Special Education Resources
Referral Forms for Evaluation
Referral Forms
For all referral forms, please complete each section and question to the best of your abilities. The information is very important in the process. All of the information is included when planning and writing a student’s evaluation report.
Students and families: ALC referrals must be made by a school district. School districts, please reach out to the Northland Learning Center for referral link.
English Language Learner Resources: Is it ESL/ELL and not SLD? This includes strategies for Tiered Intervention.
Initial
KEY POINTS:
Did the school nurse screen vision and hearing before starting interventions?
Is ASD a related concern? Complete the Common Characteristics Checklist and contact your school psychologist to do an observation before starting interventions.
DESCRIPTION:
Download and save the form. Complete and attach to an email to the school psychologist. The form could also be printed out if needed.
LINK:
Please see Forms under Student Success Team.
DD to Categorical
KEY POINTS:
The ECSE teacher needs to be invited to the evaluation planning meeting and the evaluation results meeting.
If the team determines a student has met their goals and no longer need services, the ECSE teacher is responsible for completing an exit evaluation prior to the studnet's 7th birthday.
DESCRIPTION:
The Developmental Delay (DD) to Categorical Referral Form is used by the Early Childhood Special Education (ECSE) teacher or current case manager (sometimes elementary special education teacher) to fill out approximately 90 days prior to the student's 7th birthday if the team determines the student has not met their goals and may meet eligibility for a categorical placement for continued special education services.
LINK:
Reevaluation
KEY POINTS:
If trying to meet an IEP date, please send the referral approximately 90 days before the annual IEP date.
Q&A: Reevaluations under Part B of the Individuals with Disabilities Education Act (IDEA)
DESCRIPTION:
The Reevaluation Referral Form is completed by a student's case manager approximately 90 days prior to 3 years from the student's last evaluation. It documents current concerns, grades, and strengths.
LINK:
Out of State
KEY POINTS:
Please begin an interim IEP based on information from the Out of State IEP. Contact your building coordinator and/or psychologis(s) to determine how soon you can proceed with an initial evaluation for determining Minnesota eligibility.
DESCRIPTION:
The Out of State Referral Form is completed by the assigned case manager when a student moves into the state of Minnesota on an IEP from another state or country.
LINK:
3-Year Waiver
KEY POINT:
Submit the form to your Coordinator/Assistant Director for review.
Consult with all team members on the student's IEP team prior to starting to amek sure everyone is on the same page.
Consideration Guidance Flow Chart
DESCRIPTION:
When a team is considering whether or not a re-evaluation is needed, the Three Year Reevaluation Waiver Consideration Form is completed by the case manager with input from the IEP team.
LINK:
Evaluation Report Resources
- Observations
- FBA, BIP, & PBSP
- Evaluation Score Description
- Evaluation/Re-evaluation Report Checklists
Observations
Observation Forms
MDE Observation Guidelines
Observation Guidelines
Operational Definitions of Commonly Occurring Behaviors
Data Collection Methods
Choosing a Data Collection MethodChoosing a Data Collection Method
Disability-specific observations available can be found under Disability Category Resources.
ABC Observation Forms
Time Sampling
MOMENTARY TIME SAMPLING:
Momentary Time Sample: Description, Procedure, and Example
Direct Observation Progress Monitoring System
Interval Time Sampling Form (Peer)
Momentary Time Sampling Record Form
PARTIAL TIME SAMPLING:
Partial Interval Sampling: Description, Procedure, and Example
Interval Time Sampling Form (Peer)
Partial Time Sampling Record Form
WHOLE TIME SAMPLING:
Whole Interval Sampling: Description, Procedure, and Example
Interval Time Sampling Form (Peer)
Whole Time Sampling Record Form
Frequency, Latency, Duration
DURATION:
Behavior Duration: Description, Procedure, and Example
Duration Record Form
FREQUENCY EVENT OBSERVATION:
Event Observation: Description, Procedure, and Example
Event Recording Form
Frequency Observation Form
Scatter Plot DataScatter Plot Data
INTENSITY
Intensity Behavior Scale
LATENCY:
Latency Recording: Description, Procedure, and Example
Latency Recording 1
Latency Recording 2
FBA, BIP, & PBSP
Basic Functions of Behavior
| To obtain/gain something | To escape something |
| Attention (e.g. smiles, frowns, laughter, hugs, etc.) |
Attention (e.g. avoid or get away from a person, avoid school, etc.) |
| Sensory (e.g. rocking in seat, chewing gum, rubbing hands on wall, banging head into the floor, etc.) | Sensory (e.g. turning lights off, leaving a cold room, taking medication, etc.) |
| Activities or Objects (e.g. academic task, preferred activity, preferred seating, etc.) | Activities or Objects (e.g. independent math seat work, changes in routine, loud noise, etc.) |
Behavior Doctor Seminars' Version of the Competing Pathway Chart
(Think of the ABC's of Behavior)
| Trigger (Antecedent) | Target Behavior | impacT (Consequence) |
| This is what sets the behavior in motion. | This is the behavior you'd like to target for change. | This is what the student is gaining or escaping by engaging in the behavior. |
Now you can develop a Behavioral Intervention Plan (BIP) based on the function of the behavior (what the student is trying to gain or escape).
