Consent Form (Kentucky)

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The Consent for Evaluation form is used to record the proposed evaluation(s) or reevaluation needed to determine the student's eligibility for services and whether the student's parent/guardian provided consent for the evaluation(s) to be performed. For information on general functionality, navigation, and additional plan and evaluation features, see the core Plan and Evaluation Information article.

The current format of this document is the KY Consent for Evaluation 2023 print format. Formats are selected in Eval Types.

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Consent Header

The Consent Header editor includes the dates associated with evaluation of the student, including the date the student was notified, the date of consent for initial evaluation and the date of consent for services.

Screenshot of Consent Header in an In Progress status Consent Header Editor

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Field	Description	Validation
ARC Date Required	The date the Admissions and Release Committee met.	N/A
Evaluation Type Required	The type of evaluation. Options include: Initial Evaluation Reevaluation	These options are hard-coded.
Date of Consent for Initial Evaluation	The date the parent/guardian gave consent for an initial evaluation.	N/A
Date of Consent for Reevaluation	The date the parent/guardian gave consent for an reevaluation.	N/A
Date of Revocation of Consent for Evaluation	The date the parent/guardian revoked consent for an evaluation.	N/A
Reason for Revocation of Consent for Evaluation	The reason the parent/guardian revoked consent.	N/A

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Enrollment Information

The Enrollment Information editor reports Special Education information from the student's Enrollment record. This editor is read only.

The Refresh button retrieves a fresh copy of data from the student's record. The Refresh button must be clicked before the editor can be placed in a Complete status.

See the General Information section for additional information.

Screenshot of Enrollment Information editor in an In Progress status Enrollment Information Editor

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Field	Description	Database Location (when Refresh is clicked)	Validation
Primary Disability, if currently identified	The student's primary disability.	Enrollment > Primary Disability Enrollment.disability1	This field is read-only and is pulled from the student's Enrollment record upon Refresh. Displays None when a disability is not identified.
Grade	The student's current grade.	Enrollment > Grade enrollment.grade	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
School Name	The student's school of attendance.	Learner Planning > Learning Plans > Enrollments > residentSchool enrollment.residentSchool	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
School Phone	The student's school of attendance phone number.	Learner Planning > Learning Plans > School > Phone School.phone	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District Information
District Number	The district number associated with the Enrolled school.	System Administration > Resources > District Information > State District Number	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District Name	The district name associated with the Enrolled school.	System Administration > Resources > District Information > Name	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District Address	The district address associated with the Enrolled school.	System Administration > Resources > District Information > Address	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District Phone	The district phone number associated with the Enrolled school.	System Administration > Resources > District Information > Phone	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District SPED Address	The district special education address associated with the Enrolled school.	System Administration > Resources > District Information > SPED Address	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District SPED Phone	The district special ed phone number associated with the Enrolled school.	System Administration > Resources > District Information > SPED Phone	This field is read-only and is pulled from the student's Enrollment record upon Refresh.

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Student Information

The Student Information editor displays basic information about the student such as demographic information. This is a read-only editor.

The Refresh button retrieves a fresh copy of data from the student's record. See the General Information section for additional information.

Screenshot of Student Information editor in an In Progress status Student Information Editor

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Field	Description	Database/UI Location (when Refresh is clicked)
Last Name	The student's last name.	Census > People > Demographics > Last Name identity.lastName
First Name	The student's first name.	Census > People > Demographics > First Name identity.firstName
Middle Name	The student's middle name.	Census > People > Demographics > Middle Name identity.middleName
Suffix	The student's suffix.	Census > People > Demographics > Suffix Name identity.suffix
Gender	The student's gender.	Census > People > Demographics > Gender identity.gender
Birthdate	The student's birthdate.	Census > People > Demographics > Birth Date identity.birthDate
Race, Ethnicity	The student's race/ethnicity.	Census > People > Demographics > Race/Ethnicity identity.raceEthnicity
Primary Mode of Communication of Student	The student's language they speak at home. Values available are found in the locked Attribute Dictionary, LanguageList.	Census > People > Demographics > Home Primary Language identity.homePrimaryLanguage
Address	The student's address. This field becomes a dropdown if more than one address exists for the student. The primary household displays by default.	Census > Households > Address Info address.number; address.street; address.tag; address.prefix; address.dir; address.apt; address.city; address.state; address.zip
Student Number	The student's identification number.	Census > People > Demographics > Student Number
State ID	The student's state identification number.	Census > People > Demographics > State ID
Case Manager Information *These fields are read-only.*
Name	The first and last name of the team member.	Student Information > Special Ed > General > Team Members > Case Manager Name
Title	The role of the team member.	Student Information > Special Ed > General > Team Members > Case Manager Title
Phone	The phone number of the team member.	Student Information > Special Ed > General > Team Members > Case Manager Work Phone

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Parent/Guardian Information

The Parent/Guardian Information editor populates based on the guardian checkbox on the student's Relationships tool. The editor includes Demographics information for the student's guardian.

