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ECS 300 - R

ORLEANS PARISH SCHOOL BOARD EXCEPTIONAL CHILDREN’S SERVICES REQUEST FOR SBLC/SATeam CONSIDERATION Date: ___________________________________________ Title/Position:

Requester:

__________________________________________________________

________________________________________________________ Gender M F Race of Requester _________________________

Student’s Name:

_____________________________________________________

DOB:

________________________ Gender M F Free or School: ____________________________________ Grade/Program: __________ Race of Student (see below ) Reduced Lunch Y N Circle ALL that are appropriate: Black White Hispanic Asian Am Indian/Native Alaskan Native Hawaiian/ Pacific Islander 1. Did the parent initiate the request?  Yes  No 2. If no, has the parent been contacted about the request?  Yes  No 3. Is the parent in agreement with the request?  Yes  No 4. Has student ever repeated the grade more than once? If yes, which grade(s) _______________ .  Yes  No 5. Has student been suspended during this school year? If yes, how many times _______________ .  Yes  No 6. Does the student have a Section 504 /IDEA evaluation?  Yes  No Reason for Request:

Evidence Based Interventions - Attach Supporting Data:

Summary of Findings of the SBLC/SATeam:

SBLC/SATeam DECISION:

SBLC/SATeam COMMITTEE’S SIGNATURES & TITLE

Date: 

1

     

2 3 4 5 6 7

8

Conduct /Continue Intervention - RtI, Reconsider on (date): Request Social Work Services 504 Evaluation Student Study Educational Plan Refer to SESS for Support Services Refer to SESS for Evaluation No assistance needed  Educational Rights given to parent Other:

07/11 White – Cumulative Folder

Yellow – ECS

____________ Parent initials

Pink – Parent

Principal’s Signature Goldenrod – SAT File

Date

300r-revised-11  
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