LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
REFERRAL
REFERRAL
Student Referral for Out-of District Placement Student Name ____________________________
DOB _______________________
Home School ____________________________
Grade ______________________
Person Making Referral ____________________
District _____________________
District Contact For This Referral _______________________ Phone ______________ Placement Recommendation ______ 4-8 Lane School _______ K-3 Class Lane School Consultant ________________________________________ __________________________________________ Special Education Coordinator Signature
Lane ESD Referral 2009-10 4/27/10
1
_________________________ Date
LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
REFERRAL PROCESS
Student Referral for Lane School Placement The Student Referral Packet for a Lane School Placement is a 3-step process: Step 1: District personnel or Lane School Consultant complete the following and return to Lane School a. Permission to exchange information b. General Information Sheet c. Survey of Major Behavior Problems d. A Functional Assessment of Behavior e. Social Skills Rating Scale f. Records Review g. A copy of the most recent psychological evaluation h. A copy of current Special Education eligibility i. A copy of current IEP j. Current Academic Worksheet k. Work samples l. Copy of immunization form m. Student’s Secure ID# ________ n. Student’s GPA ______
Page 3 4 5,6 7,8 9,10 11,12,13
14,15
Date Completed _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________
Step 2: A tour, informational meeting, and IEP with parents, student, district representative and Lane School staff. Page a. Tour and informational meeting 1. Physician release / meds info / release signed 2. Parent involvement form filled out
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Date Completed _________ _________ _________
b. District representative brings 1. District IEP forms 2. Parent rights pamphlet
_________ _________
c.
_________
A tentative intake date is set
Step 3: Intake a. b. c. d.
Lane School procedures are discussed with parent and student IEP review and change of placement form completed Community agency involvement / releases signed 17 Transportation arranged by district representative e. Entry date confirmed
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_________ _________ _________ _________ _________
LANE EDUCATION SERVICE DISTRICT LANE SCHOOL PERMISSION TO RELEASE OR EXCHANGE INFORMATION/PERMISSION TO OBSERVE I give my written permission to: Name of Provider, Agency, School District, Doctor to release the following information concerning educational planning/appropriate placement services. INFORMATION REQUESTED (Check items desired) Student Education Records Intelligence Test Scores/Psychological Reports Personality and/or Interest Assessments Social Work Reports Medical Information Individual Education Plan (IEP) Speech/Language and Hearing Records Other (specify) Parent/Guardian Signature
Date
In accordance with the requirements of the Family Educational Rights and Privacy Act, education records maintained by an educational agency on/about a student may not be shared with any other agency without the written consent of the parent, guardian, or the student (if eighteen years or older). All records added to student file may be open to parent. PLEASE SEND TO:
LANE SCHOOL LANE EDUCATION SERVICE DISTRICT 1717 CITY VIEW EUGENE, OR 97402 PHONE: 541-463-8500 FAX: 541-302-0938
BY SIGNING BELOW I GIVE MY PERMISSION FOR THE LANE EDUCATION SERVICE DISTRICT TEACHER CONSULTANT TO OBSERVE AND CONSULT WITH MY CHILD. Parent/Guardian Signature
Date
Address Phone Number Lane School Release information 4/28/10
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LANE SCHOOL REFERRAL LANE EDUCATION SERVICE DISTRICT GENERAL INFORMATION SHEET
Student’s Name: ________________________________ DOB: ___________________
Current Grade: ______________________
SSID # for State Testing ______________________ Sex: M
F
Medications: _________________________________________________________________________ Person Making Referral: _______________________________ District: ________________________ Phone: ____________________________
Home School: ___________________
Lane School Consultant: _______________________________ Placement Recommendation: ________ K-3
________ 4-8
Special Education Coordinator’s Signature _________________________________________________ Ethnicity:
______ White _____ Black _____ Hispanic ______ Native American
_______ Asian/Pacific Island _______ Other: ________________________________ Parent/Guardian: _____________________________________________________________________ Address: ____________________________________________________________________________ Home Phone: __________________________________ Work Phone: __________________________ Marital Status: _________ Student resides with:
______ Father _____ Mother _____ Both
Other _______________________
CURRENT LEVEL OF MAINSTREAMING: (check one) Full time regular class placement
___________
Part-time resource room/part time regular class placement
___________
Full time placement in self-contained classroom
___________
Self-contained day school placement/residential placement
___________
Other: (specify) ___________________________________________________________________
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LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
SURVEY OF MAJOR BEHAVIOR PROBLEMS
BEHAVIORS OF CONCERN: Please list the behaviors of concern. These are the behaviors that need to be changed in order for this student to be successful in school. 1. 2. 3. 4. 5. INTERVENTIONS THAT HAVE BEEN TRIED: Briefly describe interventions that have been tried and comment on the degree of effectiveness. Attach behavior plans and data on these interventions. BEHAVIOR INTERVENTIONS:
HOW LONG?
