Consent Form (Kentucky)
Last Modified on 12/16/2024 9:46 am CST
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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.
The current format of this document is the KY Consent for Evaluation 2023 print format. Formats are selected in Eval Types.
Editor Home
Editor Home
The Editor Home lists the editors available, their status, and Modification and Completion information.
| Header | Description |
|---|
| Name | The name of the editor. |
| Status | The state of the editor. Statuses can be: - In Progress indicates a user has entered and saved data in that editor.
- Not Started is the default status for all editors.
- Complete indicates a user has clicked the Complete button on the editor, and the editor is read-only. This does not lock the editor from further editing but indicates the user considers the editor finished.
- Not Needed indicates a user has clicked the Not Needed button on the editor. This is usually done for editors that do not apply to the student.
The following statuses are only available for certain state-specific documents: - ESign indicates that the editor has functionality related to the eSignature process. See the following articles for your state's eSignature information:
- Complete Pending eSignature indicates the plan has been entered and sent via the Campus Parent portal to the student's guardian for eSignature.
|
| Modified By | The date and the user by whom the editor was last edited. |
| Completed By | The date and the user who clicked the Complete button for that editor. |
General Information
The following table lists the actions available for the editors. When resizing the window, certain buttons are condensed into a single Action button.
| Button | Description |
|---|
| Save | Different editors have different save options. Click the arrow next to the Save & Stay button to view all saving options for any given editor. - Save captures progress and navigates the user to the Editor Home or to the List Screen for List editors. See the Editor Types section for additional information.
- Save & Stay captures progress and keeps the user on the current editor. This save button is the default save option and is usually found within the detail screen or list editors, such as Goals and Objectives.
- Save & Next captures progress and navigates the user to the next editor.
- Save & New captures progress and creates a new record. This save button is usually found within the detail screen of a list editor, such as Goals and Objectives. See the Editor Type section for additional information.
|
| Refresh | Retrieves a new copy of data from the student's record. This includes enrollment, student, parent/guardian, and team member information. This also returns any accidentally deleted records. Manually entered fields do not change when the refresh button is clicked. The user must Save after clicking Refresh to capture changes.
A side panel displays a listing of all the student's applicable enrollment records. See the Enrollments tool documentation for additional information. |
| Cancel | Navigates the user to the Editor Home screen or the List Screen for List editors. |
Status | Changes the status of the editor. - Complete indicates the editor is finished. This makes the editor read-only. However, this does not lock the editor from further editing. The user must click In Progress to further edit after an editor is marked Complete.
- Not Needed indicates the editor does not apply to the student's plan or evaluation. This makes the editor read-only. However, this does not lock the editor from further editing. Click the In Progress button to further edit after an editor is marked Not Needed.
- In Progress only displays when the editor is in the Complete or Not Needed status and allows additional edits to be made.
The following status is only available for the Nevada IEP: - Complete Pending eSignature only displays for certain editors. This button marks the editor as complete until the parent/guardian electronically signs those plan sections via the Campus Parent Portal. See the Special Ed eSignature Process articles for additional information.
|
| Print | Prints the entire document. |
| Editors | Opens a side panel listing all the available editors and their status. Select an editor from this list to navigate to that editor or click Close to collapse the side panel. |
| Previous | Navigates the user to the previous editor. |
| Next | Navigates the user to the next editor. |
Editor Types
There are two types of editors available: List or Basic editors. When navigating to a Basic editor, the list of fields within the editor is displayed. List editors display a list of all records within that editor. Clicking an existing record or the New button opens the detail view for an individual record.
Editor Lock Out and Release Logic
Only one user at a time can actively work on an editor. A person with a padlock icon (
) displays in the Editors side panel, Editor Home, and List Screen of list editors indicating which editors currently have users working on them. Hovering over the icon displays the name of the user who has checked out the editor, including the current user (you).
Editors that are currently being edited are read-only for all other users. The name of the person working on the editor displays in the header.
To release an editor, the user must:
- navigate to the next editor by clicking Save and Next or the Editors button and selecting the next editor from the side panel.
- click the Cancel button to return to the Editor Home screen.
- log out of the Campus application.
- navigate to a different tool in the Campus application.
Editors are automatically released when the in-application timeout limit has been exceeded. This is a back-end process and is usually around 30-60 minutes.
Template Banks
Certain fields within several editors have an Add Template icon that displays next to their name. Clicking this button displays a side panel with the available library of predetermined text for that field. Template Banks are managed in System Administration.
Template Bank Side PanelClick the plus (+) icons next to the category to view the available template values.
Expanded Category and Values SelectedTemplate Bank Categories display on the left and the selected text displays on the right. Click the Add button to add the template value. This adds the template to the queue of values on the right. The red X removes selected templates while the sequence field can be used to reorder the templates. Another option is to use the up and down arrows next to the sequence field to reorder values.
Click Cancel to go back to the document. The Clear Selected Template(s) button removes all selected template values from the right selection screen.
Once selections are finalized, click the Insert Selected Template(s) button to add the values to the field within the document in the selected order. Template values are separated by carriage returns.
Example Template Bank Selections in the Document
Text Editors
Images should not be inserted into text fields.
Editors
The following section lists each editor and describes each field on the editor.
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.
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.
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.
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 | | 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.
Parent/Guardian Information Editor
Click here to expand...
| 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.
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.
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. |
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Previous Versions
Consent Form (Kentucky) [.2315 and previous]
Editor Home
) displays in the Editors side panel, Editor Home, and List Screen of list editors indicating which editors currently have users working on them. Hovering over the icon displays the name of the user who has checked out the editor, including the current user (you).
Template Bank Side PanelClick the plus (+) icons next to the category to view the available template values.
Expanded Category and Values SelectedTemplate Bank Categories display on the left and the selected text displays on the right. Click the Add button to add the template value. This adds the template to the queue of values on the right. The red X removes selected templates while the sequence field can be used to reorder the templates. Another option is to use the up and down arrows next to the sequence field to reorder values. 
Example Template Bank Selections in the Document
Consent Header Editor
Enrollment Information Editor
Student Information Editor
Parent/Guardian Information Editor
Consent to Evaluate/Reevaluate Editor
Parental Consent Editor
