REEVALUATION REPORT Student’s Name:
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PA Mapping Document –Re-Evaluate Report (RR)
REEVALUATION REPORT (RR) School Age
Student Name:
Date of Report (mm/dd/yy): Date Report Provided to Parent/Guardian/Surrogate:
Student Birth Date: Age: Grade:
Local Education Agency (LEA):
School Student is Attending:
Current Educational Program:
County of Residence: Phone (Home):
Name and Address of Parent/Guardian/Surrogate: Phone (Work):
Other Information:
Date IEP Team Reviewed Existing Evaluation Data:
The IEP team must decide if it has enough data to determine: the student’s educational needs; the present levels of academic achievement and related developmental needs of the student; whether any additions or modifications to the special education and related services are needed to enable the student to meet the measurable annual goals in the IEP and to participate as appropriate in the general education
curriculum; and whether the student continues to need special education and related services. I. SUMMARIZE INFORMATION REVIEWED
Complete items 1-7 for all students.
1. Physical condition, social, or cultural background, and adaptive behavior relevant to the student’s disability and need for special education:
2. Evaluations and information provided by the parent (or documentation of LEA’s attempts to obtain
parental input):
a
SUMMARY: Webform & Report. ADD Logo / Letterhead between header and Re-Eval Title below.
- Fits in address into Window envelope
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REEVALUATION REPORT Student’s Name:
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PA –Re-Evaluation Report (RR)
*(See documentation for ‘Goal Book Setup for PA Statement Lookup’)
- Enable user to Link Placement & Disabilities Referral Record to this form, Alternate Code = RE
- Start Date = Form Creation Date/Today, Enable user to change it - Ability to Finalize Form
Letterhead, System or User, Report Header (School
Address/Phone)
- Logo
A Page Header Form Name & Child’s Name (First, Middle, Last, Qualifier)
1 Student Name Student, Demographic: First, Middle, Last name, Qualifier
2 Date of Report Today’s date, enable user to change date
2a Date Report to P/G Today’s date, enable user to change date
3 DOB Student, Demographics, Date of Birth Field
3a Age Calculate student age, DOB to Today’s Date
3b Grade Form, Placement, Grade Field as of ER Form Current Date
4 Local Education Agency (LEA) Options, Systemwide Options, Organization - OR_Name of System Default Organization
5 Attending School Form, Placement, Location as of ER Form Current Date
6 Current Ed. Program Form, Placement, Placement/Supports as of ER Form Current Date - Display Primary & non-primary Placement - Indicate Primary with ‘*’
7 County of Residence Student, Address, Home, County field - AD_County of Address linked to Student where AD_Home=1
8 Parent/Guardian/ Surrogate Parent/Guardian Salutation, Address information - Basic Information, Contact, Type = Parent/Guardian, Surrogate
Parent - Addresses Tab = Mail - Mail Attention Line, if blank use Contact Name fields
9 Other Information - Text Box and pull data stored…
- Student, Demographics, Notes Box
10 Date IEP Team Reviewed Existing
Re-Eval Data
Today’s date; user can modify
11 Summarized Information 1. Physical Condition
Text Box Statement – Category = ‘Re-evaluation’, SubCategory = ‘Physical’
12 2. Evaluations Text Box Statement – Category = ‘Re-evaluation’, SubCategory = ‘Parent Information’
REEVALUATION REPORT Student’s Name:
Page 3 of 13 July 2008 Revisions
3. Aptitude and achievement tests:
4. Current classroom based assessments and local and/or state assessments:
5. Observations by teacher(s) and related services provider(s), when appropriate:
6. Teacher recommendations:
7. Determining factors: A student must not be found to be eligible for special education and related
services if the determining factor for the student’s suspected disability is any of those listed below.
Respond Yes or No to, and provide evidence for, each determining factor below.
Yes No Lack of appropriate instruction in reading, including the essential
components of reading instruction. Provide evidence:
Yes No Lack of appropriate instruction in math. Provide evidence:
Yes No Limited English proficiency. Provide evidence:
II. DETERMINATION OF NEED FOR ADDITIONAL DATA, SUMMARY AND CONCLUSIONS
Based on all evaluation data reviewed, complete item 1 or item 2.
1. The IEP team determined that additional data are not needed.
Reason(s) additional data are not needed:
Conclusion: Complete section A or B or C.
