SY2425 Staff Referral for Student Support
Thank you for completing this form regarding a Georgia Cyber Academy student's need for academic, behavior, or medical support services.
Staff Email
*
example@example.com
Staff Name
*
First Name
Last Name
Job Title
*
STID
*
Student Name
*
First Name
Last Initial
LG Email Address
*
example@example.com
Student Grade Level
*
Please Select
KK
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Student Grade Band
*
Please Select
PGB
EGB
MGB
SGB
Today's Date
*
-
Month
-
Day
Year
Date
Why are you completing this form? Please check all that apply.
*
I would like to refer a student to the AIM Program (K-8) or Study Skills (9-12).
I have medical concerns about a student.
A parent has requested Hospital Homebound Services.
A parent has requested a 504 Plan.
I have dyslexia concerns about this student.
I have behavior concerns about this student.
I have speech concerns about this student.
A parent has requested Special Education testing and/or an IEP.
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Does the student have a current IEP?
Yes, for speech only.
Yes, for academic concerns and/or speech.
No
I am not sure.
Does the student need academic data collected as part of a Special Education eligibility redetermination?
Yes
No
I am not sure.
Are you requesting AIM support for math, reading, or both?
Math
Reading
Both
Student's Most Recent MAP Reading PERCENTILE
If scores are unavailable, please enter 0.
Student's Most Recent i-Ready Reading PERCENTILE
If scores are unavailable, please enter 0.
Student's Most Recent MAP Math PERCENTILE
If scores are unavailable, please enter 0.
Student's Most Recent i-Ready Math PERCENTILE
If scores are unavailable, please enter 0.
Student's Most Recent Fluency Measure {WPM}
If scores are unavailable, please enter 0.
Student's Most Recent Literacy Task Benchmark Category
Please Select
Not Applicable
Below Benchmark {0%-10%}
Below Benchmark
Approaching Benchmark
On Benchmark
A conversation with the parent is required by the teacher to express your concerns prior to completing this survey. This must be documented in the Infinite Campus Contact Log. Have you spoken to the parent and logged your contact?
Yes
No
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Medical Concerns and 504
To secure a 504 meeting for the 2023-2024 School Year, we recommend that you submit your request with appropriate documentation prior to February 16, 2024.
How did you learn of this medical condition or concern?
Provide as much information as possible regarding this medical condition.
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Hospital Homebound Services
Please send the Hospital Homebound Services Inquiry Form to the parent requesting services.
Hospital Homebound Services Inquiry Form
Please confirm that you have sent the Hospital Homebound Services Inquiry Form to the parent.
Please Select
Yes
Please confirm the date that the form was sent.
-
Month
-
Day
Year
Date
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Please explain your primary concerns for speech for this student. Please include where the concern originated? (i.e. Have you noticed the concern yourself or was it brought to your attention by a parent or guardian?)
A conversation with the parent is required by the teacher to express your concerns prior to completing this survey. This must be documented in the Infinite Campus Contact Log. Have you spoken to the parent and logged your contact?
Yes
No
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Next
Please explain your primary behavior concerns for this student. What strategies have you tried to support the student thus far?
A conversation with the parent is required by the teacher to express your concerns prior to completing this survey. This must be documented in the Infinite Campus Contact Log. Have you spoken to the parent and logged your contact?
Yes
No
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Please include any other important notes or any other information you would like to share regarding this student. {If this student is currently served in Special Education, please discuss any concerns with the Case Manager prior to submitting this form.}
Submit
Should be Empty: