SPECIAL EDUCATION FORMS AND INSTRUCTIONS. Required Notice and Consent Forms and Instructions (Updated January 2008)

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1 SPECIAL EDUCATION FORMS AND INSTRUCTIONS Required Notice and Consent Forms and Instructions (Updated January 2008)

2 TO: FROM: SUBJECT: Superintendents Special Education Directors Regional Offices of Education Interested Parties Elizabeth Hanselman Acting Assistant Superintendent for Special Education Required Special Education Notice and Consent Forms The enclosed Special Education Forms and Instructions: Required Notice and Consent Forms and Instructions represents the January 2008 update of this document, bringing Illinois into compliance with IDEA 2004 and 23 Illinois Administrative Code Part 226. All previous versions of these forms and notices are now obsolete. These are the official versions of the state-required forms and are ready for immediate implementation. Some of the forms and notices have experienced only minor changes while others have undergone more revisions. Also, three new additional forms are included: Parent/Guardian Notification of Individualized Education Program Amendment, Parent/Guardian Excusal of an Individualized Education Program Team Member and Delegation of Rights to Make Educational Decisions. The accompanying instructions, corresponding to each form and notice, will be helpful in allowing all parties to understand the purpose and use of each form. The forms and notices may also be viewed and downloaded from our website at Additional hard copies suitable for large scale duplicating may be obtained from the ISBE Springfield office at 100 North First Street, Springfield, Illinois The forms will be available in Spanish and several other languages in the near future. Questions about the forms may be addressed to the Special Education Services Division at 217/ ISBE 34-57INST (1/08)

3 TABLE OF CONTENTS I. Foreword II. III. General Instructions for Use with All Notice and Consent Forms Notice and Consent Forms and Instructions Parent/Guardian Notification of Decision Regarding a Request for an Evaluation (34-57A) Parent/Guardian Consent for Evaluation (34-57B) Parent/Guardian Consent for Reevaluation (34-57C) Parent/Guardian Notification of Conference (34-57D) Parent/Guardian Notification of Conference Recommendations (34-57E) Parent/Guardian Consent for Initial Provision of Special Education and Related Services (34-57F) Parent/Guardian Notification of Individualized Education Program Amendment (34-57G) Parent/Guardian Excusal of an Individualized Education Program Team Member (34-57H) Parent/Guardian and Student Notification of Transfer of Rights Due to Age of Majority (34-57I) Explanation of Procedural Safeguards (34-57J) Delegation of Rights to Make Educational Decisions (34-57K) III. Appendix Least Restrictive Environment Policy Statement ISBE 34-57INST (1/08)

4 FOREWORD All school districts and cooperative agreements in Illinois have been required to provide official written notice to parents of suspected and eligible special education students regarding a broad range of topics since the advent of the Education of All Handicapped Children Act (PL ) in Use of these forms, court decisions, and amendments to federal and state statutes has resulted in the need to revise the notice requirements and forms over time. On December 3, 2004, the reauthorization of the Individuals with Disabilities Education Act (IDEA - formerly known as PL ) was signed and became effective. Revisions in this law and state Special Education regulations necessitate revisions to the notice and consent requirements and forms. The information enclosed contains a copy of each form as well as corresponding instructions concerning the purpose, use and additional information. ISBE 34-57INST (1/08)

5 PURPOSE: GENERAL INSTRUCTIONS FOR USE WITH ALL REQUIRED NOTICE AND CONSENT FORMS In 1985 Public Act (which became Article of The School Code of Illinois) required the development of uniform notices within special education to be used by all school districts. The forms in this manual have been developed to obtain required informed consent from parent(s)/guardian(s) as well as provide proper parent/guardian notification of specific types of proposed or refused actions for a child being considered for or receiving special education and related services. The forms and procedures incorporate various requirements of the Individuals with Disabilities Education Act and 23 Illinois Administrative Code 226. When completed according to the instructions, these forms provide consistency and assist school districts in providing parent(s)/guardian(s) proper notification and required explanations of proposed actions including written explanation of parent rights. FORM USE: The required Notice and Consent forms are to be used to: Notify parent/guardian when a school district receives a request for an evaluation and the district's determination regarding the request (Form 34-57A). Obtain parent/guardian consent to conduct an evaluation (Form 34-57B). Obtain parent/guardian consent to conduct a reevaluation (Form 34-57C). Notify parent/guardian of a conference(s) in which they are being requested to participate (Form 34-57D). Notify parent/guardian of recommendations made at a conference (Form 34-57E). Obtain parent/guardian consent for the initial provision of special education and related services (Form 34-57F). Notify parent/guardian of an Individualized Education Program Amendment (Form 34-57G). Obtain parent/guardian consent to excusing an Individualized Education Program team member (Form 34-57H). Notify parent/guardian and student of age of majority transfer rights (Form 34-57I). Notify parent/guardian of "Explanation of Procedural Safeguards" (Form 34-57J). Delegation of Rights to Make Educational Decisions (Form 34-57K) ISBE 34-57INST (1/08)

6 INSTRUCTIONS: 1. Local school districts may transfer the forms onto their own letterhead. Spacing may also be adjusted as needed. 2. Districts may add additional copies for local district personnel who need the information for their records. 3. Copies of all notices for a given child must be maintained in the student's official temporary record. 4. The content of the forms cannot be altered with the exception of the addition of increased copies, district letterhead, spacing adjustments, and identifying information that the district feels is necessary for the parent/guardian and/or student. Space has been left toward the top of each form for the addition of identifying information. 5. Cooperatives/districts may prepare an accompanying cover letter to personalize these required forms. Information previously explained in telephone contact can be confirmed in a cover letter or appendix to the form. 6. The forms must be completed in full being sure to complete all blanks or boxes before giving the form to the parents/guardians. 7. Parent/guardians must be provided with a signed copy of the consent form evaluation (Form 34-57B or 34-57C) and initial provision of special education and related services (Form 34-57F). 8. The Explanation of Procedural Safeguards must be provided to parents/guardians, only one time a year, except that a copy also must be given upon an initial request for an evaluation, a receipt of the first written complaint or first due process complaint to the Illinois State Board of Education, upon a disciplinary removal that constitutes a change in placement, or upon request. ISBE 34-57INST (1/08)

7 Required Notice and Consent Forms and Instructions ISBE 34-57INST (1/08)

8 PURPOSE: PARENT/GUARDIAN NOTIFICATION OF DECISION REGARDING A REQUEST FOR AN EVALUATION ISBE Form 34-57A Form 34-57A notifies the parent/guardian and the source of the request, if other than the parent or guardian, whether or not a request for an evaluation is necessary at this time and states the reasons and relevant factors for this decision. FORM USE: If an evaluation/reevaluation is determined to be necessary, this form is to be utilized in conjunction with the Parent/Guardian Consent for Evaluation or Parent/Guardian Consent for Reevaluation, whichever is appropriate to the situation. When a request for an evaluation is received by a district, a response for evaluation determination must be ascertained and parent/guardian given this notification within fourteen school days. The date on the letter should be the date it is mailed. Use of this notice does not preclude follow-up phone contacts with the parent/guardian or the inclusion of other written information with the notice. INSTRUCTIONS: 1. This form must be sent to the parent/guardian regardless of the source of the request each time a student is referred for an evaluation. 2. The individual making the request for an evaluation and their title are identified on this form. 3. State reason(s) the individual making this request for an evaluation believes this child may have a disability and need for special education services - such as academic and non-academic performance, medical information, any special programs, services, or other information as provided by the requesting individual. 4. Regardless of the determination reached, the reasons and relevant factors must be completed to indicate why an evaluation or reevaluation is deemed necessary or not necessary at this time. 5. This form should be used when it is determined that an initial evaluation or reevaluation is not necessary or when the parents and school district agree that a routine three year reevaluation is not necessary. In this situation, ISBE forms 34-57B, 34-57C, and 34-57B/C need not be completed. 6. This form should be used when it is determined that an initial evaluation or reevaluation is necessary. Additionally, if it is determined that an initial evaluation is necessary, ISBE forms 34-57B and 34-57B/C must be completed. If it is determined that a reevaluation is necessary, ISBE forms 34-57C and 34-57B/C must be completed. ISBE 34-57INST (1/08)

9 7. The documentation included in the reasons and relevant factors section could include the districts' plan to address the potential need for an evaluation in the future. For example, general education interventions may be appropriate, and if unsuccessful, the district may consider an evaluation. 8. Insert name and phone number of the local school district/special education cooperative contact person on the form. The contact person should be knowledgeable of special education procedures and communicate well with the parent/guardian. 9. Include a copy of this completed form in the student's temporary record. ISBE 34-57INST (1/08)

10 PARENT/GUARDIAN NOTIFICATION OF DECISION REGARDING A REQUEST FOR AN EVALUATION DATE: STUDENT S NAME: STUDENT S DATE OF BIRTH: Dear : (Parent(s)/Guardian(s) Name) A request for a special education evaluation was made for your child on by for the following reasons: (Name and Title of Person Making Request) Request for Initial Evaluation: A review of the request has determined that an initial evaluation is deemed necessary at this time. A review of the request has determined that an initial evaluation is not deemed necessary at this time. Request for Reevaluation: A review of the request has determined that a reevaluation is deemed necessary at this time. A review of the request has determined that a reevaluation is not deemed necessary at this time. The reasons and relevant factors for the above indicated decision include: If an evaluation was deemed appropriate or a reevaluation is necessary to determine a child continues to be a child with a disability, the process will begin upon the receipt of written informed consent from the parent/guardian. You and your child have rights and protections under the procedural safeguards and may wish to review your copy of, Explanation of Procedural Safeguards, regarding the district s decision. To discuss any concerns or if you have any questions regarding this decision, please contact: Name: Title: Phone: Sincerely, (Signature) Name: Title: ISBE 34-57A (1/08) Parent/Guardian provided a copy of the Explanation of Procedural Safeguards.

