Livingston Parish Public Schools
         School Board Office Location:
         13909 Florida Blvd.
         Livingston, La.  70754

Section 1: Child Identification/ Renata D Documentation (CI)

1. Child Search Flyer (formerly CI - Renata D)

2. Order of 504 Student Blue Folder

             Section 2: School Building Level Committee (SBLC) Revised July, 2006  

                                            Refer to Forms Online Section SBLC forms

Gifted and/or Talented Screening Forms (G/T)

                                   Referral to SBLC Forms online under Gifted / Talented SBLC Committee

                                                 or the separate Gifted/ Talented Forms online section 

Section 3: 504 Service Determination Committee (504 SDC)

1. Notice of 504 Rights

2. Grievance Procedures for 504

3. 504 Flow Chart

4. Tracking Form (504 SDC)

5. Record of Examination of Confidential File form

6. 504 Initial Procedural Checklist (504-IPC)

7. Review of PA Evaluation and 504 Eligibility (504 PA-ED)

8. Procedures for providing 504 Services for Gifted/ Talented Students

Section 4: Review of Records (RR)

1. Review of PA Evaluation and 504 Eligibility (504 PA-ED)

2. Out Of System Record Review (OOSR) (504 OS-RR)  

Section 5: Evaluation Close-Out Form (ECO)

1. Report of 504 Close-out Conference (504-ECO)

2. Parent Close-out Letter of Evaluation results (504 COL)

             Section 6: Characteristics of Attention Deficit/ Hyperactivity Disorder (C.O.ADHD)

1. C.O. ADHD Assessment Checklist

2. Medical Statement from doctor (504-MS)

3. Release of Medical Information Request form (504- MR)

4. Directions for Observation

5. Observation Form (ADHD- Obs)

6. Developmental History (ADHD- DH)

7. C.O. ADHD Rating Scale-IV (ADHD- RSIV) 

8. Home Situations Questionnaire- Revised (ADHD – HSQ)

9. School Situations Questionnaire-Revised (ADHD – SSQ)

10. C.O. ADHD Assessment Evaluation Report and Summary of Results

11. C.O. ADHD Teacher Interview (ADHD-TI)

12. Functional Behavioral Assessment FBA for C.O.ADD/ADHD

 Section 7: Characteristics of Dyslexia (C.O.DYS)

1. Report Form for CBA (DYS-CBA- Report)

2. Refusal of MSL Program (MSL- Refusal)

3. Documentation Data Gathering (DYS-DG)

4. Speech/ Language Screening for C.O.DYS (DYS-SLS)

5. Parent Interview (DYS-PI)

6. Teacher Interview (DYS- TI)

7. Parental Consent for MSL Program and Characteristics of Dyslexia Assessment DYS-PC)

8. Dyslexia Assessment Plan (DYS- AP)

9. Characteristics of Dyslexia Assessment Checklist

10. C.O. DYS Assessment Evaluation Report- Notice of Findings (DYS- Eval)

11. Dyslexia MSL Program Review (DYS-MSL Review)

Section 8:  Academic Deficits in the Area of Mathematics (ACAD)

1. Review of Student’s Records (ACAD-SR)

2. CBA Report form (ACAD-CBA-Report)

3. Parent Interview (ACAD-PI)

4. Teacher Interview (ACAD-TI)

5. Assessment of ACAD Deficits in the Area of Mathematics Evaluation and 504 Eligibility Report(ACAD-Eval) 6 pages

Section 9: Social/Emotional Deficits (SE)

1. Social/ Emotional Assessment Checklist

2. Review of Student’s Cumulative Records (SE-SR)

3. Parent Interview (SE-PI)

4. Teacher Interview (SE-TI)

5. (FBA) (DIS-SE- FBA)

6. Behavior Intervention Plan (SE-BIP)

7. Medical Statement from doctor (504-MS)

8. Release of authorization for medical information (504-MR)

9. SE Assessment and 504 Eligibility Evaluation Report (SE- Eval)

Section 10: Medical Condition (MC)

1. Medical Condition Assessment Checklist

2. Review of Student’s Cumulative Records (Med-RR)

3. Teacher Interview (MC-TI)

4. Medical Statement from doctor (504-MS)

5. Release of authorization for medical information (504-MR)

6. IHP Nurses Health Care Plan (SDE-HCP)

7. Medical Condition Assessment and 504 Eligibility Evaluation Report (MC- Eval)

Section 11: Individual Accommodation Plan (IAP)

1. IAP and Test Accommodation Verification (TAV) forms (5 pages) (Oct 2008)

2. IAP Review Teacher Interview (IAP-TI)

3. Test Verification Validation Form for K-12 (Annual) 

4. Test Verification Validation Form for K-12 (Updated additions and/or Initials)

5. Test Verification Validation Form for K-12 (Emergency/ Temporary)

6. LEAP Instructions for IAPs and Accommodations Form (Spring 2008)

Section 12: ReEvalaution (ReEval)

1. ReEvaluation Checklist

2. Parent Interview (ReEval-PI)

3. Teacher Interview (IAP-TI)

4. Student Interview (ReEval-SI)

5. ReEvaluation Assessment Evaluation and 504 Eligibility Evaluation Report (ReEval - Report)

Section 13: Discipline Procedures (DIS)

1. Suspension Form (DIS-F 504)

2. Discipline Review Form (DIS-DR)

3. Functional Behavior Assessment -FBA (DIS-FBA)

4. Behavior Intervention Plan - BIP (DIS- BIP)

5. Teacher Interview Behavior/ Social (DIS-TI)

6. Grievance Form (DP/GR)

7. Manifestation Determination Form of Relatedness (DIS- MD)

Section 14: Due Process and Grievance Procedures (DP/GR)

     1. Grievance Form (DP/GR)

     2. Due Process Information Sheet

     3. Grievance Procedure for 504

Section 15: Temporary Status (TEMP)

1. Temporary Checklist

2. Teacher Interview (TEMP-TI)

3. Temporary Eligibility Determination Cover page

4. Medical Statement from doctor (504-MS)

 Section 16: Parental Participation Forms

1. Parental Participation Documentation (504-PPD)

2. Full and Effective Meeting Notice (504-FEN)

3. Full and Effective Notice Request for Informed Consent (504-FEN/PC)

4. Characteristics of Dyslexia Assessment Parental Consent for MSL Program (DYS-PC)

Section 17: Option III

1. Teacher Letter (Option III)

2. Teacher Interview (Option III-TI)

Section 18: Miscellaneous

1. Notice of Change Form (504 NC)

2. Procedures for Requesting OT Screening/ Assessment Form

3. OT Screening/ Assessment Form for At Risk Child   

Guidelines for Implementation of R.S 17:392.1 & 392.3 Louisiana Bulletin 1903