The Referral form is used to record the reason for referral to evaluate the student for special education services. 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 Referral 2023 print format. Formats are selected in Eval Types.
Editor Home
Referral Header
The Referral Header editor includes the dates associated with evaluation of the student, including the date the student was referred and the student's suspected disability.
Referral Header
Field
Description
Validation
ARC Decision Date Required
The day the Admissions and Release Committee made the decision.
N/A
Referred Date
The referral date.
N/A
Referring Person/Title
The person who referred the student and their title or position.
N/A
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 > Consent to Evaluate/Revaluate > 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 > Consent to Evaluate/Revaluate> 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 > Consent to Evaluate/Revaluate > 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 > Consent to Evaluate/Revaluate > Speech Language.
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.
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
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.
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.
Primary Mode of Communication in the Home
The language spoken at home.
Values available are found in the locked Attribute Dictionary, LanguageList.
Census > People > Demographics > Home Primary Language
identity.homePrimaryLanguage
This field populates from Census.
Student Representation
Student Represented By
The person representing the student. Options include:
Parent
Guardian
Self
Surrogate
N/A
N/A
Does Student Live with Parents?
Indicates the student live with their parent/guardian(s).
N/A
N/A
If No, With Whom Does the Student Live? *Required
The person the student lives with.
N/A
*This field becomes available and is required when No is selected for the question, Does Student Live with Parents?
Relationship *Required
The relationship of the student to the person they are living with.
N/A
*This field becomes available and is required when No is selected for the question, Does Student Live with Parents?
The Summary of Interventions Data editor provides the ability to add New Intervention Data. From the Summary of Intervention Data List, data can be selected, edited, and deleted.
Summary of Interventions Data List Screen
Summary of Interventions Data List Screen
Column Name
Description
Padlock Icon
The user currently editing the Summary of Interventions Data record.
Tier Intervention
The level of intervention.
Begin Date
The first day of the intervention.
End Date
The last day of the intervention.
Summary of Interventions Data Detail Screen
Select an existing record or New to view the detail screen.
Summary of Interventions Data Detail Screen
Field
Description
Validation
Summary of Interventions Data
Interventions Required
The level of intervention. Options include:
Tier I Interventions
Tier II Interventions
Tier III Interventions
N/A
Describe the intervention(s) implemented in the general education classroom to address the area being targeted and the name of the interventionist.
The Major Areas of Concern editor provides the ability to add New Area of Concern data. From the Major Area(s) of Concern List, data can be selected, edited, and deleted.
Major Areas of Concern List Screen
Major Areas of Concern List Screen
Column Name
Description
Padlock Icon
The user currently editing the Summary of Interventions Data record.
Area
The area of concern.
Reasons for Referring
The reason for referral.
Major Areas of Concern Detail Screen
Select an existing record or New to view the detail screen.
Major Areas of Concern Detail Screen
Field
Description
Validation
Area(s) Required
The area of concern.
Communication
Academic Performance
Health, Vision, Hearing and Motor Abilities
Social and Emotional Status
General Intelligence
Work Skills / Technical / Vocational Functioning
This field is required.
Only one entry for each area is allowed. Once an option is selected, it is removed from the drop down.
Reasons for Referring Required
The reason for the referral . The options available depend on the Area selected above.
When Communication is selected, options include:
Communicates Basic Needs and Wants
Articulation
Knowledge of Sound/Letter Association
Expressive Language
Voice Quality
Receptive Language
Other Specify
When Academic Performance is selected, options include:
Oral Expression
Written Expression
Reading Comprehension
Mathematics Calculation
Listening Comprehension
Basic Reading Skills
Reading Fluency
Mathematics Reasoning and Application
Other Specify
When Health, Vision, Hearing and Motor Abilities is selected, options include:
Gross Motor Skills-Body Control
Gross Motor Skills-Locomotion
Vision
Developmental History
Fine Motor Skills-Perceptual Motor
Fine Motor Skills-Sensory
Hearing
Other Specify
When Social and Emotional Status is selected, options include:
Interaction with Peers
Interaction with Adults
Acceptance of Rules
Acceptance of Correction
Acceptance of Disappointment
Self Help Skills/Play Skills
Team/Membership
Mood Swings
Repetitive Behaviors
Self Concept
Inactivity or Withdrawal
Cooperation
Self Control
Expression of Feelings/Affect
Lack of focus
Inattention
Easily distractible
Impulsive
Other Specify
When General Intelligence is selected, options include:
Understanding New Concepts
Interpreting Data to Make Decisions
Comparing/Contrasting Ideas of Objects
Perceptual Discrimination
Predicting Events/Results
Problem Solving
Applying Knowledge
Memory
Other Specify
When Work Skills/Technical/Vocational Functioning is selected, options include:
Attending to Task
Following Directions
Independent Work Habits
Seeking Assistance When Needed
Using Research Tools Effectively
Maintaining Physical Stamina
Having Realist Vocational Goals
Punctuality
Completing Work
Organizing Materials/Belongings
Using Technology to Gather/Organize Info
Identifying Preferences/Interests
Recognizing Personal Limitations
Other Specify
N/A
Specify Other *Required
A specific other area.
