Sevier County Special Education Forms

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

Permission for Assessment, to screen for Special Education services; it has a back page that explains each type of assessment listed

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

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

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

Special Education Exit Form, for a student reaching 18 years old and choosing to terminate Special Education services

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 April 2003.(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.)

Preparation for Reevaluation IEP Team Meeting in Word, and as a PDF

Notice of Reevaluation IEP Team Meeting and Prior Written Notice in Word and as a PDF

Parent Input for Reevaluation in Word and as a PDF file

Classroom Teacher Observation Form in Word and as a PDF

Special Education Teacher Observation Form in Word and as a PDF file

Reevaluation IEP Team Report, Sections I and II in Word and as a PDF file

Speech/Language Assessment Results for Reevaluation Section III in Word and as a PDF file

Speech/Language Assessment Results (page 2), Fluency and Voice Assessment for Reevaluation Section III in Word and as a PDF file

Speech/Language Assessment Results (page 3), Hearing Assessment for Reevaluation Section III in Word and as a PDF file

Speech/Language Assessment Results, Vision Assessment for Reevaluation Section III in Word and as a PDF file

Psycho-Educational Assessment Results for Reevaluation Section III in Word and as a PDF file

Medical/Other Health Impairment Assessment Results for Reevaluation Section III in Word and as a PDF file

Social/Emotional/Behavioral Assessment Results for Reevaluation Section III in Word and as a PDF file

Adaptive Behavior Assessment Results for Reevaluation Section III in Word and as a PDF file

Preschool Assessment Results for Reevaluation Section III (if needed) in Word and as a PDF file

Current Classroom Based Assessment and IEP Review, Reevaluation Section IV in Word and as a PDF file

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.

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.

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

Release of Information, permission for the school system to get information to and from the physician

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.

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

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

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

Elements of a Functional Behavioral Assessment, in addition to the forms, the essentials to keep in mind during FBA development. (You need to be using at least version MS Word 97 or many of the forms will not open/print correctly. This is a newer, optional package to use with or in lieu of the collection of forms listed below, which should be more familiar to you. The forms below are available in Word, Works, and PDF format, as indicated.)

Functional Behavior Assessment Worksheet in Word, and as a PDF

Functional Behavior Assessment Referral Form in Word, as a PDF, and in MS Works

Physical/Health Impaired Evaluation Summary in Word, as a PDF file, and as an MS Works document

Permission for Assessment in Word, as a PDF, and in MS Works

Attention Deficit Referral Guidelines for the IEP team to consider, in Word, as a PDF file, and as an MS Works document

Diagnostic Criteria for ADHD, requires doctor's signature

Medical Form for Consideration of ADHD prior to SpEd placement

Functional Behavior Assessment Parent Interview Form in Word, as a PDF, and in MS Works

Social Developmental History in Word, as a PDF, and in MS Works

Prevocational Skills Checklist in Excel or as a PDF file

Functional Behavior Assessment Student Assisted Interview Form in Word, as a PDF, and in MS Works

Functional Behavior Assessment Student Interview Form Following a Crisis Situation or Serious Single Incident in Word, as a PDF, and in MS Works

Functional Behavior Assessment Problem Behavior Questionnaire in Word, as a PDF, and in MS Works

Functional Behavior Assessment Classroom Observation Form in Word, as a PDF, and in MS Works

Functional Behavior Assessment Teacher Interview Form in Word, as a PDF, and in MS Works

Five Sample FBA Forms and a Summary, Attachment B of the "Elements of a Functional Behavioral Assessment" larger file above, for additional support to the Behavioral Assessment Team's information gathering

Behavior Plan in Word, as commonly used in Sevier County when necessary; also as a PDF file

FBA Behavior Support Plan in Word, as a PDF, and in MS Works. Similar to the one directly above.

Three Sample Behavioral Intervention Plan Forms, Attachment D of the "Elements of a Functional Behavioral Assessment" larger file above

Functional Behavior Assessment Report Form in Word, as a PDF, and in MS Works. For the assessment team's summary and signatures.

