Richland Parish Schools
	Department of Special Services
	Initial Screening Process
	Needs Assessment
	Student:	Teacher:
	School:	Principal	(Designee)
	Dates of Screening:
	1.	Academic Grade 	In each grade level block, specify:  P (Pass), F (Fail), S (Social Promotion).  There 
	may be more than one letter in a block.
	Promotion
	K	1	2	3	4	5	6	7	8	9	10	11	12
	2.	Academic Performance:	                                            List the last achievement tests scores recorded for student.  Give results of Statewide 
	Assessment Test.  List the final report card grades for the last two years of school attendance and grades received 
	a.	Date of 	b.	Statewide Assessment 	c.	Report Card Grades
	Name of Test:	Test	Previous 	Present 
	%ile	Stanine	Grade	Years	Year
	Level	Reading	Total Reading
	Total Reading	Total Language
	Total Language	Math	Total Math
	Total Math	Writing	Science
	Science	Social Studies
	Social Studies	Days Absent
	3.	If prior evaluation, Date:	Attach Report of Evaluation or Case Number and Current 	Additional 
	
	4.	General Health:  Explain any Yes answers to the following questions.	Information
	Does the student...	YES	NO	COMMENTS	CHECK
	a.	have recurring health problems?
	b.	regularly take medication?
	c.	have a known medical problem?
	d.	have a physically crippling 
	e.	appear to be chronically ill?
	f.	wet/soil his clothes?
	g.	receive professional treatment?
	h.	receive school help for problems?
	5.	Immunization lacking?
	6.	Screening:  (If no record, schedule immediate screening.)  Complete the following:	DATE
	Vision Results	Normal	At Risk	Date of Screening	Corrected
	Hearing Results	Normal	At Risk	Date of Screening	Corrected
	7.	Does the regular P.E. program provide for the needs of this child?	Yes	No
	If no, why not?
	8.	Is this child presently receiving speech therapy?	Yes	No
	9.	SOCIAL:  Does this child experience/pose any significant social problems?	Yes	No
	If Yes, explain:

	Richland Parish Schools
	Department of Special Services
	Initial Screening Process
	Needs Assessment
	STUDENT:	SCHOOL:
	1.   PARENT CONFERENCE:
	A conference 	was held on	.
	(Parent/Guardian)	(Date)
	This conference 	by telephone	in person.
	RESULTS/COMMENTS:
	Referring Teacher's Signature
	2.   SCHOOL BUILDING LEVEL INTERVENTION COMMITTEE 
	(a)   A SBL Intervention meeting was held on	.
	       The following persons were in attendance and participated in reviewing initial screening 
	Signature - Principal
	Signature - Intervention Chairperson
	Signature - Permanent Member (if applicable)
	Signature - Referring Teacher
	Signature - Other
	Signature - Other
	Additional strategies/interventions recommended:
	(b)   A second SBL committee was held 
	Results:
	3.   COMMITTEE DECISIONS:
	A review of the information collected through initial screening indicates that this school can resolve the 
	concerns using local school resources.  Our decision is that                                               should remain in
	 the regular class.  Date                                    .
	A review of the information collected through initial screening indicates that this school cannot resolve the 
	
	concerns using local school resources.  Our decision is that                                                should remain 
	4.   ACTION TAKEN:
	(a)   SP ED 4 sent home.  
	(b)   SP ED 4 returned to school.  
	(c)   Referral given to Assessment Teacher.  

	Richland Parish Schools
	Department of Special Services
	Initial Screening Process
	Teacher Review
	Student:	Age:	Grade:	Form Completed By:
	School:	Teacher(s):
	Dates of Screening:
	1.  Concerns/Needs	2.  Attempts To Meet Needs
	Please state the specific reasons/situations which indicate that 	Please state any attempts made within the educational program to 
	this 	resolve each stated concern.  Describe what was done, for how 
	student may be in need of special services.  Include the academic,	long, and by whom; indicate if the attempt was successful, or made
		 matters worse.
	behavioral, physical, verbal, and motor areas as pertinent to this 
	child.
	1.  	1.  
	2.	2.
	3.	3.
	4.	4.
	5.	5.
	6.	6.
	7.	7.
	Attach and date any pertinent samples of student's work.  (Check the appropriate box if attachments are included)
	Additional Information	Work Samples