| Revise the Environment | Replace the Behavior | Reframe Your Response |
| We must make changes in the environment to set the student up for success. This might be mnemonic cues, changes in seating, changes in procedures, etc. | We can't just tell students to be good. We have to teach them what we want the replacement behavior to look like, sound like, and feel like. This can be done by video modeling, social stories, video self-modeling, peer mentoring, etc. | Knowing what the student is trying to gain or escape allows us to know when to give behavior-specific praise, when to ignore, and when to implement procedures to discourage inappropriate behavior. |
Here are samples that have been implemented for specific behaviors from the Behavior Doctor Website.
Triple T- Triple R Worksheet for Blurting in the Classroom
Triple T- Triple R for Student with Low Self-Esteem
Triple T- Triple R Worksheet for a Student with ADHD
Triple T- Triple R Work Avoidance
Triple T triple R for A Student with Sensory Issues
Triple T – Triple R for a Student with Selective Mutism Due to Anxiety
Triple T- Triple R for an Isolated Student with No Friends
Triple T- Triple R for Student with Non-compliance
Triple T- Triple R for Student Who is Bullying Others
Triple T- Triple R for Teaching Young Students How to Calm Themselves
FBA
FBA Resources
9 Operational Definitions of Commonly Occurring Behavior
57 Questions to Ask Yourself When Addressing Problem Behavior
Common Setting Events
FBA Scale
FBA Screening Tool
Hypothesis Summary
Practical FBA
Questions About Behavioral Function (QABF)
QABF Scoring
Tip Sheet: FBA and Function-Based Interventions
BIP/PBSP
Behavior Resources
Behavior Analysis Work Sheet
Behavior Analysis Work Sheet Script
Behavior Strategies Based on Function
Behavior Doctor – Intervention tools, resources, training, and more!
Behavior Ownership Form
CPI Individual Documentation Form
MN PBIS
PBIS
PBIS World
Data Tracking
General Point Sheet
Points Sheet Example
Point Sheet Scoring Rubric
MDE Positive Intervention Strategies Training Modules
Visual Schedule Example
Evaluation Score Description
Evaluation Report Scores and Distribution Table
Standard Score (SS): A way to compare student performance to a standardization sample. Standard Scores in evaluation reports have a Mean (average) of 100 and a Standard Deviation of + or – 15. A standard deviation (SD) is a measure used to quantify the amount of variation from the Mean. A lower SD indicates a student performing closer to the majority with a higher SD indicating performing much lower or higher than the majority. 66% of students will score between 85 and 115.
Scale Scores have a score range of 0 – 19 points, with an average score of 10 points. These scores are typically used for “Sub-tests,” which are smaller components of a larger psychological test, such as the WISC-V, the NEPSY-2, or the DKEFs.
T Scores are standardized scores on each dimension for each type. A score of 50 represents the mean. A difference of 10 from the mean indicates a difference of one standard deviation. Thus, a score of 60 is one standard deviation above the mean, while a score of 30 is two standard deviations below the mean.
Percentile Rank of a score is the percentage of scores in its frequency distribution that are equal to or lower than it. For example, a test score that is greater than 75% of the scores of people taking the test is said to be at the 75th percentile rank. Percentile ranks are not on an equal-interval scale; that is, the difference between any two scores is not the same between any other two scores whose difference in percentile ranks is the same.
