Fillable Nebraska Department of Education Form #08-064 Statewide Assessment (Nebraska)

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Nebraska Department of Education Form #08-064 Statewide Assessment (Nebraska)

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Nebraska Department of Education
Statewide Assessment
Form #08-064
Revised 1/18/2022
500 S 84
th
St. Page | 1
Lincoln, NE 68510
2021-2022 N
EBRASKA STUDENT-CENTERED ASSESSMENT SYSTEM (NSCAS) TEST
EMERGENCY MEDICAL WAIVER REQUIREMENTS
The Nebraska Department of Education strives to ensure that all students have equitable opportunities to demonstrate their
knowledge and skills on the NSCAS tests. An emergency medical waiver may be granted by the Statewide Assessment Office
when a student cannot take the assessment during the testing window due to a significant medical emergency.
NDE values and trusts the medical opinion of physicians; however, they must be informed of the guidelines for testing prior to
providing excused waivers for students. Nebraska districts are charged with providing education to all students, regardless of
their disability. A waiver is not intended for use for a permanent disability or if the student is otherwise receiving education
services from the district or other provider.
If the request for a waiver is the result of a concussion, please refer to the Return to Academics Progression (page 2) to identify
the current step in the progression (you can also find the progression at https://bit.ly/322LhIU
).
This document is provided to help districts determine whether a medical waiver is justified. Below are some examples that may
help determine whether a student qualifies for a waiver; these are not inclusive of every medical situation but are meant as
guidelines to help determine if a student meets the requirements prior to requesting a physician signature on the waiver.
In order to maintain the confidentiality of students’ medical situations, actual medical records are not to be included with the waiver.
If you have questions about an individual situation, please do not hesitate to contact Jeremy Heneger, Jeremy.heneger@nebraska.gov.
APPROVED FOR WAIVER
NOT APPROVED FOR WAIVER
Concussion - The Return to Academics
Progression indicates student could not have
been tested during the entire window
Concussion - The Return to Academics Progression
indicates the student could have been tested
during the testing window
Emergency situation – hospitalization, e.g.
recovering from a car accident
Long term hospitalization where students are
receiving educational services outside of the
school
Emergency Medical conditions where medication
or treatment makes It impossible for student to
test. e.g. chemotherapy, radiation
Permanent disability – education is being provided
by district or other provider e.g. cerebral palsy,
multiple impairments, student participates in
alternate assessment.
Out-of-state medical care
In-state non-emergency medical care
Surgery and recovery
Surgery where student could be tested as part of
regular education
Emergency mental health issue that is
not normally part of a student’s IEP
Mental health issues that are being
accommodated by the school in an on-going basis
Emergency pregnancy complications – by doctor’s
orders
Pregnancy/birth of child where student could
be tested off-site
Page | 2
RETURN TO ACADEMICS PROGRESSION
Progression is individual. All concussions are different. Students may start at any of these steps, depending
on symptoms, and may remain at a step longer if needed. If symptoms worsen, the CMT should reassess. If
symptoms quickly improve, a student may also skip a step or two. Be flexible!
Steps
Progression
Description
1
HOME – Cognitive and physical
rest
Stay at home
No driving
Limited mental exertion – computer, texting,
video games, homework
2
HOME – Light Mental Activity
Stay at home
No driving
Up to 30 minutes mental exertion
No prolonged concentration
Progress to Step 3 when student handles up to 30 minutes of sustained mental exertion without
worsening of symptoms.
3
SCHOOL – Part Time
Maximum adjustments
Shortened day/schedule
Built-in breaks
Lunch in quiet environment
No significant classroom or standardized testing
Modify rather than postpone academics
Provide extra time, help, and adjustment
of assignments
Progress to Step 4 when student handles 30-40 minutes of sustained mental exertion without worsening of
symptoms.
4
SCHOOL – Part Time
Maximum adjustments
Shortened day/schedule
No standardized testing
