Notification Of Request For Educational Evaluation Form
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1Updated: 5/18/11
Dubois – Spencer – Perry
Exceptional Children’s Co-op
NOTIFICATION OF REQUEST FOR
EDUCATIONAL EVALUATION
Complete this form anytime a parent requests an educational evaluation for a student OR when a school proposed
and proceeds with the evaluation process.
Fax this completed form to the DSP Exceptional Children’s Co-op. (See below for the appropriate fax number.)
STUDENT INFORMATION
Student Name ___________________________________________ STN# _______________________
Gender
Male
Female
Birthdate _____________________ Grade ____________________
Ethnic Background: ____ American Indian or Alaskan Native ____ Asian or Pacific Islander
____ Hispanic
____Black American ____ White (non-Hispanic) ____ Multiracial
School of Residence ______________________________ School Attending _______________________
Gen Ed Teacher Name ________________________ Suspected Disability _________________________
Expected Special Ed Teacher Name _____________
Parents’ Names ________________________________________________________________________
Address __________________________________________________ City _______________________
Home Phone ______________ Work Phone ______________ Emergency Contact Phone ____________
Custody:
____ Natural Parent ____ Maternal Parent ___ Paternal Parent ___ Foster Parent
____ Ward of Court ___ Ward of DPW ___ Ward of DMH ___ Other
Did the student participate in a process that assessed the student’s response to scientific, research-
based interventions? __________________________________
REQUEST FOR EVALUATION
Request for evaluation made by:
School Personnel
_______________
(specify title)
skip to Written Notice section
Parent
please answer the next 2 questions
• Date request from parent was received by certified school personnel _____________________
(10-day timeline to review records begins on this date)
• How was the parent request made?
__________________________
(verbally, in writing, fax, email, etc.)
WRITTEN NOTICE (SCHOOL’S RESPONSE TO THE PARENT REQUEST FOR EVALUATION)
Date the written notice was sent to the parent: _____________________________________________
Request for evaluation was denied
Request for evaluation was granted to parent OR school proposed to evaluate the student
20 day evaluation timeline
50 day evaluation timeline
CONSENT FOR EVALUATION
Date the consent for evaluation was received from the parent __________________________________
North Office
South Office
th
1520 Saint Charles St., #2
319 S. 5
St., Room 15
Jasper, IN 47546
Rockport, IN 47635
Phone 812-482-6661
Phone 812-649-9991
Fax 812-482-9381
Fax 812-649-9997
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