Common Language and Descriptions for Scores in Evaluation Report
| Standard Score | Percentile Rank | Descriptor |
| >130 | >98 | Upper Extreme |
| 116-130 | 85-98 | Above Average |
| 110-115 | 74-84 | High Average |
| 91-109 | 27-73 | Average |
| 85-90 | 16-26 | Low Average |
| 70-84 | 2-15 | Below Average |
| <70 | <2 | Lower Extreme |
Developmental Cognitive Disability (DCD) Description of Need and Level of Support
| No Impact | Infrequent or no support rquired |
| Mild Impact | Intermittent or periodic support and supervision required |
| Moderate Impact | Limited but consistent support and supervision required |
| Severe Impact | Frequent or close support and supervision required |
| Extreme Impact | Highly intense and continuous levels of support and supervision required |
Evaluation/Re-evaluation Report Checklists
IEP Resources
Individualized Education Plan (IEP)
3525.2810 DEVELOPMENT OF INDIVIDUALIZED EDUCATION PROGRAM PLAN
PLAAFP and Goal Writing Resources
IEP Writing Resources
IEP Meeting Agenda Template
Documenting the Need for Paraprofessional Support in the IEP
Calculating IEP Service Start Dates
Assistive Technology
Supplemental Aids and Services Needed for Access to Extracurricular Activities
IEP Checklist for Compliance
Amending an IEP
Q&A: Required IEP Team Membership
Assisstive Technology Lending Libraries
Secondary Transition
- Secondary Transition IEP Agenda
- Secondary Transition Planning
- Secondary Transition Forms
- Secondary Transition in the Evaluation Report
- Transition Training Modules from MDE
Secondary Transition IEP Agenda
Secondary Transition Planning
3525.2900 TRANSITION AND BEHAVIORAL INTERVENTION PLANNING
Subp. 4. During grade nine the IEP plan shall address the pupil’s needs for transition from secondary services to postsecondary education and training, employment, and community living.
A. For each pupil, the district shall conduct an evaluation of secondary transition needs and plan appropriate services to meet the pupil’s transition needs. The areas of evaluation and planning must be relevant to the pupil’s needs and may include work, recreation and leisure, home living, community participation, and postsecondary training and learning opportunities. To appropriately evaluate and plan for a pupil’s secondary transition, additional IEP team members may be necessary and may include vocational education staff members and other community agency representatives as appropriate.
B. Secondary transition evaluation results must be documented as part of an evaluation report. Current and secondary transition needs, goals, and instructional and related services to meet the pupil’s secondary transition needs must be considered by the team with annual needs, goals, objectives, and services documented on the pupil’s IEP.
Secondary Transition Forms
These are examples of Potential Formal (F) and Informal (I) Age-Appropriate Assessments. This list is a guide and is not inclusive of the wide range of age or developmentally appropriate assessment tools. A minimum of 2 transition tools is required when addressing transition planning in the evaluation report.
Age Appropriate Transition Assessment Toolkit 4.0 Edition
| INSTRUMENT | DESCRIPTOR | RESOURCES |
| Ansell Casey Life Skills Assessment (ACLSA) |
Casey Life Skills (CLS) is a free tool that assesses the behaviors and competencies youth need to achieve their long-term goals. It aims to set youth on their way toward developing healthy, productive lives. Examples of the life skills CLS helps youth self-evaluate include:
|
Utilizing the online link, you can find both PDF and Excel versions of ACLSA. The Excel version will score for you and provide a report. This is free of charge. All you need to do is verify you are an educator. |
| Career One Stop-Interest Assessment | Identify interests and compare/learn about related jobs that may be related to the student's interest. | |
| Center for Innovative Teaching Experience (C.I.T.E.) Learning Styles Instrument | An informal tool used to identify learning styles. | |
| Deaf/Hard of Hearing (DHH) Competency Skills Checklists | Sets of informal checklists that address how a student's deaf and/or hard of hearing impairment may impact them with employment, post-secondary education, and independent living. | |
| Tools for measuring Functional Skills | Functional skills are skills that can be used every day, in different environments. Functional skills include daily living skills (e.g., cooking, cleaning ), self-help skills (bathing, brushing teeth, dressing, grooming), employment, recreation, community involvement, health, and functional academics, etc. |
|
| Indiana University Bloomington | The Transition Assessment Matrix was specifically developed for secondary transition teachers. There are variables to choose to filter our choices like topic area hoping to assess, grade level, different languages, and for students with high support needs. | https://instrc.indiana.edu/transition-resources/transition-matrix.html |
