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RTI

A1 Screening Permission    
A2 Academic Quick Facts {K-5} (rev. 10-11)
A3 Academic Quick Facts {6-8} (rev. 10-11)
A4 Academic Quick Facts ~ Grades 9-12 (rev. 5/2011)
A5 Behavior RTI Quick Facts {K-8} (rev. 10-11)
A6 Behavior RTI Quick Facts {9-12}  
A7 District RTI Behavioral Procedures {K-8} (rev. 10-11)
A8 District RTI Behavioral Procedures {9-12}
A9 District RTI Academic Procedures {K-5} (rev. 10-11)
A10 District RTI Academic Procedures {6-8} (rev. 10-11)
A11 District RTI Academic Procedures {9-12} (rev. 5/2011)

A12 RTI Parent Letter - Notification of Services (HCS)
A13 RTI Parent Letter - Graduation From Services (HCS)
A14 Non-classroom Area Procedures Worksheet
A15 RTI Prereferral Process (6/2011)
A16 School Behavior Support Team Intervention Planning Form {K-8}
A17 School Behavior Support Team Intervention Planning Form {9-12}
A18 School Behavior Support Team Request Form {K-8}
A19 School Behavior Support Team Request Form {9-12}  
A20 HCS - Motor Screening Form (Instrument)
A21 HCS - Motor-Sensory Concerns Checklist
A22 HCS - RTI Procedures for OT/PT Evals
A23 RTI Strategies - Motor
A24 ELL Prereferral - Evaluation Procedures (rev. 1/2011)
A25 Summary of Request for Eval of an ELL Student
A26 Academic RTI (2/2011)
A27 RTI Case Summary Chart  

 
Speech/Language RTI

B1 Final Fluency RTI Plan
B2 Final Language RTI Plan
B3 Final Speech Sounds RTI Plan
B4 Fluency Data Sheet
B5 Language Data Sheet
B6 Rubric for Tier Determination (1/19/2011)
B7 SLP Resource List
B8 Speech RTI Process
B9 Speech Sound Data Sheet
B10 Teacher Intervention Guide for Fluency
B11 Teacher Intervention Guide for Language
B12 Teacher Intervention Guide for Speech Sounds

 

Referral 

C1 Referral for Multi-Disciplinary Evaluation (11-12)
Must be completed in IC!!!
C2 HCS - Referral for Multidisciplinary Evaluation Checklist (9-2010)
C3 Revocation of Authorization for Appointment of a Representative for Educational Decisions  
C4 Authorization for Appointment of a representative for Educational Decisions  
C5 Statement of Authorization for Representation  
C6 Checklist Pre-Referral, Initial Referral Placement
(Rev. 8/2/11)
C7 Determination of Student Representative (09-10)

 

Referral Meeting

D1 Meeting Notice/Invitation (11-12)
Must be completed in IC!!!
D2 Procedural Safeguards
D3 Referral for Multi-Disciplinary Evaluation (11-12)
Must be completed in IC!!!
D4 Conference Summary (11-12)
Must be completed in IC!!!
 
D5 Referral Meeting Notes Page (rev. 1/2011)
D6  
 
D7 Consent to Evaluate/Re-evaluate
D8 Parent Contact Log  {May also be completed in IC}  
D9 Access to Records Log (11-12)
(Inspection of Student Records Log)
D10 Social and Developmental History  

 

Initial Evaluation Results Meeting

E1

Procedural Safeguards

E2 Conference Summary (11-12)
For reference only!!! Must Complete in IC!!!
 
E3 MDT Evaluation (w/related services reports) or Comm. Written Report w/KEG    
E4 Eligibility Forms (see eligibility forms section)    
E5 Initial Evaluation Meeting Notes (rev. 8/2011)
E6 IEP - Individual Education Plan (if applicable) (11-12)
Must be completed in IC!!!
 
