A. Include information that is related to the school of attendance, program placement, and services the student is currently receiving. B. Include behavior and/or academic successes or challenges. C. Include information regarding the use and functioning of equipment such as hearing aids and/or FM systems. D. Include medical information related to the student’s hearing. 2. Complete the Assessment Plan form (D/M 66) and obtain the parent/guardian signature. A. 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 SELPA contracted audiologist.” B. The parent/guardian should initial each applicable statement listed under the Parental Authorization section of form D/M 66. C. LEAs are encouraged to have the assessment plans signed close to the date of their LEA audiology evaluation date and within the required 60-day assessment time frame. 3. Complete the Authorization for Use and/or Disclosure of Information form (D/M 63) and obtain the parent/guardian signature. Specify the receiving agency’s name as the SELPA/DMOPS/Pacific Hearing Services. The disclosing agency will vary depending on whether it is a physician, medical center, or audiologist. Referral Procedures Forward the following completed documents to the attention of the Area Director for Desert/Mountain Operations (DMOPS). • D/M 108A Annual Request for Audiological Evaluations/Services form • D/M 66 Assessment Plan form • D/M 63 Authorization for Use and/or Disclosure of Information form (for the current school year) Timeline for Assessment The audiological assessment must occur within 60 calendar days from the date the Assessment Plan was received by the LEA. When the signed Assessment Plan is received by the LEA, it should be date stamped or the date entered in the field at the bottom of the Assessment Plan (D/M 66).
Chapter 22 – Supports and Services, Charter SELPA As of 10/17/2019 D/M Charter SELPA Steering Committee Approval
Page 77
Made with FlippingBook - professional solution for displaying marketing and sales documents online