Modified classroom testing
Moderate decrease of extra time, help,
and modification of assignments
Progress to Step 5 when student handles 60 minutes of mental exertion without worsening of symptoms.
Progress to Step 6 when student handles all class periods in succession without worsening of symptoms
AND receives medical clearance for full return to academics and athletics.
6
SCHOOL – Full Time
Full academics
No
adjustments
Attends all classes
Full homework and testing
When symptoms continue beyond 3-4 weeks, prolonged in-school supports are required. Request a 504
meeting to plan and coordinate student supports.
© 2013 ORCAS www.orcasinc.com Adapted with permission from Oregon Concussion and Management Program (OCAMP) and Slocum Sports
Concussion Program
5
SCHOOL – Part Time
Minimal adjustments
No standardized testing; routine tests are OK
Continued decrease of extra time, help, and
adjustment of assignments
May require more support in academically
challenging subjects
Nebraska Department of Education
Statewide Assessment
Form #08-064
Revised 2/18/2022
500 S 84
th
St. Page | 3
Lincoln, NE 68510
2021-2022 NEBRASKA STUDENT-CENTERED ASSESSMENT SYSTEM (NSCAS) TEST
EMERGENCY MEDICAL WAIVER FOR NSCAS/ELPA21
Directions: Please fill out all fields on the form legibly, include the calendar dates when the student was not in attendance.
FAX completed pages 3 & 4 to 402-742-2319
DISTRICT INFORMATION
District Name
School Code Number
Date Submitted
School Name
Waiver requested by
Position
I attest that this student meets the requirements stated above for a medical waiver.
Signed (Administrator Requesting Waiver):
DAC INFORMATION
DAC Name
DAC Email
STUDENT INFORMATION
First Name
Last Name
State Student ID#
Grade
List dates that student was absent during the test
window:
Check all tests that apply to this waiver & mark appropriate subjects:
ELPA21 (Feb 7 – Mar 18, 2022):
NSCAS Growth (Mar 21 – May 6, 2022): ELA Math Science
NSCAS Alternate (Mar 21 – May 6, 2022): ELA Math Science
NSCAS ACT:
Window 1 (Mar 22 – 31, 2022)
Window 2 (Apr 5 – 15, 2022)
Make-up Window (Apr 19 – Apr 29, 2022)
Please provide 1) a brief description of the circumstance(s) for the request of the waiver, 2) status based on the Return to
Academics Progression document, and 3) the amount and the kind of educational services student are receiving for the
circumstance(s).
STATEWIDE ASSESSMENT OFFICE Approved Denied
Signature: Date:
Page | 4
2021-2022 NEBRASKA STUDENT-CENTERED ASSESSMENT SYSTEM (NSCAS) TEST
EMERGENCY MEDICAL WAIVER PHYSICIAN SIGNATURE
Explanation to the Medical Professional: The Nebraska Department of Education strives to ensure that all students
have equitable opportunities to demonstrate their knowledge and skills on NSCAS tests. State tests are mandatory for
every student grade 3-8, and 11 who is enrolled in a public school. The ELPA21 is required for every English Language
Learner (ELL) in grades K-12 who is enrolled in a public school.
Nebraska Department of Education requests schools to provide medical professional signed medical waivers in cases
where a medical emergency prevents a student from participating in the NSCAS tests.
If the school is otherwise providing education with accommodations to the student for an on-going medical condition or
permanent disability, that is not considered a basis for an emergency medical waiver on the NSCAS tests. Districts are
able to provide the tests to the students at locations outside of the school buildings and/or may make other allowable
accommodations appropriate to the students’ medical needs in order for them to participate in testing.
Stude
nt’s Name:
School Dis
trict:
By signing below, I attest that the student named above is either mentally or physically unable to test due to an
emergency medical situation, or that participation in the test may be harmful to the student.
Yes. The student above should be excused from participating in the 2022 NSCAS state tests.
Signature of medical professional:
Name of medical professional (Please print):
Name of hospital or clinic:
City, State:
Medical Professional - Please return this form to the school district that made the request. The school district will
submit your statement with their request for a waiver.
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Nebraska Department of Education Form 08-064 Statewide Assessment (Nebraska)

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Completed 7 March 2022

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