E7 BIP - Behavior Intervention Plan (if applicable)  
E8 Consideration for Exclusionary and Determinant Factors Protocol
E9

Accommodations Determination 09-10 HCS

E10 HCS Confidential Notice of Special Education Student/IEP Needs  
E11 T5 - Special Transportation
E12 Participation Guidelines for Alternate Assessment    
E13 IEP Extra Goals Page
Must be completed in IC!!!
E14 Consent for Special Education and Related Services (11-12)
E15 Consent for Continuing Special Education and Related Services (8/2011)

 

Eligibility 

F1 Autism
F2 Deaf/Blind
F3 Developmental Delay (11-12)
F4 Emotional Behavior Disorder
F5 Functional Mental Disorder
F6 Hearing Impaired (11-12)
F7 Mild Mental Disability
F8 Multiple Disabilities
F9 Orthopedically Impaired
F10 Other Health Impaired
F11 Specific Learning Disability (11-12)
F12 Speech Language
F13 Traumatic Brain Injury
F14 Visually Impaired
F15 OHI Supplementary Eligibility Checklist - ADHD

 
F16

OHI Supplementary Eligibility Checklist - Health Condition

 

    

Annual Review 

G1 Meeting Notice/Invitation (11-12)
Must be completed in IC!!!
G2 Due Process Procedural Checklist for Annual Review  
G3 Procedural Safeguards
G4 Conference Summary (11-12)
For reference only!!! Must Complete  in IC!!!
 
G5 Current IEP for Review
(Must be obtained from Infinite Campus)
   
G6 IEP/BIP progress monitoring data    
G7 Draft IEP to consider    
G8 Current BIP to review (if applicable)    
G9 Draft BIP to consider (if applicable)    
G10 Current IHP to review (if applicable)    
G11 Draft IHP to consider (if applicable)    
G12

Accommodations Determination 09-10 HCS

G13 HCS Confidential Notice of Special Education Student/IEP Needs (optional)  
G14 Transportation (T-5) (if applicable)
G15 Participation Guidelines for Alternate Assessment  
G16 ILP/4 Year Plan (if applicable)    
G17 Transfer of Rights (at age 17)
G18 Destruction of Special Ed. Records (if applicable - seniors)  
G19 ACT Accommodations Consent (if applicable - sophomores going to be juniors)
G20 Medicaid forms for related services    
G21 Due Process Procedural Checklist - Preschool  
G22

Excusal Agreement (rev.09-10)

G23 Summary of Academic Achievement and Functional Performance (if applicable - graduating/exiting students)
 

  

Consent to Conduct Re-evaluation Meeting

J1 Meeting Notice/Invitation (11-12)
Must be completed in IC!!!

J2 Procedural Safeguards
J3 Conference Summary (11-12)
For reference only!!! Must Complete  in IC!!!
 
J4 Last MDT Evaluation (w/related service reports) or Comm. Written Report w/KEG    
J5  
 
J6 Consent to Evaluate/Re-evaluate
J7 Developmental and Social History Update  


Review of Re-evaluation Results Meeting

K1

Meeting Notice/Invitation (11-12)
Must be completed in IC!!!

K2 Procedural Safeguards
K3 Conference Summary (11-12)
For reference only!!! Must Complete IEP in IC!!!
 
K4 Re-evaluation Results - PR Meeting Notes Page1 (rev. 1/2011)
K5 MDT Evaluation (w/related services reports) or Comm. Written Report w/KEG    
K6 Eligibility Form(s) (see eligibility forms section)    


Reevaluation Review Meeting

L1

HCS - Re-evaluation Review

(Re-evaluation Review Summary Form/Review of Records)

L2 Meeting Notice/Invitation (11-12)
Must be completed in IC!!!

L3 Procedural Safeguards
L4 Conference Summary (11-12)
For reference only!!! Must Complete in IC!!!
 
L5 Re-evaluation Results - PR Meeting Notes Page1  (rev. 1/2011)
L6 IEP/BIP Progress Monitoring Data    
L7 Consent to Evaluate/Re-Evaluate (check "no additional information needed")
L8 Eligibility Form(s) (see eligibility forms section)    
L9 Teacher Interview/Observation for Re-evaluation Review

   

Behavior/Discipline 

M1 BIP - Behavior Intervention Plan
{also located in IC}
M2 Behavioral Observation  
M3 Behavioral Log  

M4 Archival Records Review  
M5 FBA Referral Form (Rev. 3/2011)
M6 FBA Parent/Student Interview  
M7 FBA Teacher Interview  
M8 FBA - Functional Behavior Assessment (11-12)
M9 Scatter Plot  

M10

Medication Effects Rating Scale

 

Healthcare for Special Needs 

N1 Medical Consent  
N2 Emergency Treatment Plan  
N3 Health Services Plan
N4 Program Plan Training  
N5 Special Health Care Services Record  
N6 Feeding - Eating Record  
N7 Medicaid Services Log
 