The Delete button next to each parent/guardian can be used to remove a parent/guardian from the Evaluation.

The Refresh button retrieves a new copy of parent/guardians' data. This also returns any accidentally deleted people. Manually entered fields do not change when the refresh button is clicked. The user must Save after clicking Refresh to capture changes.

Screenshot of Parent/Guardian Information editor in an In Progress status Parent/Guardian Information Editor

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Field	Description	Database/UI Location (when Refresh is clicked)	Validation
Last Name	The last name of the parent/guardian.	Census > People > Demographics > Last Name identity.lastName	This field populates from Census. This is part of the header for the parent/guardian.
First Name	The first name of the parent/guardian.	Census > People > Demographics > First Name identity.firstName	This field populates from Census. This is part of the header for the parent/guardian.
Middle Name	The suffix of the parent/guardian.	Census > People > Demographics > Suffix Name identity.suffix	This field populates from Census. This is part of the header for the parent/guardian.
Suffix	The suffix of the parent/guardian.	Census > People > Demographics > Suffix Name identity.suffix	This field populates from Census. This is part of the header for the parent/guardian.
Relationship	The relation of the parent/guardian to the student.	Census > People > Relationships	This field populates from Census. This is part of the header for the parent/guardian.
Print Sequence	The print order of the parent/guardian(s) on the IEP.	N/A	When no Sequence is selected, parent/guardian(s) print in the order displayed in the UI. When any Sequences are selected, parent/guardian(s) with a sequence number print in the order defined. Un-sequenced parent/guardians display at the bottom.
Address	The parent/guardians' address.	Census > Households > Address Info address.number; address.street; address.tag; address.prefix; address.dir; address.apt; address.city; address.state; address.zip	This field populates from Census. When there are multiple addresses for a person, a drop down with an option to select which address displays. When there is only one address, the drop down has one option. The populated address is the one marked Primary.
Home Phone	The home phone number of the parent/guardian.	Census > People > Demographics > Household Phone	This field populates from Census.
Work Phone	The work phone of the parent/guardian.	Census > People > Demographics > Work Phone	This field populates from Census.
Cell Phone	The cell phone of the parent/guardian.	Census > People > Demographics > Cell Phone	This field populates from Census.
E-mail	The primary email address for the parent/guardian.	Census > People > Demographics > Email	This field populates from Census.

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Consent to Evaluate/Reevaluate

The Consent to Evaluate/Reevaluate editor is used to document the consent given for the student to be evaluated/reevaluated for services.

Screenshot of Consent to Evaluate/Reevaluate editor with Autism selected as the student's suspected disability Consent to Evaluate/Reevaluate Editor