Student Referral for Special Education in Word, as a PDF, and in MS Works

Manifestation Determination Review in MS Word, includes a step-by-step worksheet. Also as a PDF and in MS Works

Manifestation Determination Questionnaire in MS Word, a 2-page version, similar to the FBA worksheets and checklists. Also as a PDF and in MS Works

Manifestation of Handicapping Condition Decision in MS Word, behavior or attendance record's correlation to the handicapping condition (a checklist form). Also as a PDF and in MS Works

Behavior Chart, a sample for daily tracking

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 Contract Supplement Form, for employees to be paid from Sliver Grant funds

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.

Claim for Traveling Expenses, for covered employees to be reimbursed for driving their own vehicles on official business (new form for 03-04 school year)

Dental Direct Reimbursement Claim Form, for covered employees to receive back part of their payments for covered dental work (form was revised January 2004)

Bus Conduct Report, the driver's form for reporting student behavior and corrective action taken

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

These templates are in Microsoft Word, version 97 (except for a few in the older MS Word 6.0). If you have MS Word/Office 97 or 2000 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.

Speech/Language Services

Speech/Language Request for Assessment

Informal Language Assessment Checklist

Parent Input Forms

Parent Input Form, Student's History

Parent Input on Fluency

Parent Release of Information on Voice

Auditory Processing Screening

Voice Evaluation from a medical doctor

Speech/Language Oral Peripheral Exam, also as an MS Works 4.5 document

Speech/Language Evaluation Report

Early Interventions Worksheet

Severity Rating Scales

Articulation Severity Rating Scale

Fluency Severity Rating Scale

Functional Communication Severity Rating Scale

Language Severity Rating Scale

Voice Severity Rating Scale

Teacher Input Forms

Teacher Input on Sound Production

Teacher Input on Fluency

Teacher Input on Functional Communication

Teacher Input on Language

Teacher Input on Voice

Dismissal from Speech Program

Seven Dismissal Guidelines

Dismissal Form

Section 504, Vocational Rehabilitation Act of 1973
The MS Word documents below were revised from those provided by the Jefferson County, Colorado, Public Schools.

Section 504 Made Easy, this package covers eligibility, background, evaluation, and question/answers for Section 504 case planning in Sevier County.

504 Eligibility and Meeting Expectations, a "Reader's Digest" version of the more detailed files under 504 on the Info link

Section 504 Student Review Request Form

"Substantially Limits"? questions to ask while exploring whether the impairment "substantially limits" one or more life activities

Parent Notice of Section 504 eligibility meeting date, time, and place

Section 504 Team Meeting Summary, a narrative documentation of the accommodation and service plan

State Forms

Tennessee Special Education Forms, all forms for Special Education in printer definition file [PDF] and MSWord formats. The ones titled with the "s" are the Spanish language versions.If you don't have Acrobat Reader already loaded, you can download it using the icon above. PDF files will print out with exactly the same look and pagination as the original, paper forms. For some of the ones below, after the form is loaded to your computer, a dialog popup box may say 0001data.fdf was not found. Would you like to browse for it? Just select the "No" box.

Application for Tennessee Teaching License or Amendment to Licensure, the form for adding education credits, additional endorsements, or Praxis scores

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.

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

Invitation to a Meeting, the former "Notice of Multidisciplinary Team Meeting" to parents/guardians

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

Conference Summary, the summary of concerns/recommendations addressed at the IEP or Re-eval meeting (April 2002 version). 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

Placement of IEP Folder Documentation, what goes where in Sevier County's IEP records

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.

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

Data Collection Form for Determining Extended School Year Eligibility, to be kept all year long for IEP documentation tracking

Worksheet for Determining Extended School Year Eligibility. This one includes narrative front matter. Also see ESY Eligibility on the Information link.

Extended School Year Eligibility 5 Question Worksheet, for the case manager to write up prior to the annual IEP meeting

Extended School Year Service Plan for use before and during the ESY placement to document goal progress

Prevocational Checklist, as an Excel 4.0 file

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

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

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

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.

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