005.18.31-1. Due Process, Applicable to Ages 3-21.
AR ADC 005.18.31-1Arkansas Administrative Code
Ark. Admin. Code 005.18.31-1
005.18.31-1. Due Process, Applicable to Ages 3-21.
Record of Access, Ages 3-21
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Referral Form, Ages 3-21
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Notice of Conference, Ages 3-21
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DESCRIPTION OF ANY OTHER OPTIONS CONSIDERED AND THE REASON(s) THE OPTIONS WERE REJECTED:
Description of each evaluation procedure, assessment, record or report the school district used in deciding action proposed. (See descriptions of evaluation components checked below.)
DESCRIPTIONS OF EVALUATION COMPONENTS
Relevant functional and developmental information, including information provided by the parent, may be obtained from the following evaluation components:
Adaptive Behavior/Self-Help Development: assesses your child's general behaviors at home, school and within the community.
Audiological Evaluation: pure-tone testing to include air and bone conduction and impedance testing of middle ear functioning.
Classroom-based Assessment and Observation: assesses your child's performance and behavior in a classroom setting; conducted by someone other than your child's classroom teacher.
Communicative Abilities:
Speech: assesses your child's articulation (speech sounds), voice, fluency and motor skills for speech.
Language: assesses your child's comprehension and expression of language, written and/or spoken.
Developmental/Medical history: provides information about your child's developmental progress and medical history.
Hearing Screening: screens your child for hearing acuity.
Individual Achievement: measures your child's achievement in such areas as listening comprehension, oral and reading comprehension, math calculation and reasoning, and written language.
Individual Intelligence/Cognition: assesses your child's ability to learn; is administered individually to child by a trained professional.
Individual Development: measures your child's skills and ability in areas of cognition, communication, fine and gross motor, self-help and social/emotional.
Motor Development: assesses your child's ability to use small (fine) and large (gross) muscles effectively to master hand skills, standing, walking, balancing, climbing, etc.
Observation: assesses your child's performance and behavior in a classroom setting, home or natural environment and is conducted by someone other than your child's classroom teacher.
Occupational Therapy: assesses your child's fine motor skills and abilities for general or specific activities.
Other Assessment(s): such additional assessment(s) as are required to ensure that your child is assessed in all areas, and includes information related to enabling the child to be involved in and progress in the general curriculum or preschool activities.
Physical Therapy: assesses your child's gross motor skills and abilities for general or specific activities.
Social/Emotional: information collected about your child's ability to develop and maintain functional interpersonal relationships and to exhibit age appropriate social and emotional behavior. It may include rating scales, personal inventories, behavioral observations, projective tests and personal interview.
Vision Screening: screens your child for visual acuity.
Vocational Interests/Aptitude: assesses your child's interests and capabilities for different types of work.
THE FOLLOWING ADDITIONAL FACTORS ARE RELEVANT TO THE ACTION PROPOSED:
The parents of a child with a disability, or the child with a disability, have protections under procedural safeguards of IDEA (Individuals with Disabilities Education Act). A copy of “Your Rights Under the IDEA” may be downloaded to print from the following website: http://arksped.k12.ar.us/sections/rulesandregulations.html, Appendix A, Required Forms, Item #4. The following sources are available should you need assistance in understanding your rights.
Individual/Group/Agency | Phone Number | |
Signature of Public Agency Official/Designee | Phone Number | Date |
Conference Notice Enclosure, Ages 3-21
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Documentation of Receipt of Rights Under The Individuals With Disabilities Education Act, Ages 3-21
DOCUMENTATION OF RECEIPT OF RIGHTS UNDER THE INDIVIDUALS WITH DISABILITIES EDUCATION ACT
Check one:  Parent/guardian | Student |
I have been given a copy of “Your Rights Under the IDEA.” I have also been given a copy of the Complaint Procedures of the State. These documents were explained to me, and I was given information about sources available to help me understand these rights and an opportunity to ask questions concerning the documents.
