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Petaluma City Schools |  E  6164.4  Instruction

Identification Of Individuals For Special Education   

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Sonoma County

Special Education Local Plan Area


To parent/guardian of: Date:

District:__________ School:__________ Grade:______________ Birthdate:___________

Primary language: _________________Language proficiency status:________________

To meet your child's individual education needs, the following assessments may be required. Assessment will be conducted by qualified staff and, when appropriate, suitable interpreters. You will be asked to participate in a meeting of the individualized education program (IEP) team following completion o the assessment. You may receive a copy of the assessment findings, on request, prior to the IEP team meeting. The result of completing these assessments may be: 1) a recommendation for special education placement or services, 2) a modification of current program if student is currently enrolled in special education, or 3) a recommendation to continue or discontinue special education. No placement in special education will be made without your written permission. All information and assessment results will be kept confidential.

" Language/Speech communication Development - These tests measure your child's ability to understand and use language and speech clearly and appropriately


" Health - Health information and testing is gathered to determine how your child's health affects school performance.

" Social/Adaptive Behavior - These test will indicate how your child feels about him/herself, gets along with other people, takes care of personal needs at home, school and in the community.

" Motor Development - Tests in this area measure how well your child coordinates body movements in small-muscle and large-muscle activities. Perceptual skills may also be measured.

" Academic Achievement - These tests measure reading, spelling, arithmetic, oral and written language skills, and/or general knowledge.

" Intellectual Development - These tests measure how well your child thinks, remembers, and solves problems. Tests yielding IQ scores cannot be administered to Black students.

" Other Tests

Circle as appropriate: · Vocational · Orientation &Mobility Observation · Interview

" Alternative Means of Assessment

Proposed methods: .

If you have any questions about the above assessment plan, please call;

Name and position:______________ Phone number:__________________

This form must be signed before assessment can begin. Please read Summary of Parent Information, Rights, and Appeal Procedures on the back of this form before signing.

Please check one of the following and sign:

' I consent to the assessment. I understand that the results will be kept confidential and that I will be encouraged to attend the individual education program team meeting to discuss the results. I also understand that no special educational placement or service will result from this assessment without my written permission.

' I do not consent to the assessment described above.



Address:_____________________ Phone number:_________________________


SELPA-8-Mandatory (Rev. 5/91)

Copy 1-File Copy 2-Parent


version: June 25, 2002 Petaluma, California