County Forms
These templates are filled in with general Sevier County information, but otherwise blank. They are in Microsoft Word, version 6.0 (except for the blank IEP). If you have this version or later on the computer you are connecting with, you can save the template to your hard drive, then modify it from there. If you are using MS Works instead, you'll need to save to a disk or just download from a computer that does have MS Word.
 Enrollment Card with boxes for emergency information, last school attended, who can sign out the student, and the textbook agreement
- Parent Survey, for guardians to rate the evaluation and Special Education planning process
- Parent Permission for Comprehensive Screening, for the guardians to indicate permission (or not) for the school to screen their child
- Sevier County Schools Student Referral for Special Education, the first steps in getting a general education student Special Education services
- Assessment Report, a cover sheet for the test administrator to indicate results, recommendations, and comments from the assessment testing sessions
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Specific Learning
Disabilities Eligibility Documentation, notice boxes 4a and 4b especially.
Sevier County's interpretation of an appropriate time period for an intervention
is 6 to 12 weeks.
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Documentation of Medical Diagnosis Form, for
doctors to indicate a diagnosis/prognosis for students with health/orthopedic
impairments, attention deficits, or traumatic brain injury (in MS Word, and as a
PDF file.)
- Eligibility Report, to document eligibility for Special Education services and the
instructions for completing it. Save it to your own hard drive because depending on your default printer's setup, you may have to reset a few tabs to get the check boxes to line up. Or here is the
Eligibility Report as a PDF file.
- Release of Information, the letter guardians sign so Sevier County can either send or get a student's Special Education records;
the same file in PDF format
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Physical/Health Impaired Evaluation Summary in Word,
as a PDF file, and
as an MS Works document
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Continuation of Educational Services
in MSWord and as a
PDF File, so guardians can indicate previous Special Education enrollment when their child moves around or out of Sevier County
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Special Education Exit Form, for a student reaching 18 years old and choosing to terminate Special Education services.
The same form as a PDF file.
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Support Team Forms, for
general educators to document interventions prior to special education referral, in MS Word, and as a
PDF file. The following forms match the latest State revisions from
September 2004. (You need to be using at least version MS Word 97 or many of the forms will not open/print correctly. The forms below are also available in PDF format.)
 Page 1, Instructions
- Page 2, Regular Education Referral
to Student Support Team
- Page 3, Regular Education
Documentation of Reading Interventions
- Page 4, Regular Education
Documentation of Math Interventions
- Page 5, Regular Education
Documentation of Behavioral Interventions
- Page 6, Regular Education
Documentation of Interventions (summary)
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Page 7, S-Team Tracking Form (for a
specific student)
- Page 8, S-Team Tracking Form
(summary for the school year)
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Regular Education
Interventions Checklist, may be used in place of pages 3-5 above, when a mix
of interventions are being applied;
the same file as a PDF
-
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Reevaluation Package Guidelines, instructions for completing the reevaluation summary, in MS Word, and as a
PDF file. The following forms match the latest State revisions from
September 2004. (You need to be using at least version MS Word 97 or many of the forms will not open/print correctly. The forms below are also available in PDF format.)
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Preparation for Reevaluation IEP Team Meeting in Word, and
as a PDF
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Notice of Reevaluation IEP Team Meeting and Prior Written Notice in Word and
as a PDF
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Parent Input for Reevaluation in Word and
as a PDF file
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Classroom Teacher Observation Form in Word and
as a PDF
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Special Education Teacher Observation Form in Word and
as a PDF file
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Related Service Provider Observation Form in Word and
as a PDF file
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Reevaluation IEP Team Report, Sections I and II in Word and
as a PDF file
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Speech/Language Assessment Results for Reevaluation Section III in Word and
as a PDF file
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Speech/Language Assessment Results (page 2), Fluency and Voice Assessment for Reevaluation Section III in Word and
as a PDF file
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Speech/Language Assessment Results (page 3), Hearing Assessment for Reevaluation Section III in Word and
as a PDF file
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Speech/Language Assessment Results, Vision Assessment for Reevaluation Section III in Word and
as a PDF file
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Psycho-Educational Assessment Results for Reevaluation Section III in Word and
as a PDF file
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Medical/Other Health Impairment Assessment Results for Reevaluation Section III in Word and
as a PDF file
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Social/Emotional/Behavioral Assessment Results for Reevaluation Section III in Word and
as a PDF file
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Adaptive Behavior Assessment Results for Reevaluation Section III in Word and
as a PDF file
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Preschool Assessment Results for Reevaluation Section III (if needed) in Word and
as a PDF file
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Current Classroom Based Assessment and IEP Review, Reevaluation Section IV in Word and
as a PDF file
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Reevaluation Summary and Recommendations, Section V in Word and
as a PDF file
- Initial Evaluation Timeline Waiver. Also notice that the instruction for completing it (in MS Word or as a
PDF file) require coordination with Nashville.
