobbies/courses/work):

Things that you have tried but you don’t like:

Recommendations/Needs (if appropriate):


Signatures:

Student: Teacher:

Parent: Counselor:

Other:

Original: Permanent File Date of Interview: CSE Office Parent Teacher

Commencement.doc / page 1

NEW YORK STATE EDUCATION DEPARTMENT

Career Plan Commencement Level

1. Personal Data Name: _____________________________________________________________________________ Student Identification Number: _________________________________________________________ School: _____________________________________________________________________________ 2. Review of Student Career Plan Possible Participants (Initials)

Grade Level:

Date of Review:

Student:

Parent/ Guardian:

Teacher:

Counselor:

Other:

3. Knowledge

A. Self-knowledge: Who am I? Interests: List your top three choices for each of the following areas of interest: Grade Level:

1a. Personal: Out-of-school activities that you enjoy

1b. Academic: Classes or subjects you enjoy the most

1c. Work Preferences: Working with people, ideas, and things

Attachment 1


2. Abilities: List personal skills and talents that will be helpful in a career choice:

Grade Level:

My Personal Abilities . . .

Career areas where my abilities will be useful . . .

Personal and academic areas I need to strengthen:

Grade Level:

I need to strengthen . . .

Steps I will take to strengthen these areas . . .

B. Career Exploration: Where am I going? 1. School and/or Community Experiences: I have participated in the following school and/or community

experiences:

Grade Level:

School and/or Community Experiences: Skills Acquired Through Experience:

2. Work Experiences: I have participated in the following work experiences:

Grade Level:

Work Experiences: Skills Acquired Through Work Experience:


3. Careers of Interest and Characteristics: I am interested in the following careers and have discovered the following information about these careers:

Grade Level:

Careers of Interest:

Education Requirements:

Skills I Need to Acquire:

Work Environment:

Job Outlook:

C. Future Goals and Decision-Making: How do I get there? 1. Career Goals and Action Steps: Grade Level:

Goals: (resulting from career exploration

activities)

Education Plan: (courses that relate to my

career interests)

Action Steps: (what I need to do to accomplish my goals)

Check Off Completed

Steps 4. Skills/Application: What do I need to know? What skills are important to me?

What am I learning? Why am I learning it? How can I use it? Directions: The following skills are needed to succeed in life, work, and education beyond high school. Using the

scale provided, identify for each skill the level of achievement you believe you possess at the beginning of the commencement level and the level you believe you achieved by the end of your senior year. Briefly describe a classroom experience or an activity that helped you develop each skill and identify how each skill can be used in your life and future work experiences.

Skills:

Beginning

(Check Off)

Skill Level I Possess

Experiences/Activities/Application:

Final

Achieved

Skill Level I Have

(Check Off) Basic Skills: Uses a combination of techniques to read, listen to, and analyze complex information; conveys information in oral and written form; uses multiple computational skills to analyze and solve mathematical problems.

Highly Least Developed Developed


Thinking Skills: Demonstrates the ability to organize and process information and apply skills in new ways.




Skills:

Beginning

(Check Off)

Skill Level I Possess

Experiences/Activities/Application:

Final

Achieved

Skill Level I Have

(Check Off) Personal Qualities: Demonstrates skills in setting goals, monitoring progress, and improving performance.



Interpersonal Skills: Communicates effectively and helps others to learn a new skill.



Technology: Applies knowledge of technology to identify and solve problems.



Managing Information: Uses technology to acquire, analyze and organize data, and communicates information.



Managing Resources: Allocates time and financial and human resources to complete a task.



Systems: Demonstrates an understanding of the relationship between the performance of a system and the goals, resources, and functions of an organization.



5. Culminating Activity Directions: Briefly describe the activity that you completed. Indicate the most important thing you learned

about yourself through this activity. Describe how this self knowledge will influence your plans for the future.

Activity:

Self Knowledge/Future Plans:

Related Services Contact should be made with the Central Committee on Special Education Director, Nina Blumlein, via email at [email protected] for concerns or information regarding: Occupational Therapy, Physical Therapy, Psychological Counseling, Vision Services, Assistive Technology, Speech and Language or Hearing Services and Student Equipment. Whether BPS personnel deliver related services to your school or your charter school has independent related services providers, all related service evaluations must be processed through the Central CSE staff, even if Buffalo staff does not provide the service. All related service reports and/or summary updates need to be sent to the Central CSE prior to the scheduled meeting. Provide this information two weeks prior to the CSE meeting. When requesting Occupational Therapy, Physical Therapy, Psychological Counseling services or Assistive Technology services for the first time, it is necessary to complete the Occupational Therapy Screening Referral Form and Documentation of Interventions Implemented, or Physical Therapy Referral Form and Documentation of Interventions Implemented, or, Assistive Technology Evaluation Referral Form or referral for Counseling Evaluation. This form must be submitted with a Request for a Committee on Special Education Meeting (Reevaluation) or Request for a Committee on Special Education Referral (Initial).



