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Referral Source & Assessment Type
Assessment Type checkboxes — Check all that apply:
• Initial — Mark if the assessment is being completed to determine eligibility for special education (i.e., student is not yet eligible). Starts the 60-day timeline from parent consent.
• Plan Review — Assessment conducted during an annual IEP review to update present levels.
• Reevaluation — Mark if the assessment is being completed to re-establish eligibility for special education. Must occur at least every three years as part of the triennial review process.
• Transition — Assessment focused on post-secondary needs (career, independent living). Required for students 16+.
• Interim — Mark this box if assessments are being completed as part of an interim review (i.e., students newly enrolled to the LEA).
Who referred for assessment — Check all that apply:
• Parent — ⚠ District must respond within 15 calendar days with either an Assessment Plan or Prior Written Notice of refusal.
• Teacher / SST / Other School Personnel — Should be preceded by documentation of general education interventions tried first.
Identification vs. Evaluation — Check whether this assessment proposes to determine WHETHER a disability exists (Identification) or the NATURE and EXTENT of an existing disability (Evaluation).
Description of Proposed Assessment
Reason(s) for proposed assessment — Must be specific and individualized. Reference the referral source, specific academic or behavioral concerns, and any interventions already tried. Generic language like "to determine eligibility" is insufficient.
Other options considered and reasons for rejecting them — Document alternatives the team discussed before proposing assessment. Examples: continuing general education interventions, referral to a different support program, parent consultation only.
Other factors relevant to the proposal — Include any additional context: language background, health factors, attendance issues, or recent life events that may be affecting performance.
Evaluation procedures used in deciding to propose — List all data reviewed before proposing assessment: progress monitoring data, teacher reports, existing assessments, observations, parent input.
⚠ All four narrative sections must be completed. Leaving any blank is a procedural violation and weakens the district's position if the assessment is ever challenged.
Evaluation Areas — Page 1
Check only the areas of suspected disability relevant to this student. Do not check all areas by default — assessments must be targeted to areas of need.
Academic Achievement — Reading, math, oral and written language. Typically administered by the Education Specialist (e.g., WJ-IV, WIAT-4). Required for all SLD evaluations.
Health — Administered by the school nurse. Reviews medical records and vision/hearing screenings. Required for all initial evaluations — health factors must be ruled out before attributing difficulties to a disability.
Intellectual Development — Cognitive assessment by the school psychologist (e.g., WISC-V, DAS-II). Required for most initial evaluations and for Intellectual Disability eligibility.
Examiner Title — List the credential/title of the person who will administer each assessment (e.g., Ed Specialist, School Psychologist, SLP). This must be someone qualified to administer that specific assessment type.
Student Name / Birthdate / Date / Header Info
Name / Birthdate — Pulled from SEIS/SIS — verify before presenting to parent. Must match enrollment records exactly.
Date — The date the Assessment Plan is being presented to the parent. This is NOT the consent date. The 60-day assessment timeline begins when the parent signs and returns consent — not the date the plan was given.
Assessment Plan Date / School / District / Grade — All from SIS. Verify District is correct — for charter students, the district of service should be the charter's LEA.
Native Language — From SIS home language survey. Assessment MUST be conducted in the student's native language when feasible. If not possible, document why.
English Proficiency Level — Current ELPAC level for EL students. Determines whether assessments need to be administered in primary language or with interpretation.
Evaluation Areas — Page 2 (continued)
Language/Speech Communication Development — Administered by a licensed SLP. Assesses receptive/expressive language, articulation, fluency, voice, and pragmatics. Required when SLI is suspected or communication significantly impacts school performance.
Motor Development — Administered by OT and/or PT. Assesses fine motor (handwriting, self-care) and gross motor (coordination, mobility). Required when motor deficits impact school participation.
Social Emotional/Behavior — Administered by the school psychologist using rating scales (BASC-3, BRIEF), observation, and structured interviews. Required when ED eligibility is considered or behavior significantly impacts learning.
Adaptive Behavior — Measures independent daily living skills (Vineland-3, ABAS-3). Required for Intellectual Disability determination. Also critical for transition planning.
Post-Secondary Transition — Interest inventories, career assessments, independent living skills tools. Required for students 16+ and strongly recommended starting at 14. Results must directly inform ITP goals.
Other / Alternative Means of Assessment
Other — Any assessment area not listed above. Specify exactly what will be assessed and by whom. Examples: AT evaluation, vision specialist, DHH specialist, orientation and mobility, functional vocational evaluation.
Alternative Means of Assessment — Used when standard testing procedures would not accurately reflect the student's abilities due to their disability. Must describe the alternative method.
Examples of alternative means:
• Portfolio review of student work samples
• Observational protocols in natural settings
• Dynamic assessment or curriculum-based measures
• Work sample analysis
• Structured parent/caregiver interview
⚠ Alternative means require justification — document why standard procedures are not appropriate for this student and what the alternative method will measure instead.
Parent Consent & Medi-Cal Authorization
I consent to the assessment — Parent signature here authorizes assessment to begin. ⚠ The 60-day completion timeline starts on the date the parent SIGNS this form — not the date it was given. Assessment cannot begin without written consent for initial evaluations.
I do not consent — Parent has the legal right to refuse. The district may pursue assessment through due process only if they believe it is essential. Document all efforts to explain the process.
I would like assessment information considered — Parent wants the team to review private evaluations or outside assessments. The team MUST meaningfully consider this — they cannot dismiss it without explanation.
Signature / Date — Keep the original signed form in the student's cumulative file. Document the date received.
Medi-Cal Authorization — Separate voluntary consent for the district to bill Medi-Cal for covered IEP services. Refusal does NOT affect the student's IEP services. Parent can revoke at any time in writing. Must explain this clearly before requesting signature.
Date Received by District/LEA — ⚠ This date officially starts the 60-day clock — not the date the parent signed, and not the date the Assessment Plan was presented. The 60-day timeline begins the day the LEA physically or electronically receives the signed Assessment Plan back from the parent. If a parent signs on a different day than the date they return it, the date the LEA receives it controls. Record it accurately on the day it arrives and track it actively — this is a hard federal deadline.
El Dorado County Charter SELPAAssessment PlanSpecial Education Local Plan Area