11 PARENT/GUARDIAN CONSENT FOR INITIAL EVALUATION ISBE Form 34-57B PURPOSE: Form 34-57B provides informed consent for the evaluation. FORM USE: This form is used to obtain consent to conduct initial evaluations. The evaluation process should be sufficient in scope to determine whether a student has a disability, whether the disability adversely affects his/her educational performance in the general education curriculum, and to make a determination of the nature and extent of the student s need or specially design instruction and any necessary related services. INSTRUCTIONS: 1. Form 34-57B is a two page form. 2. Informed parent/guardian consent for an evaluation is required but may only be obtained after the IEP team has completed ISBE form 34-57B/C. 3. The evaluation cannot be initiated until ten (10) days after consent is obtained. When applicable, the district may seek agreement from the parent(s) to waive the ten calendar interval requirement. 4. Delay in parent returning the notice does not change the date of referral and/or the subsequent sixty-school-day timeline. 5. Any evaluation recommended by the district must be documented on ISBE form 34-57B/C and is the financial responsibility of the district. 6. The "sources from which data will be obtained" box on ISBE form 34-57B/C should contain, at a minimum, the title of the individual who will obtain the additional data. 7. The parent is requested to list any applicable data/reports/evaluations on ISBE form 34-57B/C and provide a copy to the district 8. The IEP team may use multiple copies of ISBE form 34-57B/C as necessary to document their determinations. 9. This form must be used to obtain parent consent anytime an IEP team recommends an initial evaluation. The parent/guardian checks the appropriate consent box and must sign and date the document. ISBE 34-57INST (1/08)

12 PARENT/GUARDIAN CONSENT FOR INITIAL EVALUATION DATE: STUDENT S NAME: STUDENT S DATE OF BIRTH: Dear : (Parent(s)/Guardian(s) Name) Each school district shall ensure that a full and individual evaluation is conducted for each child being considered for special education and related services. The purpose of an evaluation is to determine: Whether the child has one or more disabilities; The present levels of academic achievement and functional performance of the child; Whether the disability is adversely affecting the child s education; and, Whether the child needs special education and related services. An evaluation considers domains (areas related to the suspected disability) that may be relevant to the educational problems experienced by the individual child under consideration. The nature and intensity of the evaluation, including which domains will be addressed, will vary depending on the needs of your child and the type of existing information already available. The IEP Team, of which you are a member, determines the specific assessments needed to evaluate the individual needs of your child. Within 60 school days from the date of parent/guardian consent, a conference will be scheduled with you to discuss the findings and determine eligibility for special education and related services. The IEP team must complete page 2 of this form prior to obtaining parental consent for evaluation. PARENT/GUARDIAN CONSENT FOR INITIAL EVALUATION I understand the school district must have my consent for the initial evaluation. If I refuse consent for an initial evaluation, the school district may, but is not required to, pursue override procedures through due process. If the school district chooses not to pursue such procedures, the school district is not in violation of the required evaluation procedures. I understand my rights as explained to me and contained in the Explanation of Procedural Safeguards. I understand the scope of the evaluation as described on page 2 of this form. I give consent I do not give consent to collect and/or review the evaluation data as described on page 2 of this form. Date: Parent/Guardian Signature: ISBE 34-57B (1/08) Page 1 of 2

13 Student Name: Date: / / PARENT/GUARDIAN CONSENT FOR EVALUATION Identification of Needed Assessments This form must be completed by the IEP Team DOMAIN RELEVANT Yes No Academic Achievement Current or past academic achievement data pertinent to current educational performance. EXISTING INFORMATION ABOUT THE CHILD ADDITIONAL EVALUATION DATA NEEDED SOURCES FROM WHICH DATA WILL BE OBTAINED Functional Performance Current or past functional performance data pertinent to current functional performance Cognitive Functioning Data regarding cognitive ability, how the child takes in information, understands information and expresses information Communication Status Information regarding communicative abilities (language, articulation, voice, fluency) affecting educational performance. Health Current or past medical difficulties affecting educational performance. Hearing/Vision Auditory/visual problems that would interfere with testing or educational performance. Dates and results of last hearing/visual test Motor Abilities Fine and gross motor coordination difficulties, functional mobility, or strength and endurance issues affecting educational performance. Social/Emotional Status Information regarding how the environment affects educational performance (life history, adaptive behavior, independent function, personal and social responsibility, cultural background). ISBE B/C (1/08)