SUCCESSFUL?
1.
YES
NO
2.
YES
NO
3.
YES
NO
4.
YES
NO
5.
YES
NO
5
LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
SURVEY OF MAJOR BEHAVIOR PROBLEMS (con’t)
ADDITIONAL INFORMATION: HAS THE STUDENT EXHIBITED: TRUANCY
YES
NO
SELF-INJURIOUS BEHAVIOR
YES
NO
TANTRUMS OR THROWING OBJECTS
YES
NO
THEFT
YES
NO
SERIOUS VANDALISM
YES
NO
ARSON
YES
NO
DRUG/ALCOHOL ABUSE
YES
NO
ASSAULTIVE BEHAVIOR
YES
NO
WEAPONS TO SCHOOL
YES
NO
IF YES TO ANY OF THESE QUESTIONS, PLEASE DESCRIBE: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ OATHER SERIOUS BEHAVIORS: ________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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Functional Assessment Checklist for Teachers and Staff (FACTS-Part A)
ep 1
Student/ Grade: ______________________________ Interviewer: _________________________________
ep 2
Student Profile: Please identify at least three strengths or contributions the student brings to school. ___________________________________________________________________________________ ___________________________________________________________________________________
ep 3
Problem Behavior(s): Identify problem behaviors
ep 4
ep 5
Date: ____________________________ Respondent(s): ____________________
___ Tardy ___ Unresponsive ___ Withdrawn
___ Fight/physical Aggression ___ Disruptive ___ Theft ___ Inappropriate Language ___ Insubordination ___ Vandalism ___ Verbal Harassment ___ Work not done ___ Other ________________ ___ Verbally Inappropriate ___ Self-injury Describe problem behavior: ____________________________________________________________
Identifying Routines: Where, When and With Whom Problem Behaviors are Most Likely. Schedule (Times)
Activity
Likelihood of Problem Behavior Low 1 2
3
4
5
High 6
1
2
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5
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Specific Problem Behavior
Select 1-3 Routines for further assessment: Select routines based on (a) similarity of activities (conditions) with ratings of 4, 5 or 6 and (b) similarity of problem behavior(s). Complete the FACTS-Part B for each routine identified.
March, Horner, Lewis-Palmer, Brown , Crone, Todd & Carr (2000)
4/24/00
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Functional Assessment Checklist for Teachers & Staff (FACTS-Part B)
ep 1
Student/ Grade: ______________________________ Interviewer: _________________________________
Date: ____________________________ Respondent(s): ____________________
ep 2
Routine/Activities/Context: Which routine(only one) from the FACTS-Part A is assessed? Routine/Activities/Context Problem Behavior(s)
Provide more detail about the problem behavior(s):
ep 3
ep 4
What does the problem behavior(s) look like? How often does the problem behavior(s) occur? How long does the problem behavior(s) last when it does occur? What is the intensity/level of danger of the problem behavior(s)?
