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Responsibilities at Referral Level
Monitor EEN referral time line to ensure compliance.

Schedule and facilitate IEP meetings.

Insure appropriate IEP paperwork is completed.

Share IEP information with all involved individuals: staff, parents, student, etc.

Monitor implementation of the IEP through normal progress checks; ie:  report cards, parent conferences.

Insure appropriate transfer of Case Manager duties when necessary; ie:  from 5th grade to 6th grade, from one program to another.

When student is dismissed from special education, notify regular education staff that they are the current Case Manager and need to continue recommendations that are Non-EEN related; ie:  classroom modifications and adaptations.

This form is for viewing purposes only.

         REFERRAL FORM     A-1

SCHOOL DISTRICT OF WAUPACA
WAUPACA, WI 54981

DIRECTIONS:        Please complete all sections of this form  I through IV.
        Incomplete forms will be returned to you.
        Send the completed Referral Form to the Director of Exceptional Education

          Initial Referral:_____        Request for Re-evaluation:_____

I     Identifying Information:

    Name of Student:_______________________________    Date of Birth:____________________________

    Address:    ____________________________________     Telephone:______________________________

        ____________________________________    Grade:__________________________________

    Parent:_______________________________________    School:_________________________________

    Person Making Referral:________________________    Position: _______________________________

    Date of Referral:_______________________________    Date Parent Notified:_____________________
 
    Method of Parent Notification:    Conference (   )          Telephone (   )             Letter (   )

II    Suspected Exceptional Needs:     Include any areas parents feel should be evaluated.

             Check area of concern:    (   )    Autism
                        (   )    Cognitive Disability
                        (   )    Emotional Disturbance
                        (   )    Hearing Impairment
                        (   )    Learning Disability
                        (   )    Orthopedic Impairment
                        (   )    Other Health Impairment
                        (   )    Significant Development Delay
                        (   )    Speech or Language Impairment
                        (   )    Traumatic Brain Injury
                        (   )    Visual Impairment
                        (   )    Other:_________________________

   
III    Has this student been referred previously?    (    )  Yes    (    )   No
   
    By whom?______________________________       When?____________________________

    If yes,   (    ) EEN    (   ) NON:EEN

    Have you reviewed that information?        (    )   Yes    (    )   No


IV    Reason for Reporting?    Please be specific in responding to all of the following areas.

Behavior:

Academic:

Background Information:

    D.    Intervention History:    (Document STAR involvement)      (Attach STAR form if available)

    E.    Has this student ever been retained?__________     What grade?__________

    F.    Parent(s) information regarding students functioning levels:

    G.    School district representative receiving referral:    ________________________________________

                                                   Date received:________________________________________   
Revised 9/00

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