14 PARENT/GUARDIAN CONSENT FOR REEVALUATION ISBE Form 34-57C PURPOSE: Form 34-57C provides informed consent for the reevaluation. FORM USE: This form is used to obtain: Consent to conduct a reevaluation; or Obtain agreement that no additional data are needed. This form must be used to obtain parental agreement with the IEP team's determination that no additional evaluation data is needed. When the IEP team determines no additional evaluation is needed, then parental agreement and not parental consent is required INSTRUCTIONS: 1. Form 34-57C is a two page form. 2. Parent/guardian consent or agreement may only be obtained after the IEP team has completed ISBE form 34-57B/C. Upon the IEP team making a decision, the parent/guardian checks the appropriate agreement or consent box and must sign and date the document. 3. The reevaluation cannot be initiated until ten (10) days after consent is obtained. When applicable, the district may seek agreement from the parent(s) to waive the ten calendar interval requirement. 4. The date of the meeting that considered the most recent evaluation results determines the three-year reevaluation due date. The meeting conducted to consider the current reevaluation results must be no later than the date of the meeting convened three years prior. 5. Any evaluation recommended by the district must be documented on ISBE form 34-57B/C and is the financial responsibility of the district. 6. The "additional evaluation data needed" box on ISBE form 34-57B/C does not need to include the names of specific diagnostic instruments but should include general information regarding the type of instruments and/or procedures to be utilized. 7. The "sources from which data will be obtained" box on ISBE form 34-57B/C should contain, at a minimum, the title of the individual who will obtain the additional data. ISBE 34-57INST (1/08)

15 PARENT/GUARDIAN CONSENT FOR REEVALUATION DATE: STUDENT S NAME: STUDENT S DATE OF BIRTH: Dear : (Parent s/guardian s Name) Each school district shall ensure that a reevaluation is conducted for each child being reconsidered for special education and related services. A reevaluation must occur at least once every three years unless the parent and school district agree that a reevaluation is not needed. A reevaluation may not occur more than once a year, unless the parent and school district agree it is necessary. The purpose of a revaluation is to determine: Whether the child continues to have one or more disabilities; The present levels of academic achievement and functional performance of the child; Whether the disability is adversely affecting the child s education Whether the child continues to need special education and related services; and Whether any additions or modifications to the child s special education and related services are needed to enable the child to meet the measurable annual goals in the Individualized Education Program (IEP) and to participate appropriately in the general curriculum, extracurricular activities and other nonacademic activities. An evaluation considers domains (areas related to the suspected disability) that may be relevant to the educational problems experienced by the individual child under consideration. The nature and intensity of the evaluation, including which domains will be addressed, will vary depending on the needs of your child and the type of existing information already available. The IEP Team, of which you are a member, determines the specific assessments needed to evaluate the individual needs of your child. Upon completion of your child s evaluation, a conference will be scheduled with you to discuss the findings and determine eligibility for special education and related services. The IEP team must complete page 2 of this form prior to obtaining parental consent for a reevaluation. If the IEP team determines no additional evaluation is needed, then parental agreement and not parental consent is required. PARENT/GUARDIAN AGREEMENT THAT NO ADDITIONAL DATA IS NEEDED I understand the school district is not required to conduct a reevaluation to determine if my child continues to be a child with a disability. However, I may request the school district to conduct the reevaluation. I agree I do not agree with the determination that no additional data is needed. Date: Parent/Guardian Signature: PARENT/GUARDIAN CONSENT TO COLLECT ADDITIONAL EVALUATION DATA I understand the school district must have my consent for the reevaluation. If I refuse consent, the school district may, but is not required to, pursue override procedures through due process. If the school district chooses not to pursue such procedures, the school district is not in violation of the required evaluation procedures. Furthermore, I understand that if I fail to respond to the request for consent, the school district may pursue the reevaluation if the school district made reasonable efforts to obtain such consent. I understand my rights as explained to me and contained in the Explanation of Procedural Safeguards. I understand the scope of the evaluation as described on page 2 of this form. I give consent I do not give consent to collect the additional evaluation data as described on page 2 of this form. Date: Parent/Guardian Signature: Page 1 of 2 ISBE 34-57C (1/08)

16 PARENT/GUARDIAN NOTIFICATION OF CONFERENCE ISBE Form 34-57D PURPOSE: Form 34-57D informs the parent(s)/guardian(s) of the date, time, and location of the conference to discuss the educational needs of their child, the purpose of that conference, and those persons, identifying name and/or title, who have been invited to attend. FORM USE: This form provides the parent(s)/guardian(s) notice each time a conference is scheduled to: Review a child's educational status and determine what additional data, if any, are needed to complete an evaluation; Review an evaluation to determine, reconsider or change a child's eligibility for special education and related services; Review a child's eligibility and needs for special education and related services ; Review and/or develop a child's IEP and determine the child s educational placement; Consider postsecondary goals and transition services (beginning at age 14 1/2); Consider the relatedness of a child's disability to behaviors that resulted in a disciplinary code violation; Consider the need for a functional behavioral intervention assessment for the child; Review a need to create or revise a behavior intervention plan for the child; Review the child s recent change of placement due to suspension Determine the location of the interim alternative educational setting; Review anticipated date of graduation; Other. PARTICIPANTS: Insert the names and/or titles of all individuals on the IEP team that will be invited for the purpose(s) identified on the form. Be sure to list all required personnel including students age 14 ½ and older when addressing needed transition services. ADDITIONAL INSTRUCTIONS: 1. This form must be dated and mailed at least ten (10) calendar days prior to the scheduled conference. When applicable, the district may seek agreement from the parent(s) to waive the ten calendar interval requirement. ISBE 34-57INST (1/08)