What are the events that predict when the problem behavior(s) will occur? (Predictors) Related Issues (setting events)
Environmental Features ___ illness ___ drug use ___ negative social ___ conflict at home ___ academic failure
Other:_________________ ______________________ ______________________ ______________________ ______________________
___ reprimand/correction ___ physical demands ___ socially isolated ___ with peers ___ Other __________________ What consequences appear most likely to maintain the problem behavior(s)? Things that are Obtained
___ structured activity ___ unstructured time ___ tasks too boring ___ activity too long ___ tasks too difficult
Things Avoided or Escaped From
ep 5 ___ adult attention ___ peer attention ___ preferred activity ___ money/things
Other: ________________ ______________________ ______________________ ______________________
___ hard tasks Other: ___________________ ___ reprimands ________________________ ___ peer negatives ________________________ ___ physical effort ________________________ ___ adult attention ________________________
ep 6
SUMMARY OF BEHAVIOR Identify the summary that will be used to build a plan of behavior support. Setting Events & Predictors Problem Behavior(s) Maintaining Consequence(s)
ep 7
How confident are you that the Summary of Behavior is accurate? Not very confident 1
2
3
4
Very Confident 5
6
What current efforts have been used to control the problem behavior? Strategies for preventing problem behavior
Strategies for responding to problem behavior
ep 8 ___ schedule change Other: ________________ ___ seating change ______________________ ___ curriculum change ______________________
___ reprimand Other: ___________________ ___ office referral _________________________ ___ detention _________________________
March, Horner, Lewis-Palmer, Brown , Crone, Todd, & Carr (2000)
4/24/00
8
Student Name:
STAFF FORM Social Skills Rating Scale Intake Skills Review Date _______ Instruction Review Dates_______ _______ _______ _______ _______ Level 3 Petitioning Review Date _______ Level 4 Petitioning Review Date _______ Exit Review Date _______
1 Never Demonstrates
2 Can talk about it but does not do it
3 Can talk about it and do it with teacher prompt
4 Can talk about it; Can sometimes do it independently
PEOPLE AND RELATIONSHIPS Demonstrates Role Recognition: Demonstrates the ability to identify and provide appropriate response toward authority figures & perceived unjust situations (P1.0, P8.0) Understanding Relationships: Demonstrates understanding of how relationships develop and how nonverbal behavior affects relationships (P2.0, P4.0, P6.0) Maintaining Relationships Demonstrates understanding of how to maintain relationships with peers and adults (P5.0, P6.0)
RATING
UNSTRUCTURED TIME Engages in recess or free-time activities Engages in recess activities by knowing and respecting boundaries for recess and staying with the group, identifies activities and interests available during recess, accesses playground equipment safely, and exhibits friendly behavior during play (P7.0, P8.0, S5.0, L1.0, L2.0, L4.0, L5.0) Participates in Games Participates in games by identifying with a peer group or a circle of friends, knows the basic rules for a several games or sports, expresses some concept of “sportsmanship”, manages being a winner, loser, and member of a team (P7.0, S5.0, L1.0, L2.0, L3.0)
RATING
5 Demonstrates consistently & independently
COMMENTS
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COMMENTS
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Adapted from Adjusting The Image Rating Scale, Willamette ESD and Portland Public Schools, 2006. 9
1 Never Demonstrates
2 Can talk about it but does not do it
3 Can talk about it and do it with teacher prompt
4 Can talk about it; Can sometimes do it independently
SELF-ADVOCACY
5 Demonstrates consistently & independently
RATING
Demonstrates Self-Knowledge: Demonstrates awareness of personal learning style and sensory processing system and is able to describe individual strategies for self-monitoring (S1.0, S3.0, P6.0) Demonstrates Self Determination Applies self-determination skills and meets personal needs (organization, goal setting, follows personal "organizational plan") (S2.0) Engages in Goal-Setting Self Assessment Is able to represent a personal goal (verbally & visually) that is relevant to the individual's overall future goals and implement the plan on a daily basis (S4.0) Problem-Solving Strategies Understands need for and applies flexible problem-solving strategies when advocating for own needs and adjusting to alternative plans. (S3.0, S5.0, P7.0) Pragmatics Demonstrates effective communication strategies when managing needs and sensory issues by appropriately requesting help, initiating sensory break, and facilitating personal sensory diet plan across settings (S5.0, P4.0, P8.0) Personal Safety Registers the motive and intent of others and demonstrates awareness of common safety issues and social judgment in various environments (S6.0, P3.0, P4.0, P5.0) Basic Hygiene Understands "making an impression" by dressing appropriately to situation and maintaining a clean appearance (S7.0, P5.0)
COMMENTS
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Revised 8/25/10
LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
SCHOOL RECORD REVIEW
Student:
D.O.B:____/____/___
School:
District:
Case Manger:
M
Grade: Phone Number:
10
Sex:
F
EDUCATIONAL HISTORY: Schools/Districts Attended: School(s)
District(s)
Kindergarten
_______________________
_______________________
Grade 1
_______________________
_______________________
Grade 2
_______________________
_______________________
Grade 3
_______________________
_______________________
Grade 4
_______________________
_______________________
Grade 5
_______________________
_______________________
Middle School
_______________________
_______________________
High School
_______________________
_______________________
Relevant Teacher Comments on School History/ Behavior Problems Noted: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Grade retentions: ___________ Attendance during current year: Present ____/_____ days
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Absent _____ days
LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
SCHOOL RECORD REVIEW (CON’T)
SPECIAL EDUCATION HISTORY: Initial Eligibility for Special Education:
________________ ____________________ (Date)
(Area of Eligibility)
Current Special Education Eligibility: LD ED OHI SP/LANG OTHER: _________ LD ED OHI SP/LANG OTHER: _________ LD ED OHI SP/LANG OTHER: _________
Date Eligibility Established: ___________ Date Eligibility Established: ___________ Date Eligibility Established: ___________
Public School Special Education Services and Placements: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Prior Out-of-District Special Education Placements: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Special Health Needs: (History of hearing or vision problems, seizures, other health concerns) __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
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LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
SCHOOL RECORD REVIEW (CON’T)
MOST RECENT ACADEMIC ACHIEVEMENT TEST SCORES: Test Name
Date
Subject Area
Score (Percentile rank, gr equiv.)