(Signature of Recipient)
(Date)
Referral Conference Decision Form, Ages 3-21 and Notice of Decision
REFERRAL CONFERENCE DECISION FORM AND NOTICE OF DECISION
Child: __________ Conference Date: __________
Public Agency: __________ Date of Birth: __________ Grade: __________
Referral Committee Members List (Include Title):
Referral Conference Decision (s): (Check those that apply)
| | I. | Evaluation performed in accordance with provisions set out in ADE regulatory documents governing Special Education and Related Services. The evaluation will be conducted in the child's native language/mode of communication (CHECK ONE) | |
| English | Other (specify)_______________ | ||
| A. Comprehensive Evaluation | |||
| B. Specialized Evaluation | |||
| C. No Evaluation Needed | |||
| | II. | Child remains in current program with or without program modification(s)/ adaptation(s). | |
| | III. | Temporary placement and development of an interim IEP in accordance with procedures set out in ADE regulatory documents governing Special Education and Related Services. | |
Reasons for: | |||
| A. Diagnostic data gathering is required | |||
| B. Observed educational needs constitute necessity for immediate intervention | |||
Professional(s) designated responsible for implementing decision(s):
__________
Signature of Public Agency Official/Designee
__________
Notification Date
Given to parent at conference Mailed to ParentInformation Regarding Consent, Ages 3-21
Confidentiality of Information
A. This public agency is required to obtain written consent before personally identifiable information is disclosed to parties, other than officials of participating agencies in accordance with paragraph A.1 of this section, unless the information is contained in education records, and the disclosure is authorized without parental consent under 34 CFR part 99.
2. Parental consent, or the consent of an eligible child who has reached the age of majority under State law, must be obtained before personally identifiable information is released to officials of participating agencies providing or paying for transition services in accordance with 34 CFR 300.321(b)(3).
3. If a child is enrolled, or is going to enroll in a private school that is not located in the LEA of the parent's residence, parental consent must be obtained before any personally identifiable information about the child is released between officials in the LEA where the private school is located and officials in the LEA of the parent's residence.
Evaluation/Placement Consent
b. If the parent of a child fails to respond or refuses to consent to services under this section, the public agency may not use the due process hearing procedures (including the mediation procedures under 34 CFR 300.506 or the due process procedures under 34 CFR 300.507 through 300.516) in order to obtain agreement or a ruling that the services may be provided to the child.
4. conducting a reevaluation before determining that the child is no longer a child with a disability. However, reevaluation is not required before the termination of a child's eligibility under the IDEA due to graduation from secondary school with a regular diploma, or due to exceeding the age eligibility for FAPE under State law.
Other Consent Requirements
B. In addition to the parental consent requirements described in paragraph A of this section, a State may require parental consent for other services and activities under this part if it ensures that each public agency in the State establishes and implements effective procedures to ensure that a parent's refusal to consent does not result in a failure to provide the child with FAPE.
D. If a parent of a child who is home schooled or placed in a private school by the parents at their own expense does not provide consent for the initial evaluation or the reevaluation, or the parent fails to respond to a request to provide consent, the public agency may not use the consent to override procedures; and the public agency is not required to consider the child as eligible for services under 34 CFR 300.132 through 300.144.
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TEMPORARY PLACEMENT CONSENT
I, as the parent/guardian of
(Child's Name)
[check one]
authorize do not authorizehis/her temporary placement, not to exceed 60 calendar days, in a program providing special education and related services in the
(Public Agency)
I understand that giving my consent for the above stated purpose is voluntary on my part and may be revoked at any time.
PARENT/GUARDIAN SIGNATURE
DATE
Local Education Agency (here)
Parental Consent to Release of Personally Identifiable Information
Student Name:
Student Identification Number:
Primary Care Physician Name:
Medicaid Information:
Is your child covered by Medicaid? Yes No
If yes, please list the corresponding number __________
***When the child was enrolled in the Medicaid program, parental consent to bill for services was received from the parent/guardian. ***
Parental Permission to Release Personally Identifiable Information:
Under the Family Educational Rights and Privacy Act (FERPA), parental permission is required in order to release student personally identifiable information to agencies not identified in the Act. This permission grants the __________ (local education agency) the ability to release these records for the purposes of billing Medicaid. The information that may be released includes: student's name, student's date of birth, student social security number, student evaluation and referral information, IEP goals and progress notes. The parent has the right to revoke this permission at any time.
Please check the following that apply:
A__________ I give permission to the local education agency to access Medicaid to receive reimbursement for healthcare services delivered to my child in the school. The local education agency can release education records each time that it accesses Medicaid for the purpose(s) of determining eligibility, billing for services, and/or completing audit/review requests.