N8 Special Health Care Guidelines {4 documents in 1}
N9 Parent-Guardian Request for Specialized Physical Health Care Services  

N10 Authorization for Administration of Specialized Physical Health Care Services  

N11 Health Care Procedures Daily Log  

N12 Medication Effects Rating Scale

 

Transition 

P1 Permission Letter - Transition Survey
P2 Transition Survey - Student  
P3 Transition Survey - Parent  
P4 WTP - Policies and Procedures (HCS) (rev. 2/2010)  
P5 WTP - Parent Information & Consent Form  
P6 WTP - Parent Consent to Continue  
P7 WTP - Referral Form  
P8 WTP - Intake Form  
P9 WTP - Eligibility Form  
P10 WTP - Student Work Agreement Form  
P11 WTP - Student Expectation Sheet  
P12 WTP - Improvement Plan  
P13

Letter of Consent: Consent for OVR

P14 Letter of Consent: Other Outside Agencies (Exchange/Release of Records - KDE)  

  

 Other Forms 

Q1 Access to Records Log (11-12)
(Inspection of Student Records Log)
Q2 NIMAS Eligibility   
Q3 Request for Materials  
Q4 Rubric Template  

Q5 IC Enrollment Information (09-10)  
Q6 Consent Letter for Other Outside Agencies - HCS
Q7

KDE - Consent for Exchange-Release of Records

 
Q8

Letter of Consent: Consent for OVR

Q9 ARC Meeting Forms Checklist (09-10)
Q10

Testing Accommodations Tracking TOR List

 

Q11

Medical Exception

 
Q12

ACT Accommodations 2010-11

Q13 ESY-Extended School Year Guidelines  
Q14

Social Work/Service Coordinator Student Referral Form

 
Q15

Social Work/Service Coordinator Referral Information

 
Q16 Transportation (T-5)

Q17 Home Hospital / IEP Services Plan 
Q18  Multi-Year Accommodation Review  
Q19

Rubric Template

 

Q20 Non-Programmatic IEP Change

 

 

Section 504 

R1 Annual Review Checklist
R2 Accommodation Plan - Vertical (504-H)
R3 Accommodation Plan - Horizontal (504-H)
R4 Conference Summary Report (504-E)
R5 Notice of Sect. 504 Eligibility/Non-Eligibility (504-J)
R6 Eligibility Determination (504-G)
R7 Evaluation Summary (504-F)
R8 Manifestation Determination Review for 504 (11-12)
R9 Notice of Conference for 504
R10 Parent Notice of Sect. 504 Referral
R11 Qualified Professionals Input
R12
Student Referral Form (504-A)
R13 Consent for 504 Eligibility Evaluation
R14 Accommodation/Modification Determination (combined)

 

 

 

 

 

Key

Download in Word Document format
Download in Adobe Reader PDF format
Download in Excel Spreadsheet format
Document Help and Procedures
  Form is located elsewhere in the website or in IC.
Ref Entry is for reference only.

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

 



Revisions

Date Changes Made
3/26/12 Add "Multi-Year Accommodation Revew" document (Q18)
3/19/12 Add "ESY-Extended School Year Guidelines" (Q13)
2/23/12 Remove Form: Remove all instances of Conference Summary (old version). Add New Conference Summary Technical Assistance documents.
2/22/12 Add Form: Teacher Interview/Observation for Re-evaluation Review (L9)
2/15/12 Update Form: Re-evaluation Review (L1) to state standard.
1/30/12 Adjust title at Q7, Add form at Q6 for Consent Letter for Other Outside Agencies-HCS
12/19/11 Update "Initial Evaluation Meeting Notes Page" (E5) with new version
9/26/11 Update due process forms
8/23/11 Merge forms on RTI page with those on Forms page. 
Update RTI Parent Letter for Notification of Services and Graduation from Services (A12, A13)
 8/8/11 Update Transfer of Rights Letter (G17)
 8/8/11 Update Confidential notice of SpEd Student/IEP Needs (G13)
8/5/11 Combine forms D6 and D7 (Eval Planning + Consent to Eval/ReEval) with revised Consent to Eval/ReEval Form
 8/3/11 Revise forms C6 and D9.

 

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Henderson County Schools
1805 Second Street
Henderson, KY 42420
270 831-5000
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1805 Second Street
Henderson, KY 42420
270 831-5000
 
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