*This field is available and required when Other Specify is selected from Reasons for Referring for any Area.
The Physical Functioning and Summary of Support Editor summarizes screening and past and present support information.
Physical Functioning and Summary of Support Editor
Field
Description
Validation
Vision
Required for all students referred for special education
Vision Screening Date
The date of the student's vision screening.
N/A
Vision Screening Results
The results of the vision screening. Options include:
Passed
Failed
N/A
Hearing
Required for all students referred for special education
Hearing Screening Date
The date of the student's hearing screening.
N/A
Hearing Screening Results
The results of the hearing screening. Options include:
Passed
Failed
N/A
Motor
Required when Specific Learning Disability suspected and as determined by ARC
Motor Screening Date
The date of the student's motor screening.
N/A
Motor Screening Results
The results of the motor screening. Options include:
Passed
Failed
N/A
Speech
Required as Determined by the ARC
Speech Screening Date
The date of the student's speech screening.
N/A
Speech Screening Results
The results of the speech screening. Options include:
Passed
Failed
N/A
Describe any Existing Medical Health Conditions Below
A description of any of the student's existing medical health conditions.
N/A
Is Student Currently on Medication?
Indicates the student is currently on medication. Options are Yes or No.
N/A
Specify Type and Dosage Below *Required
A description of the type of medication and the specific dosage.
*This field is available and required when Yes is selected for the question, Is Student Currently on Medication?
This field is limited to 8000 characters.
Summary of Past and Present Support
Has this student been evaluated for special education previously?
Indicates the student has been evaluated for special education previously. Options are Yes or No.
N/A
If yes, When was the student evaluated?
*Required
The date of the previous evaluation.
*This field is available and required when Yes is selected for the question, Has this student been evaluated for special education previously?
What was the suspected area of disability? *Required
A description of the student's suspected disability.
*This field is available and required when Yes is selected for the question, Has this student been evaluated for special education previously?
This field is limited to 50 characters.
What services is this student receiving or what services has this student received in the past? For the services below, enter [C] if currently receiving or [P] if the service was provided in the past.
Limited English Proficient
Indicates the student has received Limited English Proficiency services currently or in the past.
This field is limited to 2 characters.
Migrant
Indicates the student has received Migrant services currently or in the past.
This field is limited to 2 characters.
Title 1
Indicates the student has received Title 1 services currently or in the past.
This field is limited to 2 characters.
Speech Language
Indicates the student has received Speech Language services currently or in the past.
This field is limited to 2 characters.
504
Indicates the student has received Section 504 services currently or in the past.
This field is limited to 2 characters.
Extended School Services
Indicates the student has received Extended School services currently or in the past.
This field is limited to 2 characters.
Gifted and Talented
Indicates the student has received Gifted and Talented services currently or in the past.
This field is limited to 2 characters.
Involvement with Outside Agency(ies)
Indicates outside agencies have been involved in providing services. Options are Yes or No.
N/A
Agency *Required
The name of the agency.
*This field is available and required when Yes is selected for the question, Involvement with Outside Agency(ies).
This field is limited to 50 characters.
Describe services that are being provided to this student by the agency(ies) listed above *Required
A description of the services provided to the student by the agencies listed.
*This field is available and required when Yes is selected for the question, Involvement with Outside Agency(ies).
The Documentation of Student Progress editor provides the ability to add New Test data. From the Documentation of Student Progress List, data can be selected, edited, and deleted.
Documentation of Student Progress List Screen
Documentation of Student Progress List Screen
Column Name
Description
Padlock Icon
The user currently editing the Documentation of Student Progress record.
Test Name
The name of the test.
Documentation of Student Progress Detail Screen
Select an existing record or New to view the detail screen.
Editor Home
Referral Header
Enrollment Information Editor
Student Information Editor
Parent/Guardian Information Editor
Summary of Interventions Editor
Summary of Interventions Data List Screen
Summary of Interventions Data Detail Screen
Major Areas of Concern List Screen
Major Areas of Concern Detail Screen
School Information Editor
Physical Functioning and Summary of Support Editor
Documentation of Student Progress List Screen
Documentation of Student Progress Detail Screen