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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