Notification of Refusal for Initial Special Education Evaluation

District/LEA: Enter your district/LEA name.
Student Name: Enter the name of the student	Date of Birth: Enter the student’s DOB.

Dear Parent of Enter student name., Date: Enter a date.

Your child was referred by ☐ Parent ☐ Babies Can’t Wait (BCW) ☐ Student Support Team (SST) ☐ Other: ___________ and was recommended for evaluation to determine if your child is eligible for special education services and supports.

After reviewing the information in the referral and considering conducting an individual evaluation, the school system is refusing the request for an individual evaluation to determine if your child is eligible for special education services

The district is refusing the request for an individual evaluation for the following reasons:

Describe why the district is declining to pursue the evaluation.

Describe the evaluation procedure(s), assessment(s), record(s), or report(s) the district/LEA used in the decision.

Describe the evaluation procedure(s), assessment(s), record(s), or report(s) the district/LEA used in the decision.

Describe any other options considered and the reasons those options were rejected.

Describe any other options considered and the reasons those options were rejected.

Describe any other factors relevant to the decision.

Describe any other factors relevant to the decision.

You and your child currently have protections identified in the Parental Rights (also called procedural safeguards). A copy of those procedural safeguards has been included. If you need assistance in understanding your rights, need information translated into another language or if you have any questions about the evaluation process or need more details about the evaluation, please contact the following:

Enter Contact Name	Enter position	Enter phone number	Enter the email
Name	Position	Phone Number	Email