- Medication Administration Form, for parents to allow their child to be given or take a prescription or over-the-counter medication at school. Please see
Use of Medicines by Students, BP 627 for the complete procedure.
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Report of Accidents and Injuries (to Students); original to Central Office, copy kept at school
- Package for Requesting Homebound Services
These are in Adobe PDF file format.
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Cover Letter to Parents and Students Requesting Homebound Services, from the Director of Special Education
- Request for Homebound Services, the form to complete
- Homebound Medical Form, the doctor's medical evaluation (for use with other-than pregnancy-related requests)
- Homebound for Pregnancy Form, the physician's verification
- Homebound for Pregnancy Information, two pages of questions, answers, and advice
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Release of Information, permission for the school system to get information to and from the physician
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Parent Acknowledgement, consent for the teacher to come to the home
- SCS Anecdotal Record, for documenting day-to-day incidental reports to students' records. You may want to print this one on green paper to match what is currently in the files.
- Information for SPED Census, the form (in MS Word) for faxing to Rebecca Campbell after programming changes involving any Special Education student
- Special Education Staffing Report, for building-level IEP Monitors to update the Trula Lawson Center records monthly (by faxing to Rebecca Campbell after each month's updates)
- Request for Special Transportation, complete and fax to Rebecca Campbell
- Field Trip Permission to Parents one fill-in-the-blanks model to send home. Also see
Field Trips and Excursions, Sevier County School Board Policy 515.
- Tracking Calls Home one way, or
a second way to record talks with parents
- Note to Home, a progress update to send home with the student each day
- CDC/SDC Meeting Record, a table-structured conference form, for keeping all staff working with the same students informed of the same highlights or actions needed
- Special Education Class Roster, single page access to students' contact information, goals, modifications, related services, etc.
- Class Listing of Accommodation/Modifications, for the caseload manager to share with the students' general education teacher(s)
- Class Listing of Accommodation/Modifications, for the caseload manager to share with the students' general education teacher(s) (same file as above, but as a PDF)
- Caseload Management Chart, another single-look at dates, background of the students on your caseload
- Group Goal/Objective Matrix, for setting up group instruction by motor, adaptive, communication, social, and cognitive goals
- Assessment Summary, 1-page tracking of a single student's assessment progress over her or his school career
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Inclusion Schedule, for weekly tracking of rooms students are to be in for certain periods
- Four Year Educational Plan, a worksheet to plan credits for grades 9 through 12
- CDC Transition Planning Worksheet for 17 - 21 year olds, to track by name or total number your students' transition to work progress
- CDC Program Tracking for High School, a checklist to help CDC teachers keep up with the paper work and other to-dos month-to-month
- CDC Program Tracking for Primary, Elementary, Middle, and Intermediate School, a checklist to help CDC teachers keep up with the paper work and other to-dos month-to-month
- Review of Progress Toward IEP Goals, for use in drafting six week progress reports
- Lesson Plan Form,
an MS Word template covering what is required in lesson plans for
nontenured teachers
- Student's Skill Summary, another way of reporting progress on IEP goals
- IEP Progress Report Cover Sheet, for the parent and teacher to send and receive comments each grading period
- Behavior Plan in Word, as commonly used in Sevier County when necessary; also
as a PDF file
- Therapeutic
Crisis Intervention Restraint Incident Form in PDF format, for documenting
student restraints that last more than a couple minutes
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FBA Behavior Support Plan in Word,
as a PDF, and
in MS Works. Similar to the one directly above.
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Manifestation Determination Form, the documentation of review needed for
determining if a student's behavior was or was not a manifestation of the
disability (in MS Word, and as a PDF file.)
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Report of
Suspension Form to be used for all Sevier County student suspensions.