| Minnesota Career Information System (MCIS) for high school students |
Resources of Minnesota specific career exploration assessment, curriculum, and tools. |
https://portal.mn.cis360.org/ |
| Minnesota State Career Explorations |
The career service teams at Minnesota State college campuses have compiled resources for individuals to discover career paths, gain insight to industry, and understand skills of specific jobs. |
https://www.minnstate.edu/careerexploration/index.html |
| Minnesota Transition Checklist for Blind and Visually Impaired Persons | A checklist and fill-in-the-blank form completed by student and parent addressing transition pillars: Daily Living, Recreation and Leisure, Community Use, and Post-Secondary Training for individuals who are blind or visually impaired. | |
| Northland Learning Center Information Transition Questionnaire | An informal questionnaire used to aid in transition planning. | |
| Transition Planning Inventory-Second Edition (TPI-2) | A systematic way to address critical thinking planning areas and to account for individual student preferences, interests, strengths, and needs. Key information is gathered from students, parents, guardians, and school personnel through the use of rating scales and open-ended questions. |
Secondary Transition in the Evaluation Report
Transition Planning in the Evaluation Report
What kind of information can be gathered for age-appropriate transition assessments?
- Functional life skills
- Reasoning and problem-solving skills
- Learning styles
- Communication skills
- Self-awareness and self-advocacy skills
- Assistive Technology checklist
- Transferable skills
Students must have their strengths, interests and preferences determined.
Here are some examples:
- Perceptual skills: the ability to judge where, how, and if things fit together
- Interpersonal skills: attitude, cooperation, teamwork, and communication skills
- Work aptitudes: ability to remember and follow instructions and procedures; ability to plan, organize, and improve with practice
- Work behaviors: the ability to concentrate and stay on a task and ability to remain motivated
- Interests: personal goals and interests, hobbies, leisure-time activities, academics, and favorite and least-favorite subjects
- Cognitive skills: reading and math skills, concept formation, thinking style, and problem-solving abilities.
- Motor skills: using one’s hands, eye/hand coordination, fine motor skills, and mobility
Transition Training Modules from MDE
Related Services and School Nurse in the IEP
- Related Service Providers
- School Nurse
- FAQ on Orientation and Mobility Services
- MDE Q&A: Related Services
Related Service Providers
Related Services are defined in the Individuals with Disabilities Act (IDEA) as “transportation and such developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education.” The Minnesota Department of Education (MDE) provides information and resources to assist related service personnel to meet the needs of students receiving special education services.
Related services in schools may include but are not limited to:
- Audiology
- Counseling services
- Early identification and assessment of disabilities in children
- Interpreting services
- Medical services (for diagnostic or evaluation purposes)
- Occupational therapy
- Orientation and mobility services
- Parent counseling and training
- Physical therapy
- Psychological services
- Recreation including therapeutic recreation
- Rehabilitation counseling
- School health services and school nurse services
- Social work services in schools
- Speech-language pathology services
- Transportation
Links to national and state professional organizations for related service personnel
- American Occupational Therapists Association (AOTA)
- American Physical Therapy Association (APTA)
- American School Counselor Association (ASCA)
- American Speech-Language-Hearing Association (ASHA)
- Minnesota Chapter of the American Physical Therapy Association
- Minnesota Occupational Therapy Association (MOTA)
- Minnesota School Counselors Association (MSCA)
- Minnesota School Psychologist Association (MSPA)
- Minnesota School Social Worker Association (MSSWA)
- Minnesota Speech-Language-Hearing Association (MSHA)
- National Association of School Nurses (NASN)
- National Association of School Psychologists (NASP)
- School Nurse Organization of Minnesota (SNOM)
- School Social Worker Association of America (SSWAA)
Additional Resources
National Dissemination Center for Children with Disabilities (NICHCY) serves the nation as a central source of information on disabilities in infants, toddlers, children, and youth. The center also provides easy-to-read information on IDEA. There are State Resource Sheets that provide information on disability agencies and organizations in each state.
