SBLC Log/Request of Screening Log: *Please date each column that applies, and (√ ) all screenings that were completed. *10 day deadline from the date of the request for assistance to the Initial SBLC Meeting date.

*Revised August 2017

Eligible for §504 Y or N

Implementation (if deemed necessary)

SBLC Meeting of Results and

ADHD ADDES √

KTEA-3 Math √

KTEA-3 Reading √

LLP-√

Signed Permission for Screening date Date Date Screened

Initial SBLC Meeting Date

Name

Date referred

*60 day deadline from the date of the request for assistance to the completion date of the assessment and implementation, if deemed necessary-SBLC Meeting of Results