(Here is the same file as a PDF.)
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Educational Status of Detainees in Sevier County, an MS Word form for tracking students who are incarcerated. (Also see
Educating Incarcerated Youth with Disabilities in Sevier County for questions and answers on the education rights of special education students who are in jail.)
You'll need Adobe Acrobat Reader for the following three files. If you don't have Acrobat Reader already loaded, you can download it from here. Printer definition files [PDFs] will print out with exactly the same look and pagination as the original, paper forms.
- Application for Employment with the Sevier County School System, for teaching assistants or others requesting work that does not require certification
- Application for Teaching Employment with the Sevier County School System, for those requesting teaching or other certified positions
- Certified, Noncertified, and Substitute Teacher Applications are available in MS Word under the "Documents" link at this Sevier County page
- County
Employee Authorization Form, for new employees and their supervisor to sign
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County Contract Supplement Form, for employees to be paid from Sliver Grant funds
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Flexible Inservice Credit for
Noncertified Staff, for paraprofessional staff to document the 6 hours of inservice time required each year. The
same form as an Acrobat PDF file
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Flexible Inservice Credits, for professional staff to document the 6 (or more) hours of inservice time required each year. The
same form as an Acrobat PDF file.
- Request
for Professional Leave, must be signed by the principal and director of
curriculum and instruction before the date(s) requested
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Claim for
Conference Travel Reimbursement, for covered employees to be reimbursed for
hotel, dining, and travel after returning from official business trips for which
Sevier County Schools agreed to pay
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Claim for Traveling Expenses,
for covered employees to be reimbursed for driving their own vehicles on
official business
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Dental or Vision Direct Reimbursement Claim Form, for covered employees to receive back part of their payments for covered dental work
or eye exams, glasses, contacts, etc. (form was revised to add vision in January 2004)
- Bus Conduct Report, the driver's form for reporting student behavior and corrective action taken
- Bus Emergency Card, for quick contact of the guardians and medical information on the students
- Bus Cell Phone Policy, concerning students' phones on special education buses
- Special Education Bus Driver Absentee Form,
the driver's form to self-report mornings or afternoons missed. The same form as an MS Works file
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Special Education Bus Attendant Absentee
Form, the bus attendant's form to self-report mornings or afternoons missed.
The same form as an MS Works file
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Weekly Special Education Bus Transportation Log, to document days that
students rode a Sevier County school bus.
The same form as an PDF file
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Bus Maintenance/Completion Reporting Form, Sevier County Schools Form 620, for the driver to indicate a problem and the garage staff to report how they fixed the vehicle
 Application for Tennessee Teaching License or Amendment to Licensure, the form for adding education credits, additional endorsements, or Praxis scores
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Table of Endorsement Titles and Corresponding Codes, includes most (but not all) Tennessee Teaching License add-on endorsement codes. Link to the full list. This also lists disability codes.
- Individualized Education Program (IEP). Also see
the IEPs links on the Sevier County Information Page for IEP documents that aren't forms.
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Checklist for Multidisciplinary Team Meeting/IEP Creation, steps to keep in mind and their IDEA '97 and 34 CFR 300 regulatory references
- IEP Meeting Before and After Evaluation, especially useful for teachers new to IEP meetings
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Invitation to a Meeting, the former "Notice of Multidisciplinary Team Meeting" to parents/guardians
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Invitation to a Meeting, the former "Notice of Multidisciplinary Team Meeting" to parents/guardians (in MS Works 4)
- IEP or Re-evaluation Tracking, year-at-a-glance format for tracking when students' IEPs or evaluations need to be ready
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 Conference Summary, the IEP Team Meeting Minutes, summary of concerns/recommendations addressed at the IEP or Re-eval meeting (December 2006 version replaces the April 2002 version). Here it is as a PDF file. You may want to print this one on pink paper to match what is currently in the IEP files.
- IEP Summary, a table for matching the students with their common IEP goals
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Placement of IEP Folder Documentation, what goes where in Sevier County's IEP records
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Placement of IEP Folder Documentation, what goes where in Sevier County's IEP records (MS Works 4 file)
- Record of File Review, the page that goes on top of the left side of the IEP record, for reviewers to sign
- Certification Forms enumerating the handicapping condition and giving the date of either the
Psychological Evaluation,
Medical Evaluation,
Audiological Evaluation,
Psychological Evaluation or Speech/Language Assessment, or
Psychological/Medical Evaluation. These certification forms aren't required, but are used locally by Sevier County's School Psychologists. Case managers may leave them on top of the eligibility report, or just put the eligibility report (which is required) on the left side of the IEP folder atop all of its supporting documentation.