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Field	Description	Validation
Consent to Evaluate/Reevaluate
Suspected Disability	The potential disability of the student. Options include: Autism Deaf-Blindness Developmental Delay Emotional-Behavioral Disability Functional Mental Disability Hearing Impairment Mild Mental Disability Multiple Disabilities Orthopedic Impairment Other Health Impairment Specific Learning Disability Speech or Language Impairment Traumatic Brain Injury Visual Impairment No Disability Suspected	Multiple options can be selected. Options available are found in a locked Attribute Dictionary, Evaluation > Suspected Disability.
Select disability area(s) for 'Developmental Delay'	The disability areas associated with the student's developmental delay, when applicable. Options include: Cognition Motor development Self-help/adaptive behavior Communication Social-emotional development	This field is available when Developmental Delay is selected as the Suspected Disability. Multiple options can be selected. Options available are found in a locked Attribute Dictionary, Evaluation > Developmental Delay.
Select disability area(s) for 'Specific Learning Disability'	The disability areas associated with the student's specific learning disability, when applicable. Options include: Oral Expression Written Expression Reading Fluency Skills Mathematics Calculation Listening Comprehension Basic Reading Skills Reading Comprehension Mathematics Reasoning	This field displays when Specific Learning Disability is selected as the Suspected Disability. Multiple options can be selected. Options available are found in a locked Attribute Dictionary, Evaluation > Specific Learning Disability Field Name = SLD.
Select disability area(s) for 'Speech or Language Impairment'	The disability areas associated with the student's speech or language impairment, when applicable. Options include: Speech Sound Production and Use Language Fluency Voice	This field displays when Speech or Language Impairment is selected as the Suspected Disability. Multiple options can be selected. Options available are found in a locked Attribute Dictionary, Evaluation > Speech Language.
For each evaluation (Initial or Reevaluation), mark 'X' for the assessment components determined to be addressed within the multidisciplinary assessment. Mark 'E' if the assessment exists within the educational records of the student and will be considered.
Health, Vision, Hearing, and Motor Abilities
X and E checkboxes	X and E checkboxes display for each of the following options: Medical / Health Evaluation Vision Exam Functional Vision / Learning Media Assessment Orientation and Mobility Braille Skills Inventory Hearing Fine Motor Gross Motor Occupational Therapy Physical Therapy Behavior Observation Assistive Technology Other.	Both values can be selected per option.
Specify Other *Required	The other Health, Vision, Hearing, and Motor Abilities assessment component.	*This field is available and required when Other is selected above.
Academic Performance
X and E checkboxes	X and E checkboxes display for each of the following options: Basic Reading Reading Comprehension Reading Fluency Math Calculation Math Reasoning Oral Expression Listening Comprehension Written Expression Performance Based Tests Criterion Referenced Tests Curriculum Based Tests Norm-Referenced Tests Behavior Observation Other	Both values can be selected per option.
Specify Behavior Observation Areas *Required	The specific Behavior Observation Area assessment component.	*This field is available and required when Behavior Observation is selected above.
Specify Other *Required	The specific Academic Performance assessment component.	*This field is available and required when Other is selected above.
General Intelligence
X and E checkboxes	X and E checkboxes display for each of the following options: Cognitive / Intellectual Assessment (aptitude and mental processing) Behavior Observation Other	Both values can be selected per option.
Specify Other *Required	The specific General Intelligence assessment component.	*This field is available and required when Other is selected above.
Social and Emotional Status
X and E checkboxes	X and E checkboxes display for each of the following options: Adaptive Behavior / Self-Help Behavior Observation Behavior Rating Scale Functional Behavioral Assessment Other	Both values can be selected per option.
Specify Other *Required	The specific Social and Emotional Status assessment component.	*This field is available and required when Other is selected above.
Communication Status
X and E checkboxes	X and E checkboxes display for each of the following options: Receptive Language Expressive Language Speech Sound Production Voice Fluency Oral Mechanism Hearing Behavior Observation Augmentative Communication Other	Both values can be selected per option.
Specify Other *Required	The specific Communication Status assessment component.	*This field is available and required when Other is selected above.
Vocational Evaluation/Transition Needs
X and E checkboxes	X and E checkboxes display for each of the following options: Vocational Aptitude Interest Inventory Learning Style Behavior Observations Other	Both values can be selected per option.
Specify Other *Required	The specific Vocational Evaluation/Transition Needs assessment component.	*This field is available and required when Other is selected above.
Other
X and E checkboxes	X and E checkboxes display for each of the following options: Social and Developmental History IEP Progress Data RTI Data State Assessment Data Developmental Assessment Other	Both values can be selected per option.
Specify Other *Required	Any other assessment component.	*This field is available and required when Other is selected above.
List the recommendations for student needs (e.g., glasses, hearing aids), any modifications/adaptations of evaluation instruments, procedures, or settings to be used for the evaluation.	A description of the recommendations for the student's needs.	N/A
List existing reports/assessment data, which will be used as part of the multi-disciplinary assessment.	A description of existing data used as part of the assessment.	N/A

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Parental Consent

The Parental Consent editor includes the individual providing consent to evaluation, whether consent was given, and the areas to be evaluated.

Screenshot of Parental Consent editor with the Yes checkbox marked Parental Consent Editor

Field	Description	Validation
The parent agrees for evaluation in each of the ARC selected area(s) for assessment indicated on the Consent to Evaluate/Reevaluate editor.	Options include: Yes, I understand the above information and do give my consent for a full individual evaluation in the area(s) listed above. For Reevaluation purposes, I acknowledge that there is no additional data needed to determine that my child/student continues to be a child/student with an educational disability. I have been informed of the reasons no additional data is needed. I understand that I may request further assessment should I feel it is needed. No, I understand the above information and do not give my consent.	Only one selection can be selected.

Field

Description

Validation

The parent agrees for evaluation in each of the ARC selected area(s) for assessment indicated on the Consent to Evaluate/Reevaluate editor.

Options include:

Yes, I understand the above information and do give my consent for a full individual evaluation in the area(s) listed above.
For Reevaluation purposes, I acknowledge that there is no additional data needed to determine that my child/student continues to be a child/student with an educational disability. I have been informed of the reasons no additional data is needed. I understand that I may request further assessment should I feel it is needed.
No, I understand the above information and do not give my consent.

Only one selection can be selected.

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Previous Versions

Consent Form (Kentucky) [.2315 and previous]

Consent Header

Enrollment Information

Student Information

Parent/Guardian Information

Consent to Evaluate/Reevaluate

Parental Consent

Previous Versions

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