Name	Student ID:	Date:
	
LEA:	DOB:  	Grade:  	Age:	
Parent:	Phone:	Address:

A group that is comprised of the same individuals as an IEP team and other qualified professionals, as appropriate, shall review existing evaluation data on the student.  The following existing evaluation data was reviewed (check all that apply) with a summary included below each section:
□	Evaluations and information provided by the parent(s) of the child
□	Current classroom-based, local, or state assessments and classroom-based observations
□	Observations by teachers and related service providers
□	Other
On the basis of the above review and input from the parent(s), identify what additional data, if any, are needed to determine
 Whether the child is, or continues to be, a child with a disability;
1.	The present educational needs of the child;
2.	The child’s present level of academic achievement and related developmental needs;
3.	 Whether the child needs or continues to need special education and related services; and
4.	Whether any additions or modifications to the special education and related services are needed to enable the child to meet the measurable annual goals set out in the IEP of the child and to participate, as appropriate, in the general education curriculum.
The group determined that (check one)	
	Additional data are needed to determine whether the child is or continues to be a child with a disability and to determine the child’s educational needs and the other matters set forth above.  (Attach Prior Notice and Consent to Evaluate forms)	
	NO additional data are needed to determine whether the child is or continues to be a child with a disability and to determine the child’s educational needs and the other matters set forth above.  (Provide the child’s parent(s) with prior written notice.  For reevaluations, include the right of the parent to request an evaluation to determine whether the child continues to be a child with a disability and to determine the child’s educational needs.)
The child continues to qualify for special education services as a student under the disability category of 
	
□ Virginia Procedural Safeguards Notice was provided to the parent.
Signatures of qualified professionals and the parent(s) of the child and student if appropriate:
Signature	Position/Relationship	Date	Agree/Disagree*	

				

*Attach dissenting opinions