Buffalo Public Schools Referral for Counseling Evaluation

Please complete all sections:

Student’s Name: Date of request: Student ID #: Date of Birth: Teacher: School:

1) List specific behaviors or concerns that indicate a need for counseling:

2) Specifically document strategies/interventions tried to alleviate problems/concerns listed above. Specify date, length and type of intervention:

3) List specific educational objectives to be met by counseling:

OCCUPATIONAL THERAPY SCREENING REFERRAL FORM AND

DOCUMENTATION OF INTERVENTIONS IMPLEMENTED

Check areas which apply to the student who you are referring: Occupational Performances

Academics (lack of organization of classroom materials and poor progress in core curricular areas) Self care (dressing, feeding, grooming skills)

Performance Components Gross Motor Skills

Seems weaker than others his/her age, tires easily Difficulty with hopping, jumping, skipping, or running compared to classmates Appears stiff or awkward in his/her movements Clumsy, bumps into things, falls out of his/her chair Reluctant to participate in sports and group physical activities Poor desk posture (slumps, leans on arms, holds face too close to work)

Fine Motor Skills Difficulty with drawing, coloring, copying, cutting or avoidance of these activities Poor pencil grasp, drops pencil frequently or holds pencil too tightly Lines drawn are tight, wobbly, too faint, too dark, or breaks pencil often Lacks well established dominance after six years of age/laterality

Regulation of Sensory Systems Reacts negatively to touch or seeks out excessive contact (laying on others) Tends to wear coat when not needed; will not allow long sleeves to be pulled up Has trouble keeping hands to self, will poke or push other children Apt to touch everything he/she sees, seems to learn through touching Dislikes being cuddled or hugged Student scratches and rubs skin often Vestibular Sensation Fearful of activities involving moving through space ex. Swinging or gym games Observed poor balance or avoids activities that challenge balance Excessive craving for swinging, bouncing, sliding, merry-go-rounds or rocking School aide/teacher reports child to be easily carsick/bus sick History of frequent inner ear infections Apt to be impulsive, heedless, accident prone Distracted by background noise or internal thoughts/impulses

Visual Motor Integration/Visual Perception Difficulty discriminating colors, shapes, completing puzzles Letter reversals after first grade Difficulty in visual-tracking (difficulty following objects with eyes) Difficulty in copying designs, numbers or letters Difficulty imitating gestures/movements Poor organization of written work

Social/Emotional Does not accept changes in routine easily Becomes easily frustrated; gives up easily Acts out behaviorally, difficulty getting along with others Easier to handle in small groups or individually Marked mood variations, outbursts, or tantrums Frequently out of seat

Name: DOB: School: Teacher: Grade: Pupil Service Center: ID#: Health concerns: Medication: Special Alerts:

OCCUPATIONAL THERAPY SCREENING REFERRAL FORM AND


Please complete and return to Related Services Office – School 12 - 33 Ash Street – Buffalo, NY 14204 Page 2 of 2

Student’s Name: Date of Birth:

Specifically document strategies/interventions tried to alleviate problems/concerns listed above. Specify date, length and type of intervention: List specific educational objectives to be met by Occupational Therapist:

PHYSICAL THERAPY REFERRAL FORM AND



Name: DOB:

School: Teacher: Grade:

Pupil Service Center: ID#:

Health concerns:

Special alerts and environmental restrictions:

Medication:

Indications for use:

Below are areas of concern in the domain of physical therapy:

FUNCTIONAL MOBILITY

Difficulty getting on and off school bus safely Difficulty walking on uneven surfaces and negotiating curbs Difficulty negotiating stairs Difficulty keeping up with class in the hallways, trips?, falls? Difficulty keeping up with peers on field trips Difficulty efficiently exiting during fire drill

GROSS MOTOR SKILLS

Seems weaker than others his/her age, tires easily Appears short of breath after minimal exertion Appears stiff or awkward in his/her movements Clumsy, bumps into things, falls out of his/her chair Difficulty with hopping, jumping, skipping, running, using playground equipment

MOVEMENT OBSERVATIONS

Difficulty following directions for gross motor activities Movements in impulsive, careless Lacks safety awareness Reluctant to participate in sports and group physical activities

PHYSICAL THERAPY REFERRAL FORM AND



Student’s Name: Date of Birth:

Specifically document strategies/interventions tried to alleviate problems/concerns listed above. Specify date, length and type of intervention: List specific educational objectives to be met by Physical Therapist:

Buffalo Board of Education Assistive Technology Service

462 Grider Street Buffalo, New York 14215

(716) 816-4080 ext. 1137, FAX (716) 897-8081

5/7/2013 1 | P a g e

Assistive Technology Evaluation Referral Form

Student Name: DOB: Age: School: Grade:

School Contact Person: Telephone: Person Completing Form Date Completed

Parent(s)/Guardian’s Names: Parent/Guardian Telephone#: Student’s Primary Language: Family Primary Language:

Disability (Check all that apply) Speech/Language PDD – ASD Cognitive Disability Other Health Impairment Emotional/Behavioral Disability Specify Orthopedic Impairment Specific Learning Disability

Type Health Impairment Vision Impairment Specify

Specify Traumatic Brain Injury Classroom Setting

Regular Educational Classroom Self - Contained Consultant Teacher Services Specify

Specify Other Home Instruction Specify

Current Service Providers Speech Language Hearing Services Physical Therapy Mobility Services Vision Services Other Occupational Therapy Specify

Medical Considerations (Check all that apply) History of Seizures Fatigues easily Has degenerative medical condition Has frequent pain

Specify Has frequent upper respiratory infections Has frequent ear infections Has allergies to: Has multiple health problems Specify

Specify Has digestive problems Currently taking medication for Other

Specify Specify Other Concerns:

Assistive Technology Currently In Place (Check all that apply) None Low Tech Writing Aid(s)

5/7/2013 2 | P a g e

Communication Boards(s) Dedicate Communication Device Low Tech/Visual Aids Specify Environmental Control Unit Amplification system Power Wheelchair Manual Wheelchair Switches Portable Word Processor

Specify Computer Other: Type (Platform)

Specify Word Prediction What do you feel are the student’s major assets?

Fine Motor Skills Uses both hands Uses one hand Uses fingers right left

Specify Hand dominance right left

Assistive Technology Justification: What OUTCOMES do you expect from the assistive technology evaluation to improve performance in these targeted areas? Who would be in charge of implementing and maintaining assistive technology recommendations? Teacher(s):

Response To Intervention This must be completed PRIOR to requesting an Assistive Technology Evaluation THIS WILL BE RETURNED TO YOU IF YOU DO NOT COLLECT DATA FOR 12 WEEKS

What’s expected of a student at this age/grade level? What are his peers

doing? (I.e. write two sentences, write a three paragraph report? Add,

subtract single digits, carry on a conversation, etc.)

How is the student achieving grade level

expectation for the area of concern? SPECIFY

Baseline Measurement (i.e., Teacher observation, Tally,

etc.) BE SPECIFIC

Intervention/Accommodation - modification tried. (Be Specific) (See Tools and

Strategies to use BEFORE requesting an AT

Evaluation)

Dates of interventions. Weeks 1 thru 6 (must be 6

weeks) Reading

Writing

Math

Communication

Other

Response To Intervention This must be completed PRIOR to requesting an Assistive Technology Evaluation THIS WILL BE RETURNED TO YOU IF YOU DO NOT COLLECT DATA FOR 12 WEEKS

Progress/Data for Weeks 1 thru 6 (Did it work? If not

why didn’t it work?)

If no progress during first 6 weeks, describe the modification-

accommodation tried during Weeks 7 thru 12. (use additional paper if

necessary)

Dates of interventions. Weeks 7 thru

12 (must be 12 weeks total)

Progress/Data for weeks 7 through 12 (Did it work? If not, why didn’t it work) BE SPECIFIC Additional Comments

Tools and Strategies to use BEFORE requesting an Assistive Technology Evaluation

Begin with No Tech and move through to High Tech. DON’T begin with High Tech.

Classroom Management and Environment

• Student planner- personal calendar and notebook for student to keep records of events, assignments, important dates, etc.

Low Tech

• Visual schedule- order of student turn-taking, daily schedule, order of tasks

• Check lists- “Did I…?” or “TO DO… “ lists which students check as they go

• Prompt cards- to illustrate the steps required to complete a task, including materials needed

• Environmental labels- using pictures, words, photos, or symbols to designate where items belong in the class

• Basket/bins- use bin or baskets for work “to do” and work “done” clearly defined

Comprehending, Composing, and Organizing

Learning: No Tech

• finger tapping- syllabification • Provide extensive preview of material • Multi modal presentation-use as many inputs as possible

(visual, auditory, tactile) • Visualization-teach imagery • Connect information- overtly note the link to previously

mastered knowledge

Materials: Low Tech

• Notebook- a specific location to record key points • Exemplars/models- post examples of completed

assignments, noting scores awarded • Materials list- personal or class list of items needed to

complete task Organizing time or space:

• Color coded template: assign specific colors to parts of speech for sentences or other grammatical sequences

• Highlight- main ideas or other key information (character, setting, problem).

