Procedure – Category 5000 (Students) AR 5005.4 – SELPA Referral Procedures
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Annual Students who have previously been referred and evaluated for audiological services as part of the SELPA Audiological Program are eligible for annual audiological assessments. A. Pre-referral LEA Responsibility: LEAs participating in the SELPA Audiological Program may request an annual audiological assessment by following the procedure listed below. It is not necessary that the IEP team convene for this type of referral. 1. Complete the Annual Request for Audiological Evaluation/Services form (DM 108A). Please DO NOT complete the Initial Request for Audiological Evaluation/Services form (DM 108) for annual referrals. • Include information that is related to the school of attendance, program placement, and services the student is currently receiving. • Include behavior and/or academic successes or challenges. • Include information regarding the use and functioning of equipment such as hearing aids and/or FM systems. • Include medical information related to the student’s hearing. 2. Complete the Assessment Plan form (DM 66) and obtain the parent/guardian signature. The person making the referral should check the box that corresponds to the type of assessment(s) requested. Most often the “other” box is checked followed by the statement, “Audiological assessment to be completed by the SELPA contracted audiologist.” The parent/guardian should initial each applicable statement listed under the Parental Authorization section of form DM 66.
AR 5005.4 – SELPA Referral Procedures Desert Mountain Charter Special Education Local Plan Area (DMCS) (rev. 8/9/22)
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