LEE COUNTY SCHOOLS DECISION TO REQUEST A SPECIAL EDUCATION EVALUATION PERMISSION FOR VISION AND/OR HEARING SCREENING

(SCHOOL) ___________________________________ Dear Parent,

(Date) ____________________

As the parent of ______________________________________________, either you have requested a referral for special education testing, or school personnel have requested a referral for special education testing. Before we begin the process, we need to check your childs vision and hearing. If he/she does not pass the vision and hearing screening, we will not be able to proceed with testing for special education. If the screening indicates there might be a problem in either area, you will be notified.

_____Vision Screening

_____Hearing Screening

Parents, please check one of the responses, sign and date, and return this form to your childs teacher or the school office. ____________Yes, I give permission for the screenings. ____________No, I do not give permission for screenings. _____________________________________ (parent/guardian signature) _______________ (date)

Thank you for allowing us to better serve your child. Please feel free to contact us with questions.

______________________________________________________ School Representative

10/1/2013