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REEVALUATION REPORT Student’s Name:
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A. The student has a disability AND continues to need specially designed instruction.
i. Disability Category
Primary disability category:
Secondary disability category(s), if any:
ii. Summary of Findings
Student’s educational strengths and needs:
Present levels of academic achievement and related developmental needs, including
transition needs as appropriate:
Recommendations for consideration by the IEP team regarding any additions or modifications to the special education and related services needed to enable the student to
meet the measurable annual goals in the IEP and to participate as appropriate in the general education curriculum (including special considerations the IEP team must consider before developing the IEP, measurable annual goals, specially designed instruction, and supplementary aids and services):
OR
B. The student does not have a disability and no longer is eligible for special education. (The
parent may request an assessment to determine whether the student continues to be a student with a disability.)
OR
C. The student has a disability but no longer needs specially designed instruction, and no longer
is eligible for special education. (The parent/guardian/surrogate may request an assessment to determine whether the student continues to be a student with a disability.)
2. The IEP team determined that there is a need for additional data.
The LEA must issue the Permission to Reevaluate – Consent Form and administer tests and other evaluation materials as may be needed to produce the data below.
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REEVALUATION REPORT Student’s Name:
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PA –Re-Evaluation Report (RR) - Continued
13 3. Aptitude Testes Text box
14 4. Assessments Text box
PerformancePLUS Assessment Look-up Utility enabled on form.
15 5. Observations Text Box
16 6. Teacher Recommendations Text Box
Statement – Category = ‘Re-evaluation’, SubCategory = ‘Teacher Recommendations’
17a 7. Determining Factors -Lack of Reading Instruction
Check Box, Text Box Statement – Category = ‘Re-evaluation’, SubCategory =
‘Reading Instructions’
17b - Lack of Math Instruction Check Box, Text Box
Statement – Category = ‘Re-evaluation’, SubCategory = ‘Math Instruction’
17c - LEP Check Box, Text Box Statement – Category = ‘Re-evaluation’, SubCategory = ‘LEP’
18 II. Determination, Conclusions 1. Additional Data NOT needed
Check Box, Text Box
18a 1a. Primary Disability & Secondary Disability
Radio Button - Student, Disability, Primary & Secondary Disabilities
- Disability must be within the date range of the form. - Ability to Manage Disabilities here also
19 ii. Summary of Findings Educational Strengths & Needs
Text box - Add ability to enter Evals/Test records
Handle Eval/Tests by security within form
20 Present Levels of Academic Text Box
21 Recommendations Considered Text Box
22 B. No Disability, no special Ed Radio Button - Disability ended on or before the date of the RR form
- If open disability, use RR date and end disability
23 C. Disability but no SDI, no special
ed
Radio Button
24 2. Need for Additional Data Check Box
REEVALUATION REPORT Student’s Name:
Page 6 of 13 July 2008 Revisions
NOTE: IF REEVALUATING THE STUDENT TO DETERMINE SPECIFIC LEARNING
DISABILITY, COMPLETE THE DETERMINATION OF SPECIFIC LEARNING DISABILITY
COMPONENT AT THE END OF THIS DOCUMENT BEFORE COMPLETING THE SECTION BELOW.
Interpretation of additional data:
Conclusion: Complete section A or B or C.
A. The student has a disability AND continues to need specially designed instruction.
i. Disability Category
Primary disability category:
Secondary disability category(s), if any:
ii. Summary of Findings
Student’s educational strengths and needs:
Present levels of academic achievement and related developmental needs, including transition needs as appropriate:
Recommendations for consideration by the IEP team regarding any additions or modifications to the special education and related services needed to enable the student to meet the measurable annual goals in the IEP and to participate as appropriate in the general
education curriculum (including special considerations the IEP team must consider before developing the IEP, measurable annual goals, specially designed instruction, and supplementary aids and services):
OR
B. The student does not have a disability and therefore no longer is eligible for special
education.
OR
C. The student has a disability but no longer needs specially designed instruction, and no longer is eligible for special education.
Upon completion of the reevaluation, the Local Education Agency will complete and issue the report to the members of the evaluation team.
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REEVALUATION REPORT Student’s Name:
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Evaluation Team Participation
Agreement and Disagreement
required ONLY when evaluating
students for specific learning
disability.
