To                                                                                              

     (Parent/Legal Educational Decision Maker)

Date                                                                                           

On behalf of                                                                             

                      (student's name)

Address                                                                                    

On                                                                 ,  we met to review the evaluation/assessment data on your child, including any evaluations or information you provided, current classroom-based assessments and observations, and teacher or other staff observations to determine, with your input:

□  Whether your child was eligible for special education

□  Special education and related services needed by your child

□  The appropriate educational placement to provide special education and related services identified in your child’s Individualized Education Program (IEP)

□  Any additions, changes or modifications to the special education and related services or educational placement that are needed to enable your child to meet the measurable annual goals set in the IEP and to participate, as appropriate, in the general curriculum.

To the maximum extent appropriate, your child is to be educated with other children in the general education classroom.  Your child shall be removed from the general educational environment only when the nature or severity of his/her needs are such that education in general education classes, with support services, cannot be achieved satisfactorily.  If services are not to be provided in the general education classroom, the reasons for that are given below, along with the results of our meeting.

□ A.  IDENTIFICATION/ ELIGIBILITY  (Parental Consent Not Required)

□ YOUR CHILD IS ELIGIBLE FOR SPECIAL EDUCATION

□ Your child meets the criteria as a child with an exceptionality

and

□ Special education services are necessary to enable your child to receive educational benefits in accordance with his/her abilities or capabilities

                □ YOUR CHILD IS NOT ELIGIBLE FOR SPECIAL EDUCATION

□  Your child does not meet the criteria as a child with an exceptionality.

or

□  Special education services are not necessary to enable your child to receive educational benefits in accordance with his/her abilities or capabilities

□ B.  SPECIAL EDUCATION & RELATED SERVICES  (Parental Consent Required)

As explained below, an Individualized Education Program (IEP) proposing appropriate Special Education and related services was written for your child.

□ C.  EDUCATIONAL PLACEMENT  (Parental Consent Required)

As explained below, an Individualized Education Program (IEP) proposing an appropriate instructional environment for delivering special education and related services was written for your child.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

□ D.  Change in Services

            □ Change In Services  (Parental Consent Not Required)

As explained below, we are proposing a change (not a material change) of a special education service, a related service, or a supplementary aid or service specified on your child’s IEP.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

or

      □ MATERIAL Change In Services  (Parental Consent Required)

As explained below, we are proposing a change that results in a decrease or increase of 25% or  more of the duration or frequency of a special education service, a related service ,or a supplementary aid or a service specified on your child's IEP.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

□ E.  Change in Placement

          □ Change In Placement  (Parental Consent Not Required)

As explained below, we are proposing a change (not a substantial change) in placement from a less restrictive environment to a more restrictive environment, or from a more restrictive environment to a less restrictive environment.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

or

      □ SUBSTANTIAL CHANGE IN PLACEMENT  (Parental Consent Required)

As explained below, we are proposing a change in placement that results in the movement of more than 25% of your child's school day from a less restrictive environment to a more restrictive environment, or from a more restrictive environment to a less restrictive environment.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

□ F.  The [LEA] refuses to initiate or change the identification, EVALUATION, educational placement, or provision of special education and related services as explained below. (Parental Consent Not Required)

1)  A DESCRIPTION OF THE ACTION PROPOSED OR REFUSED:  

        2)  EXPLANATION OF WHY THE ACTION IS PROPOSED OR REFUSED:  

        3)  OPTIONS CONSIDERED AND WHY THE OPTIONS WERE REJECTED:

        4)  DESCRIPTION OF THE DATA USED AS BASIS FOR THE PROPOSED OR REFUSED ACTION

(including each evaluation procedure, assessment, record or report used as a basis for the proposed or refused action):

        5)  OTHER FACTORS RELEVANT TO THE PROPOSAL OR REFUSAL (e.g. LRE, harmful effects):

ADDITIONAL INFORMATION

You may contact any of the following resources to help you understand the federal and state laws for educating children with exceptionalities and parental rights (procedural safeguards) granted by those laws:

Kansas State Dept. of Education 800-203-9462

Other Local Resources:

Disability Rights Center of Kansas (DRC): (877) 776-1541

Families Together, Inc. 800-264-6343

Keys for Networking  785-233-8732

REQUEST FOR CONSENT FOR SPECIAL EDUCATION ACTION

If the above statements are correct, we ask that you give us consent to carry out the special education action as indicated.  Any disagreement we have regarding any of the above matters may be resolved by our mutual agreement, through mediation or through due process proceedings.  An explanation of mediation and due process proceedings is provided upon request.

The proposed action(s) will begin within 10 school days (unless there is a reasonable justification for delay) upon receiving your written permission.  If you have any questions regarding this notice, you may contact the following school representative or sign and date this form and return it to:

___________________________________ at __________________________________ or _____________________

(School Contact)                                                      (Address)                                                                  (Phone)