Application for Support Under Criteria " C "

Chbox1.jpg (411 bytes)    Eligibility Criteria Reviewed

 

Student:______________________________________________

Birth date:____________________________________________

Grade:_______________________________________________

Board:_______________________________________________

School: ______________________________________________

Students Residential Address:_____________________________

Student is not attending neighborhood/zoned school

____yes    or    ____no
 

If no, give reason ______________________________________

               

Chbox1.jpg (411 bytes)     Documentation of             Chbox1.jpg (411 bytes)     Redocumentation of     



Please forward the following to the director of Student Support Services, Department of Education:

 
                            ____Form 1        Programming Pathways Chart

                            ____Form 2        Comprehensive Assessment Chart

                            ____Form 3.1     Confirmation of Eligibility

                            ____Form 3.2     Informed Consent by Parent ( s ) /
                                                          Guardian ( s )

                            ____Form 3.3     District Office Confirmation of Procedures




1. Programming Pathways have been explored:

Please indicate the school years, as well as the curriculum/program areas of each pathway

Programming Pathway Identify all programming pathways which have been attempted with this child. Indicate all curriculum/program
areas		 Identify the child's current programming pathways. Indicate all
curriculum/program
areas.  		Identify the programming pathway needed by the child and which will be followed subsequent to this documentation
procedure.
Pathway 1:
All "regular" curriculum
without support



      
Pathway 2:
"regular" curriculum with support



      
Pathway 3:
"modified"courses/
subjects/
curriculum


      
Pathway 4:
"alternate" courses/
subjects along with "regular" and/or "modified"
courses/subjects
      
Pathway 5:
An "alternate" curriculum



      

Notes on the Programming Pathways Chart:
    1. For further information on these pathways, refer to the following Department of Education publications:
           Pathways to Programming and Graduation, A Handbook for all Teachers and Administrators (1998)
           Programming for Individual Needs, Pre-referral Intervention (1996)
           Programming for Individual Needs: Individual Support Services Plans (1996)
           Programming for Individual Needs: Alternate Courses (1996)
           Using Our Strengths: Programming for Individual Needs (1992).
    2. For children entering Kindergarten, columns one and two may be omitted where appropriate.

 

 

2. A comprehensive assessment* has been completed:

 

Domain Formal** Assessment Completed (give date/instrument) Informal Assessment Completed (give specifics) Individual/ Agency Completing Assessment Environments Assessed*** Level of Support Required****
1. Communication

 

 

          
2. Gross/Fine Motor

 

 

          
3. Self-Help

 

 

          
4. Adaptive/ Behavioral/ Social

 

 

          
5. Cognition/ Metacognition

 

 

          
6. Academic

 

 

          

Notes on assessment chart: A summary of the assessment results must be completed by a qualified person.

*Refer to Items 2.1 to 2.6 in Procedure.
** If  formal assessment has not been undertaken in any area, please attach a letter explaining the reason.
*** For "environment assessed" , indicate: home, school and/or community.
****For "level of support",  indicate: Level 1 ( intermittent ),   Level II  ( Limited ),  Level III  ( Extensive ),
or Level IV ( Pervasive ).

See pages 31-36 in Coordination of Services for Children and Youth in Newfoundland and Labrador: Profiling the Needs of Children/Youth (1997) for elaboration on the levels of support.

 


3.Confirmation of Eligibility:

3.1

We, the undersigned, have been involved in the assessment and individual support services planning

process and confirm that this assessment verifies that __________________________________                                                                                                            (student)

meets the Eligibility Criteria for Criteria C support as defined i.e.

_____exhibits moderate or severe impairment in cognitive functioning ( IQ of 50 or below ),

_____severe impairment in adaptive functioning in the following areas:

            Chbox1.jpg (411 bytes)     communication
            Chbox1.jpg (411 bytes)     gross/fine motor
            Chbox1.jpg (411 bytes)     self-help
            Chbox1.jpg (411 bytes)     adaptive/behavioral/social
            Chbox1.jpg (411 bytes)     academic

_____requires an alternate curriculum in all areas

_____does not have a sensory or physical disability

_____has a sensory disability_____not a primary disability

_____has a physical disability_____not the primary disability

 

_________________________________
(date)

_________________________________      __________________________________
(Classroom/home room teacher)                   Special Education teacher-(non categorical)

_________________________________      ___________________________________
(Psychologist/Guidance Counselor)               Special Education-(Criteria C, If Applicable)

_________________________________      ___________________________________
(Principal)                                                        (Other)


_________________________________       ___________________________________
(Other)                                                              (Other)

 

 


3.2 Informed Consent by Parent (s) / Guardian (s)

 

 

  Yes   No
I have been involved in the assessment of my child

_________________________________(Child's name)
and the assessment results have been explained to me.

 ________ ________
 

I have been fully involved in the individual support
services planning process for my child.

________ ________
 

The continuum of programming pathways and the implications of each have been discussed with me. 

________ ________
 

The continuum of service options (Regular Classroom/
subject teacher, Non-categorical Special Education
teacher and Criteria C teacher have been reviewed with me.

 ________ ________
 

I understand and approve of this documentation Procedure.

 ________ ________

 

 

Parent(s)/Guardian(s) signature

_________________________________         ______________________________


_________________________________
Date

 



 

 

 

3.3 District Office Confirmation of Procedures

 

The documentation, including a summary report of the comprehensive assessment and an ISSP

identifying an alternate curriculum, has been completed and is on file at this office. The

procedures as outlined by the Department of Education have been followed, and the

documentation verifies that____________________________________________________

meets the eligibility criteria  for Criteria C support.


_________________________________________
Program Specialist for Student Support Services

_________________________________________
Director of Assistant Director (Programs)

_________________________________________
Date