Evaluation Team Participants* Title Agree Disagree**
* A certified school psychologist is required for evaluation of the following disability categories: Autism,
Emotional Disturbance, Mental Retardation, Multiple Disabilities, Other Health Impairments, Specific Learning Disability or Traumatic Brain Injury. A certified school psychologist is not required for Deaf-blindness, Deaf and Hard of Hearing, Speech/Language Impairment, Visual Impairment and Orthopedic Impairment.
** For specific learning disability only, if a team member disagrees with the team’s conclusion related to the identification of the student as having a specific learning disability, the member must submit a separate statement presenting the member’s dissent to the LEA. This information must be attached to the Reevaluation Report. Please submit this statement to:
LEA Representative Name Phone Number
Email Address
A copy of the Procedural Safeguards Notice is available upon request from your child’s school. This document explains your rights, and includes state and local advocacy organizations that are available to help you understand your rights and how the special education process works.
For help in understanding this form, an annotated Reevaluation Report is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on the website. If you do not have access to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.
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REEVALUATION REPORT Student’s Name:
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PA –Re-Evaluation Report (RR)
25 Interpretation Addtl Data Text box
26 Conclusion 2a.Disability & Needs
SDI
Radio Button (dependent on 26, 30, 31) - Student, Disability
- Primary & Secondary Disabilities - Ability to Manage Disabilities here also
27 ii. Summary of Findings Educational Strengths
Text Box
28 Present Levels Academic Achievement
Text Box
29 Recommendations Text Box
30 B. No Disability, no longer eligible
Radio Button (dependent on 26, 30, 31)
31 C. Disabled but no SDI Radio Button (dependent on 26, 30, 31)
32 Evaluation Team
Text Box
33 LEA Representative, Phone, Position, Email.
- Text box and/or Add, Manage Code Tables, Letterhead Enclosure = ‘School District Contact’
(Note: Add if not in districts code tables) Maintenance, Letterhead, Staff Type/Enclosure = School District Contact
(Letterhead_Enclosure_sub.rpt-01) Name: Letterhead, Staff type/Enclosure = School District contact, Line 1 Phone: Letterhead, Staff type/Enclosure= School District contact, Line 3
Email: Letterhead, Staff type/Enclosure= School District contact, Line 4 - Enable user to change text or manually enter text here
NEW: Display text from Letterhead addition on screen currently it only displays on the report.
REEVALUATION REPORT Student’s Name:
Page 9 of 13 July 2008 Revisions
DETERMINATION OF SPECIFIC LEARNING DISABILITY
NOTE: This component must be completed when reevaluating students for Specific Learning Disability. The information must be attached to and/or incorporated into Section II Item 2 of the completed Reevaluation Report.
Provide documentation for items 1-10.
1. The student does not achieve adequately for the student’s age or does not meet State-approved grade-
level standards in one or more of the following areas when provided with learning experiences and scientifically based instruction appropriate for the student’s age or State-approved grade level standards and level of English language proficiency: oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, mathematics calculation, and
mathematics problem-solving.
2. Check below to identify the process(es) used to determine eligibility.
Response to Scientific Research-Based Intervention (RtI). Document the criteria below.
The student does not make sufficient progress to meet age or State-approved grade-level standards
in one or more of these areas: oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, mathematics calculation, and mathematics problem-solving:
Severe Discrepancy between Intellectual Ability and Achievement. Document the criteria below.
The student exhibits a pattern of strengths and weaknesses in performance, achievement or both relative to age, standards or intellectual development:
3. The instructional strategies used and the student-centered data collected:
4. The educationally relevant medical findings, if any:
5. The effects of the student’s environment, culture, or economic background:
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REEVALUATION REPORT Student’s Name:
Page 10 of 13 July 2008 Revisions
6. Data demonstrating that prior to referral or as part of the referral process for an evaluation for specific learning disability, the student’s regular education instruction was delivered by qualified personnel, including the English as a Second Language (ESL) program, if applicable:
7. Data based documentation of repeated assessments of achievement at reasonable intervals, reflecting
progress during instruction, which was provided to the parents:
8. An observation in the student’s learning environment (including the regular classroom setting) to
document the student’s academic performance and behavior in the areas of difficulty. Note the
relationship of that behavior to the student’s academic functioning:
9. Other data, if needed, as determined by the evaluation team:
10. Include a statement for each item below to support the conclusions of the evaluation team that the
findings are not primarily a result of
Visual, hearing, motor disability:
Mental retardation:
Emotional disturbance:
Cultural factors:
Environmental or economic disadvantage:
Limited English proficiency:
Upon completion of the SLD Component, attach and/or incorporate this information into Section II Item 2 of the completed Reevaluation Report.