• tab/flag: designate main ideas or other key information • Index cards: segment component of a paragraph or story so

they may be physically manipulated. Learning:

• Word dice • Personal materials: student is given a personal version of

class materials, to increase focus, customize it to their needs. • Pictures: photos, pictures with words to convey ideas and

promote recall of information.

• Word wall • Story Grammar Marker: to preview/review story narrative and

support reading of text • Word rings: laminated vocabulary cards or sentence strips

hooked on to large metal book rings • Word Windows: bind together sequences of letter cards and

word windows- student flip cards • Story starters • Word games

• Personal recorder: small hand held for students to record their homework assignments

Mid Tech

• Hand held talking dictionary/speller

• Power point slide show” create slides of words for word identification

High Tech

• Inspiration/Kidspiration- provides a variety of formats for visually representing, organizing, recording, and relating ideas and concepts

Mechanics of Writing/Drawing

• Allow more time to complete assignments No Tech

• Reduce quantity of final product • Explore different forms of writing (print versus cursive) • Model writing first: teacher/peer/aide writes the word to show

the student how to form letters • Use “fill in the blank” answer format • Modify worksheets- simplify; make templates for student to

complete • Use multiple choice format • Support spelling skills through use of word searchers and

crossword puzzles • Warm up exercises: for hands/arms prior to writing

• Word walls: reinforce frequently used words and topic/story vocabulary

Low Tech

• Word rings • Spelling journals • Vertical/slant surfaces can support access, especially for

young children • Slant board or notebook turned sideways sloping toward

student • Easel • Little blackboard, chalkboard or write on/wipe off board • Felt board • Handwriting instructional booklets: Beginning Connected

cursive writing… • Tactile letters: “writing” letters in sand, finger paints, puff

paints, glitter • Magnetic alphabet board • Scrabble letters or tiles

• Dot to dot letters • Pencil grips: stabilizes grip on pen or pencil (See OT) • Adapted pencils • Nitewriter lighted pen: supports visual tracking while writing • Shift position of paper • Enhanced lined paper(see OT) • Plastic writing guides • Finger grip ruler: keeps fingers out of way while drawing a line

• Voice recorder: record homework assignments, Mid Tech

• All-turn-it-spinner: story parts can be written on a wheel and randomly selected by student

• Hand held talking dictionary/speller • Language Master

Mathematics

• Minimize number of items on page No Tech

• Eliminate need to copy problems- have student record answers only when possible

• Avoid mixing signs – to avoid confusion • Provide additional time • Peer/adult support • Cross age tutoring • Mental arithmetic- if writing presents barrier have student

narrate math process • Finger math • Mnemonic devices • Multimodal instruction

• Modified paper: bold line, raised, assorted graph, enlarged graph (see OT)

Low Tech

• Rubber stamps • Finger pinch ruler • Math matrix: charts/tables; number fact sheets 100’s… • Mathline: tangible number rod with gliding markers • Number lines: raised, large, tactile, life size, used to show

size… • Computational aides: abacus, counters, manipulatives,

beads, base ten blocks… • Enlarge worksheets/print • Highlighter tape • Tangrams: Chinese, manipulative piece puzzles

• Calculators Mid Tech

• Tape recorder: • Automatic number stamp • Coin-u-lator

• Any Mac or Windows based Math Software program High Tech

Edited 5/06/13 7

Transition Planning

Transition is required for students with disabilities, beginning at age 15 (or turning 15 during the implementation period of the IEP). Information needs to include coordinated set of transition activities and post secondary measurable goals which will reasonably enable students to meet their post-secondary goals for living, further education, and employment. Transition planning and services must also be integrated into the PLEP (Career/Vocation/Transition).

Post-Secondary Exit Summary For students who are graduating or leaving school, a Post-Secondary Exit Summary and a meeting will be held by your school with the student and parent before the end of the school year. The chairperson assigned to your building will send you the packet of forms which includes the following:

• Parent Invite for Student Exit Summary • Student Invite for Student Exit Summary • Exit Summary Edits/Revisions with the printed information from the student’s

IEP • Part II: Post-Secondary Goals and Recommendations

After the meeting is held, send the completed packet to the CSE chairperson and it will be entered into IEPDirect. The exit summary will then be sent to the student.

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