- Parental
Fee-for-Service Claim Notice, as an MS Word file, and as a PDF
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Individual Education Plan (IEP), for use in planning IEP meetings. This has on it the changes added in September 2003, to the accommodations/standardized testing planning page. You'll need MS Word 97 or later to open this one; the rest of the Word files on this site are Winword 6.0 accessible.. The
blank IEP as a PDF file, for those handwriting the IEP.
- Notice of Provision of Free, Appropriate Public Education, the summary page that parents/guardians receive with the IEP
 PWN Initial Evaluation Template, a Prior Written Notice template for an initial referral meeting
- PWN for a 3-Year Re-evaluation Template, a Prior Written Notice template for use during a re-evaluation meeting
- Extended School Year Service Plan for use before and during the ESY placement to document goal progress
- Extended School Year Student
Information Form to fax to Dr. Thomas with the rest of the ESY package
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Prevocational Checklist, as an Excel 4.0 file, and as a PDF
- Preschool Prevocational Skills Checklist, a slightly different version for the 3 to 5 year olds
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Parent/Professional Vision Observations Checklist, a 3-page PDF used as part of the functional vision assessment
- Student/Parents' Comprehensive Vocational Assessment Questionnaire/Inventory. Vocational planning is required as part of the IEP review process from 14 years old on.
- Parents' Survey for Transition Planning in
MS Word or
HTML. Transition planning is required as part of the IEP review process from 14 years old on.
- Student's Survey for Transition Planning in
MS Word or
HTML
- Behavior Plan in Word, as commonly used in Sevier County when necessary; also
as a PDF file
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FBA Behavior Support Plan in Word,
as a PDF, and
in MS Works. Similar to the one directly above.
- TCAP Alt Addendum, for students who will be considered 3rd through 11th grade for the year the IEP covers, when the IEP Team is recommending an alternative to the Tennessee Comprehensive Assessment Program. The same
file as a PDF.
- TCAP Testing Allowable Accommodations Table as revised for the new school year
- English Language Learner Accommodations for TCAP achievement, competency, writing, and Gateway testing
- TCAP Testing Accommodations Instructions for the IEP as revised for the new school year
- The 2003-2004 Special Accommodations table listing all nine accommodations is on page 7 of the 12 page PDF file linked above
- Breakout of Calculator Use for Grades 3 - 8 by test and part
- Breakout of Times Allowed for Grades K - 2 by test and part
- Accommodations
Checklist, a 2-page expanded listing for modifications to make for students,
especially in general education settings
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TCAP Testing Accommodations as revised for the new school year (4 pages; print out only the one you need, as described below and retain the completed sheet with the IEP). Of the nine accommodations mentioned above, only those available for each of the four testing situations appears on each of the four sheets
- Page 1, TCAP Achievement Accommodations
- Page 2, TCAP Writing Accommodations
- Page 3, TCAP Competency Accommodations
- Page 4, TCAP End-of-Course or Gateway Accommodations
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Unique Adaptive Accommodations Request, needs SpEd Dept and Central Office approval before going to State; the
same form as a PDF file
- IEP Evaluation Data and Procedural Safeguards Sheet, a 1-page checklist to check for compliance with timing, procedures, and documentation in an IEP folder
- IEP Data Sheet, a 1-page checklist to check for the presence of required documentation in an IEP
- Home/Community Activities Inventory for Primary and Elementary Students, a product of Tennessee's LRE for LIFE Project. It helps parents give input prior to IEP development.
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Home/Community Activities Inventory for Middle, Intermediate, and High School Students, a product of Tennessee's LRE for LIFE Project. This file also comes with a final page on which the student and parent can let the teacher know which goals they think are most important for the coming year.
- Other LRE for LIFE forms and publications in MS Word. You can get copies of the two H/CAIs above and a lot of other CDC-specific documentation.
- Data Collection and Behavior Documentation Forms, a growing assortment of PDF-file forms from PolyXO.com
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