1. INITIAL EVALUATION COVER SHEET
      2. Documentation   Date

Haysville USD 261



INITIAL EVALUATION COVER SHEET
 

Student Name:_________________________ DOB:______________________________________
 
SSN:_________________________________ GRADE:____________________________________
 
Enrollment School:_____________________ Attendance School:___________________________
 
Parent(s):_____________________________ Address:____________________________________
 
  _____________________________ ___________________________________
 
Psychologist:__________________________ Staffing Date:________________________________
 
Casemanager:_________________________ Status:______________________________________
 
Primary Exceptionality:_________________ Secondary Exceptionality:______________________
 



Documentation      Date
 
Gen. Ed. Intervention Info  _____________  
 
Eval. Consent Received    _____________
 
Health Report      _____________
 
Teacher Report      _____________
 
Psychologist’s Report    _____________
 
Speech/Lang. Report    _____________
 
OT Report      _____________
 
PT Report      _____________
 
Team Report      _____________
 
Regression Wkst      _____________
 
Observation      _____________
 
Parent Conf. Notice    _____________
 
Staffing Summary    _____________
 
Placement Consent Form    _____________
 
IEP        _____________
 

___________________________
Special Education Administrator

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