The IRIS Center is a national center that aims to provide high-quality resources for college and university faculty and professional development providers about students with disabilities by offering free online interactive resources that translate research about the education of students with disabilities into practice. The materials cover a wide variety of evidence-based topics, including behavior, RTI, learning strategies, progress monitoring and related services.
Sam Ortiz Videos on Cross Battery Assessments for English Language Learner (ELL) students can be found on the Minnesota School Psychology website. There are six sessions on the following topics:
- The Testing of Bilinguals: Early Influences and a Lasting Legacy
- Implications of Language Development for ELLs
- Effect of Early Language Development and Language of Instruction on Academic Outcomes
- Traditional and Current Approaches in the Evaluation of ELLs
- Current Approaches in the Evaluation of ELLs (continued): Introduction to the Culture-Language Interpretive Matrix (C-LIM)
- Case Studies in the Interpretation of the C-LIM
The Minnesota Positive Behavior interventions and Supports (PBIS) site represents the energy, collaborative work and learning of a broad constituency of Minnesota schoolwide PBIS implementers, trainers, coaches, practitioners, stakeholders, teachers, advocates, researchers, volunteers, administrators, regional and Minnesota PBIS project leadership staff.
The Technical Assistance Center on Positive Behavior Interventions and Supports has been established by the Office of Special Education Programs (OSEP), U.S. Department of Education to give schools capacity-building information and technical assistance for identifying, adapting, and sustaining effective school-wide disciplinary practices.
Intervention Central provides teachers, schools and districts with free resources to help struggling learners and implement Response to Intervention.
The Evidenced Based Intervention Network has been developed to provide guidance in the selection and implementation of evidence-based interventions in the classroom setting.
The National Professional Development Center on Autism is a multi-university center to promote the use of evidence-based practice for children and adolescents with autism spectrum disorders.
The Autism Internet Modules were developed with one aim in mind: to make comprehensive, up-to-date, and usable information on autism accessible and applicable to educators, other professionals, and families who support individuals with autism spectrum disorders (ASD). Written by experts from across the U.S., all online modules are free, and are designed to promote understanding of, respect for, and equality of persons with ASD.
The National Autism Center is May Institute’s center for the promotion of evidence-based practice. It is a nonprofit organization dedicated to serving children and adolescents with ASD by providing reliable information, promoting best practices, and offering comprehensive resources for families, practitioners, and communities
Literacy Information and Communication System (LINCS) is a national dissemination and professional development system, providing information on literacy research, practice, and resources.
The purpose of the I am NORM campaign is to promote inclusion by seeking to redefine the meaning of “normal” in our culture. It was inspired by the work from Including Samuel by Dan Habib which is a highly personal, passionately photographed film that captures the cultural and systemic barriers to inclusion.
School Nurse
School Nurse Role in Special Education Evaluations
MN Statute: 8710.6100 SCHOOL NURSE
The school nurse is an integral part of the special education team and should be involved in the pre-referral process in order to determine if there may be a health need that is impacting learning or is educationally significant.
- Collects and provides health-related information for the IEP team
- Professionally interprets and synthesizes health-related information in order to determine
- how the health condition impacts learning and the school environment
- the student's need for nursing services during the school day.
The school nurse uses a health interview style tool to gather. The information needed for special education evaluations. This tool is called the Health and Physical Assessment. This is a necessary component of evaluations for students who have health conditions (physical or mental) that require school nursing.
Such as:
- Individual or Emergency Care Plans
- Direct services: Medications, treatments, hearing monitoring
- Indirect Services: Medication management, care coordination, chronic condition management
Also recommended when:
- Little or no information is known of the student’s condition
- If the student has a complex health history.
- If the student has a physical or mental health condition and additional information is needed in order to understand how the condition impacts learning or participation in school.
- The Health and Physical Assessment is mandatory for eligibility under the Physically Impaired (PI) category (MN Rule 3525).
- It is also highly recommended when documentation of a health condition by a health care provider is required when determining eligibility, such as for Other Health Disabilities (OHD) and Traumatic Brain Injury (TBI).
- In Minnesota, the Health and Physical Assessment tool must be completed by a Licensed School Nurse (LSN) or Public Health Nursing (PHN), and should meet current professional standards.
Resources
Health and Physical Assessment
School Nurse Organization of Minnesota (SNOM)
PPT. School Nurse’s Role in Special Education & Third Party Billing
