1. HAYSVILLE U.S.D. 261



HAYSVILLE U.S.D. 261
SPECIAL EDUCATION STAFFING, ELIGIBILITY, & EVALUATION SUMMARY
 

Student Name: ________________________________________________  Date: _______________________
 
Parent/Guardian: ______________________________________________  Parent Present: r Yes r No
 
Type of Staffing                 Evaluation Reports Provided

         
    
Initial IEP IEP Review Parent Meeting Psychologist
                            Dismissal           ___________________________ Special/General Education Teacher
Type of Evaluation Speech/Language Pathologist
Initial Comprehensive Speech Only Reevaluation Occupational/Physical Therapist
Educational / IEP Review:  
   
   
   
   
Evaluation Information:  
   
   
   
Information from Parent:  
   
   
   
Eligibility Determination:  
   
   
Anticipated Needs/Services:  
   
   
   
Team Recommendations:  
   
   
   
      
 Name Date Position
_________________________________________ _____________________ _______________________
_________________________________________ _____________________ _______________________
_________________________________________ _____________________ _______________________
_________________________________________ _____________________ _______________________
_________________________________________ _____________________ _______________________
_________________________________________ _____________________ _______________________
_________________________________________ _____________________ _______________________
_________________________________________ _____________________ _______________________
Dissenting Opinions: r Yes r No Attachments: r Yes r No
White=Central Office Yellow=Teacher Pink=Parent

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SE-113