Download board of education of wicomico county

BOARD OF EDUCATION OF WICOMICO COUNTY
CONSENT FOR ASSESSMENT
Student: ________________________________________________________ DOB: ______________
School: _____________________________________________________________________________
In considering the information presented at the IEP Team meeting on _____________, the IEP Team has
recommended the following assessment(s). All assessments will be completed by personnel certified
and trained to conduct the assessments indicated.
_____
AUDIOLOGICAL: may include instruments and observations which are designed to measure outer, middle, and
sensorineural function, hearing acuity for pure tones and speech as well as speech discrimination abilities.
Instruments and observations may include those sensitive to central auditory processing abilities, performance with
hearing aids/FM auditory trainers, electroacoustic analysis of hearing aids and fit/design of ear molds.
_____
EDUCATIONAL: may include instruments which are designed to measure achievement in readiness skills (e.g.
alphabet knowledge, number concepts), basic reading skills, reading comprehension, mathematics calculation,
mathematics reasoning, and written language (e.g., grammar, sentence/paragraph construction, spelling).
_____
FUNCTIONAL VISION: determines the quantity and quality of vision the child functionally uses.
_____
HEALTH/MEDICAL: may include a physical examination, interview, and test by a qualified physician.
_____
LANGUAGE: may include instruments and observations which are designed to measure vocabulary development,
language processing, sentence structure, expressive/receptive language, and hearing.
_____
OBSERVATION: includes classroom/school environmental observation of the student’s behaviors as they relate to
his/her functioning and academic performance. If the student is not enrolled in school, the observation will occur in
the appropriate environment.
_____
OCCUPATIONAL THERAPY: may include instruments and observations designed to measure fine motor skills,
sensory-motor development, balance, reflex integration, and eye-hand coordination.
_____
PHYSICAL THERAPY: may include a neuro-muscular examination and developmental evaluation.
_____
PRE-VOCATIONAL/VOCATIONAL: may include instruments and observations designed to measure a student’s
vocational interests, aptitudes, and areas of need related to development of general or specific job skills and
attitudes.
_____
PSYCHOLOGICAL: may include instruments which are designed to measure cognitive functioning,
perceptual/motor functioning, memory, developmental patterns, social/emotional development, adaptive behavior,
and academic achievement.
_____
SPEECH: may include testing and observations which are designed to measure formation of speech sounds, voice
quality, stuttering, hearing, and visual inspection of the mouth (tongue, lips, teeth, hard/soft palate).
_____
OTHER: ____________________________________________________________________________________
I grant my permission for the assessment(s) indicated above. I understand that my consent is voluntary
and may be revoked at any time.
Signature: ________________________________________________ Date: ______________
9/2003