Glenbard Township High School District 87
Policy 6:120-E1
Instruction
Exhibit - Request to Access Classroom(s) or Personnel for Special Education Evaluation and/or Observation Purposes
Student name: ______________________________________________________________________ DOB: _______________
School attending: ____________________________________________________________________ Grade: ______________
The following information must be completed by individuals requesting to access a school building, facility, and/or educational programs or to interview District personnel or the student named above for the purpose of assessing the student's special education needs. Please complete this form and return it to the Building Principal or Program Director where the student is enrolled. He or she will contact you to coordinate your visit:
Parent/Guardian (Complete this section if the person making the request is the parent/guardian)
Name: ____________________________________________________________________________ Phone: _________________________
Address: ____________________________________________________________________________________________________________
___ I am the parent/guardian of the above-named student and wish to observe my child in the following classroom/settings:
________________________________________________________________________________________________________________
___ I am the parent/guardian of the above-named student and wish to observe the following classroom/settings which have been recommended for my child:
________________________________________________________________________________________________________________
for the purpose of: _________________________________________________________________________________________________
Observations are limited to one hour or one class period per school quarter.
Parent's Independent Evaluator or Other Qualified Professional (Complete this section if the person making the request is not the parent/guardian)
Name: ____________________________________________________ Agency/Company: ________________________________________
Phone: ____________________________________________________ Email Address: __________________________________________
Address: ___________________________________________________________________________________________________________
My professional training and/or licensure or certification, if applicable, is (check all that apply):
___ Teacher, certified in the areas of _________________________________________ Illinois Certified? Y N
___ Clinical Psychologist
___ School Psychologist
___ Licensed Clinical Social Worker
___ Licensed Social Worker
___ School Social Worker
___ Occupational Therapist
___ Physical Therapist
___ Speech/Language Pathologist
___ Audiologist
___ Psychiatrist
___ Registered Nurse
___ Certified School Nurse
___ Other qualified professional (list credentials): ___________________________________________________
I have been requested by the above named student's parent/guardian to conduct an evaluation of the student for the purpose of:
__________________________________________________________________________________________________________________
As part of this evaluation, I am requesting the following for the length of time noted (check all that apply):
___ Observation of student in the following classroom(s)/setting(s): ___________________________________________________________
Duration ___________________________________
___ Opportunity to interview the following personnel believed to work with the student: ____________________________________________
Duration: _______________________________________
___ Opportunity to interview the student.
___ I will need more than one hour or one class period for my visit for the following reason(s):
_______________________________________________________________________________________________________________
___ Student records, as noted in the attached, signed Authorization to Release Student Record Information.
Acknowledgement (To completed by the person making the access request)
I understand that the School District will allow me reasonable access to the school, school facilities, or educational programs or individual(s) I have requested as related to the purpose of my visit. I have been provided with a copy of 6:120-R2, Access to Classrooms and Personnel, and agree to comply with its terms and conditions. I further understand that during my visit, I must honor all students' confidentiality rights and refrain from any re-disclosure of such records.
__________________________________________________________________________________________________________________
Individual Requesting Access Signature Date
Parent/Guardian Verification (Must be completed whenever an independent evaluator or other qualified professional request access)
I, _____________________________________________________, am the parent/guardian of the above-named student, and I confirm that I have requested an evaluation of my child by the individual named herein, for the stated purpose(s). If requested above, I consent to my child being interviewed by the named evaluator as part of this visit understanding that the District has not conducted a background check on the evaluator. I have no reason to believe the evaluator poses a safety risk to my child or others. I further understand and agree that it is my responsibility to notify the School District in writing if I end my working relationship with the named evaluator prior to the completion of the tasks outlined herein and that the School District otherwise will work with the evaluator to provide reasonable access to the school,
school building, school facility, personnel, or my child at mutually agreed upon times and in a manner that is least disruptive to the school setting or my child's academic program.
__________________________________________________________________________________________________________________
Parent/Guardian Signature Date
REVIEWED: September 13, 2010
ADOPTED: September 27, 2010
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