D/M 119 Rev. 3/15 Page ____ of ____
DESERT/MOUNTAIN SPECIAL EDUCATION LOCAL PLAN AREA
DESERT/MOUNTAIN CHARTER SPECIAL EDUCATION LOCAL PLAN AREA
17800 HIGHWAY 18 • APPLE VALLEY, CA 92307
(760) 552-6700 • (760) 242-5363 FAX
Triennial Assessment Determination Form
(To be completed prior to the Triennial due date to determine what assessments, if any, need to be conducted.)
STUDENT INFORMATION
Student Name:
Date of Birth:
Grade:
School Site:
District of Attendance:
District of Residence:
Triennial Due Date:
Parent/Guardian/Surrogate contacted on: (Date)
Method of Contact: Phone Conference IEP Meeting Other Meeting Written Conference
As part of determining the need for reassessment the district has completed all of the following steps:
1. Existing assessment data has been reviewed, including assessments provided by the parents
2. Current classroom-based assessments have been reviewed
3. Teacher and related service provider(s) observations have been reviewed
4. Parent/Guardian input has been reviewed and considered
Based upon a review of the information referenced above, the district, in collaboration with parent, has determined that
Yes No
additional assessment is needed.
If “YES,” it is recommended that assessment be completed in the following areas (D/M 66 must be completed): (Check all that apply)
Academic Assessment Cognitive Data Social/Emotional Behavioral Data Motor Skills Data Health Data
Language/Speech Occupational Therapy Physical Therapy Adapted P.E. Postsecondary Transition
Vision and Hearing: (Check all that apply below)
Vision and Hearing assessment dated to be used for this evaluation period (within one year)
Parent to provide privately-obtained Vision or Hearing assessment
Parent declined Vision and Hearing screening by the district
Alternate means of assessment: (Describe, if applicable)
Other:
Additional assessment data is needed to determine:
1. Whether the student has a particular category of disability and/or continues to meet the eligibility criteria as a child with a disability
2. The present level of performance of the student and the student’s educational needs
3. Whether the student continues to need special education and related services
4. Whether any additions or modifications to special education and related services are needed to enable the student to meet the annual
goals included in the student’s IEP and to participate, as appropriate, in the general curriculum
If “NO,” state reason(s) it was determined that further assessment data was not needed:
NOTE: PARENTS MAY REQUEST FULL ASSESSMENT TO DETERMINE ELIGIBLITY/INELIGIBILITY FOR SERVICES AT
ANY TIME, OR MAY AGREE TO FOCUSED DATA COLLECTION IN SPECIFIC AREAS.
I have been advised of and given a copy of the Special Education Procedural Safeguards/Parent Rights
I agree and understand that assessment is needed in the areas marked above (Assessment Plan is required, form D/M 66)
I agree and understand that no new assessment is needed
Parent/Guardian/Surrogate Date Parent/Guardian/Surrogate Date
LEA Representative Date Student Date
Special Education Teacher Date General Education Teacher Date
School Psychologist Date Speech-Language Pathologist Date
Other/Title Date Other/Title Date