B__________ I do not give my permission for the local education agency to access Medicaid for healthcare services delivered to my child in the school.
C__________ My child is not covered by private insurance.
D__________ My child is covered by private insurance (please see next page).
Parent or Guardian Signature | Public Agency Official Signature |
____________________ | ____________________ |
Date | Date |
Local Education Agency (here)
Parental Consent to Release Personally Identifiable Information Third Party Liability Section
This section should only be completed if section D of the previous page is checked and if the student is covered by private insurance.
Information Related to Billing Third Party Insurance:
Title 42 Code of Federal Regulations (CFR), Part 433, Subpart D, Third Party Liability requires that all third party sources must be utilized before reimbursement can be made by Medicaid. Part B of the Individuals with Disabilities Education Act (IDEA) prohibits a public agency from requiring parents, where they would incur a financial cost, to use insurance proceeds to pay for services that must be provided to a child with disabilities under the “free appropriate public education” requirements of these statutes. IDEA does not create exceptions to Title 42 CFR, Part 433, Subpart D. All Medicaid providers should attempt to exhaust third party liability prior to making claims to Medicaid, including schools districts and education service cooperatives (ESC).
Private Insurance Information:
Insurance company: __________
Address:
__________
Phone:
Name of Policy Holder:__________
Policy Holder Date of Birth:
__________
Social Security Number:
Policy Number:__________ Group Number:__________
Please circle one below:
Yes | No | I give permission to the local education agency to bill my private insurance for healthcare services delivered in the school. |
Parent or Guardian Signature | Public Agency Official Signature |
Date | Date |
Systematic Observation of Student Performance
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Group Report for Specific Learning Disability (SLD)
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Evaluation/Reevaluation Decision Form, Ages 5-21
When evaluating a child for receipt of special education services, the following criteria apply:
Initial Evaluations
For initial evaluation, a formal assessment of individual intelligence/cognition is required. In some cases, other developmental and non-linguistic performance procedures may be necessary in order to meaningfully assess cognitive functioning. When measuring the relevant contribution of cognitive factors and adaptive behavior, the examiner must have used instruments that possess technically sound characteristics.
Achievement testing must include both norm-referenced and relevant assessment in the general curriculum. This will need to include data that will enable the development of an individualized education program (IEP) with measurable outcomes. The assessment procedures for determining the instructional needs of a child are based upon the child's ongoing performance in the school's regular curriculum. A regular education curriculum is defined to include instructional/ learning experiences in academic, social and adaptive domains. These assessment procedures will assist in determining the child's individualized education program, relevant to:
Materials and procedures used to assess a child with limited English proficiency (LEP) are selected and administered to ensure that they measure the extent to which the child has a disability and needs special education, rather than measuring the child's English language skills.
If an assessment is not conducted under standard conditions, a description of the extent to which it varied from standard conditions (e.g., the qualifications of the person administering the test, or method of test administration) must be included in the evaluation report.
General assessments regarding communicative abilities, at a minimum, must assess both receptive and expressive language. To determine eligibility under Speech or Language Impairment, additional assessment is required. If the child is non-speaking, the communicative intention of the child should be determined using multiple procedures/methods. Describe how the child communicates (e.g., Braille, sign language, gestures, electronic communication devices, communication boards, etc.), and how alternative communication is used by the child to access the regular curriculum.
Reevaluations
Any time the child is reevaluated, utilize the Existing Data Review and Conference Decision Form and Evaluation/Programming Conference Decision Form at the appropriate time.
Some disabilities necessitate more frequent reevaluation than other disabilities due to their variability in functional impact over time, such as traumatic brain injury or mental retardation as a result of fetal alcohol syndrome.
The public agency must provide a copy of the evaluation report and the documentation of determination of eligibility to the parent.
(*) Evaluation/Programming Conference Decision Form and Notice of Decision
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(*) Existing Data Review and Notice of Decision
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Parent Consent for Initial Placement, Ages 3-21
PARENT CONSENT FOR INITIAL PLACEMENT
I, as parent or guardian of __________ (Child's Name),
[check one]
authorize do not authorizehis/her placement in a program providing special education and related services in the
(Public Agency)
I understand that the need for this placement will be reviewed, in terms of my child's progress, at least annually.