17 2. A choice of dates and times may be offered to the parent/guardian either by letter or phone prior to sending this notice. In such cases, this form can be used to confirm selected time/date. 3. The conference for which this notice is sent may be multipurpose. If this is the case, ALL boxes which apply or which may apply must be checked to ensure documentation of notice. For adequate notice to occur, parents must be notified in advance of any intended purpose(s) of a conference. 4. The form should list all individuals and/or their titles who are being invited to the conference. If any district personnel are unable to attend, the conference must still include the necessary participants. 5. Insert name and telephone number of the local district/special education cooperative contact person on the form. The contact person should be knowledgeable of special education procedures and communicate well with the parent/guardian. 6. Include a copy of this completed form in the student's temporary record. ISBE 34-57INST (1/08)

18 PARENT/GUARDIAN NOTIFICATION OF CONFERENCE DATE: STUDENT S NAME: STUDENT S DATE OF BIRTH: Dear : (Parent(s)/Guardian(s) Name) In order to discuss the educational needs of your child, you are invited to attend and IEP conference meeting to be held:: Date: Time: Location: You are a participant on the IEP Team which will meet to address the purpose as indicated in the next section. You have the right to bring other individuals who have knowledge or special expertise regarding your child. If you plan to bring other individuals, please notify the individual indicated below prior to the meeting so arrangements and accommodations for participants can be made. If these meeting arrangements are not agreeable and/or you require an interpreter or translator, please contact the individual indicated below. The purpose of this conference is to : Review your child s educational status and determine what additional data, if any, are needed to complete your child s evaluation. Review your child s recent evaluation to determine, reconsider or change your child s eligibility for special education and related services. Review your child s eligibility and needs for special education and related services. Review and/or develop your child s Individualized Education Program (IEP) and determine the child s educational placement. Consider postsecondary goals and transition services (beginning at age 14½). Consider relatedness of disability to disciplinary code violation(s). Consider the need for a functional behavioral assessment for your child. Review a need to create or revise a behavior intervention plan for your child. Review your child s recent change of placement due to suspension. Determine the location of the interim alternative educational setting. Review anticipated date of graduation. Other The invited individuals and/or their titles are listed below. If one of the required individuals listed below is unable to attend due to unforeseen circumstances, the district should designate an appropriate and suitable replacement to attend the IEP meeting. Any student age 14 ½ and older must be invited to any meeting if the purpose of the meeting is to consider transition service needs. Name and/or Title (General Education Teacher) Name and/or Title (Special Education Teacher) Name and/or Title (LEA Representative) Name and/or Title Name and/or Title Name and/or Title Name and/or Title Name and/or Title You and your child have protection under the procedural safeguards of special education regulations. The school district must provide you a copy of Explanation of Procedural Safeguards once a year. Please contact the district if you need a copy of Explanation of Procedural Safeguards. Name: Title: Phone: Sincerely, (Signature) Name: ISBE 34-57D ( ) Title:

19 PARENT/GUARDIAN NOTIFICATION OF CONFERENCE RECOMMENDATIONS ISBE Form 34-57E PURPOSE: Form 34-57E summarizes and notifies the parent/guardian of any recommendations made at the conference(s). FORM USE: At the conference(s), it will be determined that the student: Is eligible or continues to be eligible for special education and related services as listed in the IEP; Is not eligible for special education and related services as listed in the IEP; Requires a change in eligibility as listed in the IEP conference summary report; Will receive the special education and related services as listed in the IEP; Requires a change of special education and/or related services/educational placement as indicated in the IEP; Requires a placement in an alternative educational setting as documented in the IEP; Will be discontinued from special education and related services due to determination of ineligibility or reaching the age of 22; Is recommended for graduation; Will be assessed with the IAA; Other. ADDITIONAL INSTRUCTIONS: 1. ALL boxes that apply should be checked which summarize recommendations determined at the conference(s). 2. Insert name and phone number of the local district/special education cooperative contact person on the form. The contact person should be knowledgeable of special education procedures and communicate well with the parent/guardian. 3. When applicable, the district may seek agreement from the parent(s) to waive the ten calendar interval requirement prior to initiating or changing a child s placement. 4. Include a copy of this completed form in the student's temporary record. ISBE 34-57INST (1/08)

20 PARENT/GUARDIAN NOTIFICATION OF CONFERENCE RECOMMENDATIONS Date: Student s Name: Student s Date of Birth: Dear, (Parent s/guardian s Name) The purpose of this letter is to provide you with notification of the educational recommendation developed for your child at the conference held on at. At this conference it was determined that your child: Is eligible or continues to be eligible for special education and related services as listed in the IEP (Eligibility Determination: ) Is not eligible for special education and related services. Requires a change in eligibility, as listed in the IEP conference summary report. Will receive the special education and related services as listed in the IEP. Requires a change of special education and/or related services/educational placement as indicated in the IEP. Requires a placement in an alternative education setting as documented in the EIP. Will be discontinued from special education and related services due to determination of ineligibility or reaching the age of 21. Is recommended for graduation. Will be assessed with the Illinois Alternate Assessment (IAA). The IAA is aligned with the Illinois Learning Standards (grade level academic content) and scored against alternate achievement standards. Other CHECK ONE, WHEN APPLICABLE: I understand that as soon as possible following development of the IEP, but not more than ten (10) calendar days, special education and related services will be provided to my child in accordance with the IEP, and I agree to waive the requirement of a ten calendar day interval before an initial or change in placement occurs. I do not agree to waive the requirement of a ten calendar day interval before an initial or change in placement occurs. (Date) (Parent/Guardian Signature) Please refer to your copy of the IEP conference summary report which contains the information used in making these recommendations. Please review the parental rights information the Explanation of Procedural Safeguards. If you wish to discuss any concerns or have questions regarding your rights or this information, please contact: Name: Title: Phone: Sincerely, Name: (Signature) ISBE 34-57E (1/08) Title:

21 PURPOSE: PARENT/GUARDIAN CONSENT FOR INITIAL PROVISION OF SPECIAL EDUCATION AND RELATED SERVICES ISBE Form 34-57F Form 34-57F provides the parent/guardian consent for initial special education and related services. FORM USE: Form 34-57F is used to obtain a parent/guardian s voluntary written consent when a student has been determined eligible for special education and related services, an IEP has been developed, and the student has been recommended for initial special education services. It is also used if a parent/guardian does not give consent for special education and related services programming as indicated in the IEP and exempts the local school district of any violation of a free and appropriate public education (FAPE) for the child. ADDITIONAL INSTRUCTIONS: 1. The district must ensure that parents understand that the services will be provided in accordance with the conference recommendations and the date of initiation in the IEP. 2. The initial provision of services must occur as soon as possible, but no more than ten (10) calendar days, following development of the IEP. In some instances, such as a child turning three, services may have to begin prior to the ten calendar days. When applicable, the district may seek agreement from the parent(s) to waive the ten calendar interval requirement. 3. Insert name and phone number of the local school district/special education cooperative contact person on the form. The contact person should be knowledgeable of special education procedures and communicate well with the parent/guardian. 4. Include a copy of this completed form in the student's temporary record. ISBE 34-57INST (1/08)

22 PARENT/GUARDIAN CONSENT FOR INITIAL PROVISION OF SPECIAL EDUCATION AND RELATED SERVICES DATE: STUDENT S NAME: STUDENT S DATE OF BIRTH: Dear, (Parent s/guardian s Name) At a recent conference your child was recommended for initial provision of special education and related services and an Individualized Education Program (IEP) was developed. Before a school district can provide the special education services described in your child s IEP, your informed written consent is required. Your consent is voluntary and you may revoke your consent at anytime. If you revoke consent, it does not negate an action that occurred after the consent was given and before it was revoked. CHECK ONE: I give consent For the initial special education and related services of my child as indicated on the Individualized Education Program (IEP). The proposed special education and related service(s) have been fully explained to me and are consistent with the IEP developed for my child. I understand that my consent is voluntary. I understand that my consent is not required for continued services or change in services/placement. At least annually, I will be given reasonable opportunity for comment on and input into my child s IEP. I received a copy of the Explanation of Procedural Safeguards which have been fully explained to me by school personnel, including the procedures for requesting an impartial due process hearing. I understand that as soon as possible following development of the IEP, but not more than ten (10) calendar days, special education and related services will be provided to my child in accordance with the IEP. I do not give consent For the special education and related services of my child as indicated in the Individualized Education Program (IEP). I understand that the school district will not be in violation of the requirement to make available a free appropriate public education for my child if I refuse to give consent. I have received Date: Copy of the IEP Eligibility Summary Copy of the Individualized Education Program (IEP) Other Parent/Guardian Signature: If you have any questions concerning this process or require additional information regarding your and your child s rights, please contact: Name: Title: Phone: Sincerely, (Signature) Name: ISBE 34-57F (1/08) Title:

23 PARENT/GUARDIAN NOTIFICATION OF INDIVIDUALIZED EDUCATION PROGRAM AMENDMENT ISBE Form 34-57G PURPOSE: Form 34-57G notifies the parent/guardian of changes that have been made to the IEP when the school district and the parent/guardian agree not to reconvene the IEP meeting for the purposes of making changes to a student s IEP. A written document to amend the student s current IEP must be completed. FORM USE: Form 34-57G is used to provide written documentation of IEP changes. ADDITIONAL INSTRUCTIONS: 1. It is recommended that this form be used only for IEP changes that do not significantly change a student s services and/or placement. 2. The form should be used to document that the parent and school district agreed to make changes to an IEP without reconvening the IEP meeting. 3. This can not take the place of an annual review meeting. 4. The form must be attached to the child s IEP. 5. The district should communicate with the parent/guardian about the changes to the IEP. The date of contact, district personnel and title, and the mode of communication should be documented on the form. 6. The actual changes and an explanation of the changes should be documented. The district should ensure that the written documentation of the changes reflects the communication that took place with the parent/guardian. 7. Include a date that the changes will begin. 8. The name, title, and phone number of a district contact person should be included. 9. This form must be attached to the student s current IEP. 10. A copy of the student s current IEP, along with this form should be given to the parent/guardian. ISBE 34-57INST (1/08)