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REEVALUATION REPORT Student’s Name:
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PA –Re-Evaluation Report (RR) – Continued
Determination of SLD *(See documentation for ‘Goal Book Setup for PA Statement Lookup’- Set Active, use SPI Default Goalbook)
34 1. SLD Standards not
met
Text Box
Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Adequate Achievement’
35 2. SLD RTI not making progress
Check box, Text Box
36 SLD Intellectual
Discrepancy
Check box, Text box
Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Severe Discrepancy’
37 3. SLD Instructional Strategies
Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Instructional Strategies’
38 4. SLD Educationally
Relevant Medical
Text Box
Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Medical Finding’
39 5. SLD Background Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Effects of
Environment’
40 6. SLD qualified Regular
Ed staff
Text Box
Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Qualified Personnel’
41 7. SLD Assessments Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Progress
Monitored’
42 8. SLD Observation Text Box
Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Student Behavior’
43 9. SLD Other Data Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Other Data’
44 10. SLD Vision/Hearing Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD
Visual/Hearing’
45 SLD Mental Retardation
Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD MR’
46 SLD Emotional Disturbance
Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD ED’
47 SLD Cultural Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD Cultural’
48 SLD Environmental Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD
Environmental Disadvantage’
49 SLD LEP Text Box Statement – Category = ‘Re-evaluation’. SubCategory = ‘SLD LEP’
Print Form Number / Date
Print on the bottom of the form.
REEVALUATION REPORT Student’s Name:
Page 12 of 13 July 2008 Revisions
PA – Re-Evaluation Report Form
Q&A’s FORM ID#_______
Field QU_Area QU_Section QU_Subsection
FAW_State
FAW_Notes
9 PA_RR_OtherInformation Text Text 11 PA_RR_Summarize Physical Text 12 PA_RR_Summarize Evaluation Text 13 PA_RR_Summarize Tests Text 14 PA_RR_ Summarize Assessments Text
15 PA_RR_ Summarize Observation Text
16 PA_RR_ Summarize TeacherRecommendations Text
17a PA_RR_ Summarize Reading X Text
17b PA_RR_Summarize Math X Text
17c PA_RR_Summarize LEP X Text
18 PA_RR_Determination NoAdditionalData X Text
18a PA_RR_Determination DisabilityandSDI X
19 PA_RR_Determination Needs Text
20 PA_RR_Determination PresentLevels Academic Text
21 PA_RR_Determination Recommendation Text
24 PA_RR_Determination NeedAdditionalData X
25 PA_RR_Determination InterpretationAdditionalData
Text
27 PA_RR_Conclusions SummaryofFindings Text
28 PA_RR_Conclusions PresentLevelsAcademic Text
29 PA_RR_Conclusions Recommendations Text
33 LEARepresentative Text
34 PA_RR_SLD NotMeetStandards Text
35 PA_RR_SLD RTI X Text
36 PA_RR_SLD SevereDiscrepancy X Text
37 PA_RR_SLD InstructionalStrategies Text
38 PA_RR_SLD EducationallyMedical Text
39 PA_RR_SLD Effects of environment Text
40 PA_RR_SLD DataInstructionbyQualifiedPersonnel
Text
41 PA_RR_SLD Data Text
42 PA_RR_SLD Observation Text
43 PA_RR_SLD OtherData Text
44 PA_RR_SLD VisualHearingMotor Text
45 PA_RR_SLD MentalRetardation Text
46 PA_RR_SLD EmotionalDisturbance Text
47 PA_RR_SLD Cultural Text
48 PA_RR_SLD Environmental Text
49 PA_RR_SLD LEP Text
Revision History: 7/2010: Ability to used goal book statements if SPS Default Goal Book is active and statements have been added to this book. 7/30/10: Evaluation Team Participation section now has a total of 15 signature lines on the report.
REEVALUATION REPORT Student’s Name:
Page 13 of 13 July 2008 Revisions
8/17/2011: Added line indicated the PeformancePLUS Assessment Look-Up Utility is enabled on this
form.