_________________________
________
_______________
______________________________
_________________________
________
_______________
______________________________
_________________________
________
_______________
______________________________
_________________________
________
_______________
______________________________
BEHAVIOR REFERRALS: Number of behavior referrals in current school year:
________
Types of behaviors noted in referrals: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Number of Days Suspended in Current School Year: _____________ OTHER IMPORTANT INFORMATION THAT WOULD HELP IN PROGRAM PLANNING AND PLACEMENT: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
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LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
REFERRAL PROCESS
ACADEMIC WORK SAMPLES We would like the following types of work samples attached to this packet:: WRITING: A recent sample of writing that shows the student’s skills in spelling, capitalization and
punctuation, and sentence structure. READING: A copy of a page from the student’s current reading material, with notations as to the quality of a student’s oral reading ability, noting errors and number of words read per minute MATH:
Samples, which show the level of functioning and the skills mastered
These work samples will assist us in placing the student at the appropriate instructional level. If you need clarification or assistance in completing the packet, you may contact a Lane School Consultant at (541) 463-8500 Fax (541) 302-0938
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LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
CURRENT ACADEMIC SKILLS SHEET
Please describe the specific skills and materials that this child is currently working on. This will assist us in developing an appropriate educational program.
SUBJECT
SPECIFIC SKILL LEVELS CURRENTLY BEING TAUGHT
TEXTS AND OTHER MATERIALS USED
___________________________________________________________________________ READING
___________________________________________________________________________ MATH
___________________________________________________________________________ WRITTEN LANGUAGE/SPELLING
___________________________________________________________________________ SOCIAL STUDIES/SCIENCE
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LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
PARENT INFORMATION FORM
Parent’s Name: ___________________________
Date:
_____________________
Child’s Name:
District:
_____________________
___________________________
Contact Person in District:
__________________
Phone
_____________________
Parents: Your child is being considered for an out-of-district placement. We would like to include important information about your child’s interests and strengths as we develop a plan for your child. Please complete this form at your earliest convenience and return it to the contact person listed above. Thank you! Describe your child’s strengths. (This may include your child’s interests / hobbies / free-time activities.)
List the behaviors that you are most concerned about, and would like to see addressed.
What strategies have you tried at home that were successful in maintaining positive behavior?
Is there additional information that you would like to share about your child that could help us to develop an appropriate plan for your child?
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LANE EDUCATION SERVICE DISTRICT LANE SCHOOL
COMMUNITY AGENCIES
Wrap-Around Services/ Community Agency Involvement: Agency Name
Contact person / phone
_____ Services to Children and Families
________________________
_____ Lane county Mental Health
________________________
_____ Lane County DYS / Oregon Youth Authority
________________________
_____ Oregon Social Learning Center (OSLC)
________________________
_____ Direction Service
________________________
_____ Looking Glass Program
________________________
(Specify)__________________________
________________________
_____ Other: ___________________________
________________________
Physician ______________________________
________________________
Medication ______________________________ Will medication be dispensed at school? ____ yes
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Date prescribed ______________ ____ no
