Prior Written Notice Of District'S Proposal/refusal Functional Behavioral Assessment Form

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PRIOR WRITTEN NOTICE OF DISTRICT’S PROPOSAL/REFUSAL

Functional Behavioral Assessment

Hancock County Schools

Student’s Full Name: ___________________________________________

Date: _____________________

School: ______________________________________________________

DOB: _____________________

Parent(s)/Guardian(s): __________________________________________

Grade: ____________________

Address: ______________________________________________________

WVEIS #: __________________

City/State: ___________________________________________________

Telephone: __________________

Dear

As a result of:

a Student Assistance Team (SAT) meeting conducted on

an Eligibility Committee (EC) meeting conducted on

an Individualized Education Program (IEP) Team meeting conducted on

a disciplinary action occurring on

_X_ other behavioral problems displayed at school

the district is providing you with written notice of the district’s _X_proposal /

refusal of the following action(s) with regard to:

the educational evaluation or reevaluation of the student.

the identification of the student as having a disability.

the educational services and/or placement of the student.

the provision of a free appropriate public education (FAPE) to the student.

_X_ other plan to conduct a Functional Behavioral Assessment

Specifically, the district is proposing to conduct a Functional Behavioral Assessment of your child.

The district is proposing or refusing this action because: need to determine patterns and functions of behavior.

The evaluation procedure(s), assessment(s), record(s) or report(s) the district used as a basis for the _X_ proposed/

refused

action are: teacher reports and/or disciplinary reports.

Other options considered include: not conducting a FBA.

The reasons the above options were rejected are: need to determine functions of behaviors in the school setting.

Other factors relevant to the district’s _X_ proposal /

refusal are: none needed

Exceptional students and their parents have protections under the procedural safeguards. A copy of the Procedural Safeguards Brochure and assistance in

understanding the provisions of the procedural safeguards may be obtained by contacting the Director of Special Education at 304-564-3411, as appropriate, the local

Parent Educator Resource Center and/or the West Virginia Department of Education, Office of Special Programs at 304-558-2696 or 1-800-642-8541.

Sincerely,

Signature/Position

Date

West Virginia Department of Education

July 2013