Section and Fields in the Referral Document

Student Name

Name of the student (integrated from eSchoolPLUS)

No.

Yes

Student Information

None

Populated from Student Information Profile. Captured through the {StudentName} field.

ID

Student ID (integrated from eSchoolPLUS)

No.

Yes

Student Information

None

Populated from Student Information Profile.
Captured through the {stateid} or {ID} field.

Date of Birth

Student’s Date of Birth (integrated from eSchoolPLUS)

No

Yes

Student Information

None

Populated from Student Information Profile.
Captured through the {DOB} field.

Age

Age of the student as of the Referral Date. (Auto-calculated)

No

Yes

None

None

Calculated as per the Referral Date and {DOB} field, and is captured through the {AgeAsofReferral} field.

Grade

The academic grade the student is enrolled in (integrated from eSchoolPLUS)

No

Yes

Student Information

None

Populated from Student Information Profile.
Captured through the {Grade} field.

School/Site

The name of the School the student is enrolled in (integrated from eSchoolPLUS)

No

Yes

Student Information

None

Populated from Student Information Profile.
Captured through the {School} field.

Native Language/ Mode of Communication of Child

Select if English is the native language of the student.
If not, then specify the language the student speaks, checking the box, Other (Specify)

Yes

Yes

N/A

N/A

Manually entered by user

Interpreter Needed?

Choose Yes if the student and the parents need an interpreter.

Yes

Yes

N/A

N/A

Manually entered by user

Captured through the {IsInterpreter} field.

Name of Person(s) Referring Child

Name of the person who has referred the student for Special Education.

Yes

Yes

N/A

Referral Information

User selects from Look-up or manual entry by selecting Non-Lookup

Captured through the {ReferralSource} field.

Date of Referral

Specify the date on which this referral was made.

Yes

Yes

N/A

Referral Information

User selects date from date picker or manual entry
Captured through the {DateofReferral} field.

Name and Address of Parent/Guardian

Parent/guardian names prepopulate from the Student Contacts profile.  Contacts with “Receives Mail” checkbox selected (connected to Registration Labels in eSchoolPLUS) will appear in the document as read only. 

Yes

Yes

Student Contacts Profile

N/A

Populated from Student Contact Profile. Click the More menu, Update Document from Student Profile if the names need to be refreshed.

Captured through the {ParentAddress} field.

The {ReceivesMail} flag for the address should be enabled.

Describe academic/developmental and/or behavioral performance that prompted referral?

Yes

Yes

N/A

N/A

Captured through the {PerformanceReferral} field.

Describe the child's strengths.

Yes

Yes

N/A

N/A

Captured through the {ChildStrength} field.

Summarize and/or attach any additional information text box.

Yes

Yes

N/A

N/A

Captured through the {AdditionalInfo} field.

Has the student repeated a Grade?

Select this field if the student had repeated their current grade. If you select ‘Yes’, the following field appears.

Yes

Yes

N/A

N/A

Captured through the {IsRepeatedGrade} field.

If yes, which grade?

Please provide the specific grade that the student has repeated in the current school year.

Conditional

Yes

N/A

N/A

Captured through the {RepeatedGrade} field.

Days absent this school year

Provide the count of days for which the student was absent from the school in the current program year. If no absences, enter 0.

Yes

Yes

N/A

N/A

Captured through the {DaysAbsent} field.

Has the student been suspended or expelled this school year?

Select this field if the student was suspended or expelled from the school in the current school year.

If you select ‘Yes’, the following field appears.

Yes

Yes

N/A

N/A

Captured through the {IsStudentSuspended} field.

If yes, how many days?

Please provide the number of days for which the student was suspended or expelled from

Conditional

Yes

N/A

N/A

Captured through the {SuspendedDays} field.

Has the student previously been referred for a Special Education evaluation?

Select this field if the student was previously referred for a Special Education evaluation.

If you select ‘Yes’, the following field appears.

Yes

Yes

N/A

N/A

Captured through the {PreviouslySPEDReferred} field.

If yes, provide information, if available:

Please provide the details regarding when the student was referred for a Special Education evaluation.

Conditional

Yes

N/A

N/A

Captured through the {SPEDReferredInfo} field.

Date of vision screening

The date on which the vision test will be done on the student.

Yes

Yes

N/A

N/A

Captured through the {VisionDate} field.

Date of hearing screening

The date on which the audio test will be done for the student.

Yes

Yes

N/A

N/A

Captured through the {HearingDate} field.

Public Agency Official/Designee Receiving Referral

The official from the Public Agency or their designated representatives must attend the referral meeting.

Yes

Yes

N/A

N/A

Captured through the {PublicAgency} field.

Date of Delivery

The date on which the document was provided to the parent/guardian. T

Yes

Yes

Document Delivery Profile

N/A

Captured through the {DateOfDelivery} field.

Mode of Delivery

Select the mode of delivery.

Yes

Yes

Document Delivery Profile

N/A

Captured through the {ModeOfDelivery} field. Uses the DeliveryMethod keyword table.