I understand that giving my consent for the above stated purpose is voluntary on my part and may be revoked at any time.
Parent/Guardian's Signature
Date
Separate Programming Conference Decision Form, Ages 3-21 and Notice of Decision
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Annual Review Form, Ages 3-21 and Notice of Decision
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SAMPLE: Letter of Agency Notification
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IEP Team Member Excusal from Attendance at IEP Meeting
IEP TEAM MEMBER EXCUSAL FROM ATTENDANCE AT IEP MEETING
Date: __________
Child:
Date of Scheduled IEP Meeting:
Name of Parent:
Name of Public Agency Representative:
Position of Public Agency Representative:
UNDERSTANDINGS
I have been informed and understand that the IEP Team must include at least the following: (a) parent of the child; (b) one regular education teacher of the child (if the child is, or may be, participating in the regular education environment); (c) one special education teacher or special education provider of the child; (d) a representative of the school district/public agency [as set forth in 34 CFR 300.321(4)]; (e) an individual who can interpret the instructional implications of evaluation results.
I have also been informed and understand that: (a) all of the required members of an IEP Team (listed in the above paragraph) must attend each IEP meeting unless both the parent and the school/public agency representative agree in writing that a required Team member does not need to attend all or part of an IEP meeting; and (b) that a required Team member may be excused from attending a meeting that will involve a modification to or a discussion of the required group member's area of the curriculum or related services, only if: (1) both the parent and the school/public agency representative give written consent for the member to be excused; and (2) the member submits written input regarding the development of the IEP to both the parent and the other members of the IEP Team prior to meeting.
IEP TEAM MEMBER'S AREA OF THE CURRICULUM OR RELATED SERVICES IS NOT BEING MODIFIED OR DISCUSSED
__________ (Position of Team Member)
The member of the IEP Team noted above will not attend the IEP meeting as both the school/ public agency and the parent agree that the Team member's attendance at this meeting is not necessary.OR
The member of the IEP Team noted above will attend only the portion of the IEP meeting in which the following issues are discussed:I agree disagree with the above marked statement.
agree disagree with the above marked statement.____________________ | |
Parent Signature | Date |
I agree disagree with the above marked statement.
agree disagree with the above marked statement.____________________ | |
Authorized Public Agency Representative | Date |
Signature |
IEP TEAM MEMBER EXCUSAL FROM ATTENDANCE AT IEP MEETING
Date: __________
Child:
Date of Scheduled IEP Meeting:
Name of Parent:
Name of Public Agency Representative:
Position of Public Agency Representative:
UNDERSTANDINGS
I have been informed and understand that the IEP Team must include at least the following: (a) parent of the child; (b) one regular education teacher of the child (if the child is, or may be, participating in the regular education environment); (c) one special education teacher or special education provider of the child; (d) a representative of the school district/public agency [as set forth in 34 CFR 300.321(4)]; (e) an individual who can interpret the instructional implications of evaluation results.
I have also been informed and understand that: (a) all of the required members of an IEP Team (listed in the above paragraph) must attend each IEP meeting unless both the parent and the school/public agency representative agree in writing that a required Team member does not need to attend all or part of an IEP meeting; and (b) that a required Team member may be excused from attending a meeting that will involve a modification to or a discussion of the required Team member's area of the curriculum or related services, only if: (1) both the parent and the school/public agency representative give written consent for the member to be excused; and (2) the member submits written input regarding the development of the IEP to both the parent and the other members of the IEP Team prior to meeting.
THE IEP TEAM MEMBER'S AREA OF THE CURRICULUM OR RELATED SERVICES MAY BE MODIFIED OR DISCUSSED
__________ (Position of Team Member)
The member of the IEP Team noted above is excused from attending this IEP meeting, providing that the member submits written input related to the development of the IEP to both the parent and the other members of the Team prior to the meeting.
I consent to the excusal do not consent to the excusal
consent to the excusal do not consent to the excusal____________________ | |
Parent Signature | Date |
I consent to the excusal do not consent to the excusal
consent to the excusal do not consent to the excusal____________________ | |
Authorized Public Agency Representative | Date |
Signature |
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 005.18.31-1, AR ADC 005.18.31-1
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