24 PARENT/GUARDIAN NOTIFICATION OF INDIVIDUALIZED EDUCATION PROGRAM AMENDMENT DATE: STUDENT S NAME: STUDENT S DATE OF BIRTH: *Use this form to document that the parent and school district agreed to make changes to an IEP without reconvening the IEP meeting. This can not take the place of an annual review meeting and the form must be attached to the child s IEP. Dear : (Parent s/guardian s Name) On you and (Date of Contact) (School District Personnel and Title) met in person spoke on the phone exchanged s exchanged faxes and agreed to make the following changes to your child s current IEP as indicated below: Changes and Explanation of Changes: Enclosed is a copy of your child s current IEP along with the changes. The changes will begin on be implemented in your child s current placement. and If you disagree with the changes, want to request a meeting to discuss the changes above, or want to request a copy of Explanation of Procedural Safeguards, please contact the person indicated below with any questions in regards to the above changes, Name: Title: Phone: Sincerely, ISBE 34-57G (1/08) (Signature) Name: Title:

25 PARENT/GUARDIAN EXCUSAL OF AN INDIVIDUALIZED EDUCATION PROGRAM TEAM MEMBER ISBE Form 34-57H PURPOSE: Form 34-57H provides the written documentation for the excusal of one of the required team members. A required team member is described in the regulations as, the general education teacher, special education teacher, LEA representative, and/or an individual who can interpret the instructional implications of evaluation results, who may be a member of the team already identified. A school district and the parent/guardian may agree, in writing, to excuse an IEP team member in whole or part under the following circumstances: FORM USE: If the attendance of the member is not necessary because the member s area of curriculum or related services is not being modified or discussed in the meeting, or If the meeting does involve a modification to or discussion of the special and related services but the team member submits, in writing, input into the development of the IEP prior to the meeting. Form 34-57H is used to provide written documentation for the excusal of an IEP team member. Allowing team members to be excused from attending an IEP meeting is intended to provide additional flexibility to parents in scheduling meetings. It is important to emphasize that the IEP team should consist of individuals who are necessary to develop an IEP taking into account the best interests of the child and his/her needs. Although, this form is to be used to document an excusal of only the required team members, the district should make every effort to ensure that other team members are present at the meeting. If one of the other invited individuals is unable to participate, that team member is encouraged to submit, in writing, input into the development of the IEP prior to the meeting. ADDITIONAL INSTRUCTIONS: 1. The district should communicate with the parent/guardian about the excusal prior to sending the written notice. The type of communication should be noted on this form. 2. This notification should be received by the parent/guardian prior to the meeting. 3. Some instances may not allow prior notice (e.g. staff absent on the day of the meeting). In these instances, the parent can agree to continue with the meeting by agreeing to excuse the team member(s) or may request that the meeting be rescheduled. ISBE 34-57INST (1/08)

26 4. Indicate the appropriate excusal section on the form. The IEP team member s name and area should be included on the document. 5. The parent/guardian s signature is required to demonstrate agreement with the excusal of the IEP team member. 6. This form should include the name, title, and phone number of a district contact person. 7. Once excusal of a team member, whose curriculum or services will be discussed, is approved, the excused member must submit, in writing, input into the development of the IEP prior to the meeting. 8. A signed copy of this notice and the written input of the excused team member should be attached to the student s IEP. 9. A school district should not routinely excuse IEP team members as this would not be in compliance with the regulations. ISBE 34-57INST (1/08)

27 PARENT/GUARDIAN EXCUSAL OF AN INDIVIDUALIZED EDUCATION PROGRAM TEAM MEMBER Date: Student s Name: Student s Date of Birth: Dear : (Parent s/guardian s Name) An IEP Team meeting is scheduled for your child on. We met in person spoke on the phone exchanged s exchanged faxes and agreed to the following: Allowing team members to be excused from attending an IEP meeting is intended to provide additional flexibility to parents in scheduling meetings. The presence and participation of the required Individualized Education Program (IEP) team member(s) identified below is/are not necessary and has/have been excused from being present and participating in the meeting. The team member is described in the regulations as, the general education teacher, special education teacher, LEA representative, and/or an individual who can interpret the instructional implications of evaluation results, who may be a member of the team already identified. Content area of excused member not discussed at the meeting Yes NA The school district and parent/guardian agree the following member(s) is/are not required to attend the IEP meeting in whole or in part because the individual s area of curriculum, content or related service will not be discussed or modified. Name and Area Name and Area Name and Area Name and Area Content area of excused member discussed at the meeting Yes NA The school district and parent/guardian agree the following member(s) may be excused from attending the IEP meeting in whole or in part, when the meeting involves a modification to or discussion of the member s area of the curriculum or related services, if the member submits input into the IEP in writing to the parent and to the team prior to the meeting. Name and Area Name and Area Name and Area Name and Area Parent/Guardian Signature Authorized School Personnel Signature Date Date If you have any questions or would like a copy of Explanation of Procedural Safeguards, please contact: Name: Title: Phone: Sincerely, ISBE 34-57H (1/08) (Signature) Name: Title:

