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ROCS Form

The document is a request form for observation and/or consultation (ROCs) from Van Buren Intermediate School District. It includes information about the student such as name, birthdate, parents' names, and contact information. It also lists the presenting problem, requested consultations and placement options to be considered. The operating district administrator must sign and date the form before it is submitted to the appropriate department at the Special Services Center.

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46 views

ROCS Form

The document is a request form for observation and/or consultation (ROCs) from Van Buren Intermediate School District. It includes information about the student such as name, birthdate, parents' names, and contact information. It also lists the presenting problem, requested consultations and placement options to be considered. The operating district administrator must sign and date the form before it is submitted to the appropriate department at the Special Services Center.

Uploaded by

pyramid_06
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Van Buren Intermediate School District

Request for Observation and/or Consultation (ROCs)


rev. 10-02-09

Student Name:       Birthdate:      


Parent(s) Name:       Home Phone:      
School District:       Building:       Grade:    
School/Team Contact Person:       Phone/E-mail:      
The applicable building team members have been informed about this ROCs

Describe Presenting Problem (be specific):


     

Check Consultation Requested:

Visually Impaired TC (submit to ISD) PT (submit to ISD)


Hearing Impaired TC (submit to ISD) OT (submit to local OT)
Autism Spectrum Disorder TC (submit to ISD) Work Experience (submit to ISD)
Emotionally Impaired TC (submit to BEC) Assistive Technology (submit to ISD)
Cognitively Impaired TC (submit to ISD) Other       (submit to ISD)
FBA-BIP (submit to local psychologist)

Check Placement Option to be Considered:

Instructional Base (submit to ISD)


Young Adult Program/MiCI Program (submit to ISD)
Bert Goens Learning Center (submit to BGLC)
Behavioral Education Center (submit to BEC)
Other:      
(please specify)

Operating District Administrator Signature Date

**NOTE:
• “Submit to ISD” Special Education Department Supervisor or Secretary located at the
Special Services Center
• Additional Information may be requested after receipt of this ROCs

-------------------------------------------(for office use only)-


-------------------------------------------

Date Action Taken by Assigned Staff:


Date

Attach Written Response to this ROCs


____________________________________________________________________________

Date Received: Initials: Staff Assigned:

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