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Custer School District 16-1

To Educate Every Student to His or Her Potential

Custer School District 16-1
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EVALUATION & IEP FORMS

Evaluation Specific

Referral to Special Education
Review of Existing Data-Initial Evaluation
Review of Existing Data- Reevaluation
Evaluation Report Template
Evaluation Report-Who Does What
MDAT Meeting Sign In
PPWN-Consent for Evaluation
Summary of Progress (SOP) for Graduating/Age Out of Services

Alternative Assessment for the IEP Meeting

Alternative Assessment Determination Worksheet
Alternative Assessment Eligibility Evidence

Information Gathering

Parent Input (PawPrint)
Teacher Input (PawPrint)
Teacher Interview Form w/ Organizational Checklist
Teacher SLD Interview and IP Checklist
Social-Developmental History Form
Student Structured Interview
Student Structured Interview-ADHD version

Evaluation/IEP Shared Forms

Meeting Notice
Team Meeting Sign in Sheet
Consent for Information Disclosure
SLD Skills Graph
PPWN
Request to Excuse Team Member
Consent to Invite Outside Agency
IEP Meeting Agenda
HIPPA Consent Form

Get In Touch

527 Montgomery St., Custer, SD 57730

Phone: 605-673-3154 Fax:

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CSD Non-Discrimination Statement The Custer School District 16-1 does not discriminate on the basis of race or color, national origin, gender (including pregnancy),disability, sexual orientation, age, religion and creed, military/veteran status, or marital status, in admission or access to or treatment or employment in its programs and activities: and provides equal access to the Boy Scouts and other designated youth groups. For inquiries concerning the District’s compliance with Title VI or the Age Discrimination Act please contact the Superintendent of Schools, 527 Montgomery St., Custer, SD, 57730, (605) 673-3154; for Title IX please contact the Activities Director, 1645 Wildcat Lane, Custer, SD, 57730, (605)673-4473; or for Section 504 of the Americans with Disabilities (ADA) act please contact the Special Education Director, 527 Montgomery St., Custer, SD, 57730, (605)673-3154. For further inquiries contact the South Dakota Regional Office for Civil Rights, Kansas City Office, U.S.Dept. of Education, One Petticoat Lane, 1010 Walnut Street, Suite 320, Kansas City, MO, 64106, phone (816) 268-0550, TDD (800) 877-0599, Fax (816) 268-0559, e-mail: OCR.KansasCity@ed.gov. USDA Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) mail: program.intake@usda.gov. This institution is an equal opportunity provider.

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