28 PARENT/GUARDIAN AND STUDENT NOTIFICATION OF TRANSFER OF RIGHTS DUE TO AGE OF MAJORITY ISBE Form 34-57I PURPOSE: Form 34-57I provides the parent/guardian and student notice of the transfer of rights when the student reaches the age of majority (18 years of age). FORM USE: Form 34-57I must be sent to the parent/guardian and student one year prior to the student's eighteenth birthday. This provides notice that the transfer will occur automatically on the student's eighteenth birthday. ADDITIONAL INSTRUCTIONS: 1. All of the parental rights discussed in this document will transfer to the eligible student at the age of majority, unless the school district is notified otherwise. 2. If a student with a disability has been determined to be incompetent under State law, the student's parent/guardian must provide the district with a copy of the court order. This document will identify the individual designated to represent the student's educational rights. 3. The parent/guardian retains the right to receive ten (10) day notice prior to the date of any conference. ISBE 34-57INST (1/08)

29 PARENT/GUARDIAN AND STUDENT NOTIFICATION OF TRANSFER OF RIGHTS DUE TO AGE OF MAJORITY DATE: STUDENT S NAME: STUDENT S DATE OF BIRTH: Dear and (Parent s/guardian s Name) (Student s) When a student with a disability reaches 18 years of age (the age of majority under State law) all educational rights transfer from the parent(s)/guardian(s) to the student. The Individuals with Disabilities Education Act (IDEA) requires that both parent(s)/guardian(s) and the student receive notice of the transfer of educational rights one year prior to the student s eighteenth birthday. However, the parent(s)/guardian(s) will continue to receive the ten day notice prior to the date of any special education meeting after the student turns eighteen. On the date of age of majority, all rights pertaining to the special education program/services shall transfer from the parent(s)/guardian(s) to the student unless the school district is otherwise notified (e.g. Delegation of Rights to Make Educational Decisions form). Student s legal name: Date of age of majority: CHECK ONE: This serves as your one (1) year prior notice of the anticipated transfer of educational rights to the above named student under IDEA. This serves as your notice that all educational rights under IDEA have been transferred to the above named student. If you have any questions concerning this procedure or require an additional copy of your rights, the Explanation of Procedural Safeguards, please contact: Name: Title: Phone: Sincerely, (Signature) Name: Title: ISBE 34-57I (1/08)

30 PARENT/GUARDIAN EXPLANATION OF PROCEDURAL SAFEGUARDS ISBE Form 34-57J PURPOSE: The Explanation of Procedural Safeguards summarizes and notifies the parent/guardian regarding the procedural safeguards to which they and their child are entitled. FORM USE: The Explanation of Procedural Safeguards must be utilized upon: An initial request for an evaluation; Upon receipt of the first written State complaint; Upon receipt of the first due process complaint; Upon a disciplinary removal that constitutes a change in placement; and Upon parental request. ADDITIONAL INSTRUCTIONS: District and cooperative procedures must be developed and implemented to provide parents/guardians with a copy of the procedural safeguards at the appropriate times noted above. ISBE 34-57INST (1/08)

31 NOTICE OF PROCEDURAL SAFEGUARDS FOR PARENTS/GUARDIANS OF STUDENTS WITH DISABILITIES (As of January 2008) As the parent/guardian of a student or adult student with a disability who is receiving or may be eligible to receive special education and related service, you have rights which are safeguarded by state and federal law. The rights to which you are entitled are listed below. A full explanation of these rights is available from your child s school district. Please review this document carefully and contact the district if you have questions or need additional clarification regarding your child s services or the procedural safeguards available to you. The notice of your procedural safeguards must be made available to you only one time a year, except that a copy also must be given upon an initial request for an evaluation, a receipt of the first written complaint or first due process complaint to the Illinois State Board of Education, upon a disciplinary removal that constitutes a change in placement, or upon request. Additional information regarding your rights is available on the ISBE website: in a document entitled, A Parents Guide: The Educational Rights of Students with Disabilities. PRIOR WRITTEN NOTICE The local district is required to provide you with prior written notice: When the district proposes to initiate or change the identification, evaluation, educational placement or the provision of a free, appropriate public education to your child; or When the district refuses to initiate or change the identification, evaluation, educational placement or the provision of a free, appropriate public education to your child; or One year prior to your child reaching the age of majority (18 years of age). All educational rights transfer from parent(s)/guardian(s) to the student unless determined otherwise. The written notice must be provided at least 10 days prior to the proposed or refused action and must include: A description of the action proposed or refused by the district, an explanation of why the district proposes or refuses to take action, and a description of any other options the district considered and the reasons why those options were rejected; A description of each evaluation procedure, test, record or report the district used as a basis for the proposed or refused action; A description of any other factors which are relevant to the district s proposal or refusal; A statement that you have due process rights and, if the notice is not an initial referral for evaluation, the means by which a copy of the procedural safeguards can be obtained; and Sources for you to contact to obtain assistance in understanding your due process rights.

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