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THOMAS R. SUOZZI DAVID M. ACKMAN,
M.D., M.P.H.
COUNTY EXECUTIVE COMMISSIONER
REQUEST FOR
TRANSLATION
AND/OR
BILINGUAL
EVALUATION
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PROGRAM ADMINISTRATION
240 OLD COUNTY ROAD
MINEOLA, NEW YORK
11501-4250
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FISCAL OFFICE STE #200
60 CHARLES LINDBERGH BOULEVARD
UNIONDALE, NEW YORK
11553-3687
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NASSAU COUNTY
DEPARTMENT OF HEALTH
OFFICE OF CHILDREN WITH
SPECIAL NEEDS
Preschool
Special Education Program
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CHILD’S NAME:
________________________ PARENT’S
NAME: ___________________________
ADDRESS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
LANGUAGE: ____________________________________
SCHOOL DISTRICT AUTHORIZING EVALUATION:
___________________________________________
EVALUATION AGENCY:
_______________________________________________________________
____ PARTICIPATION OF A TRANSLATOR FOR THE EVALUATION PROCESS
____ TRANSLATION OF SUMMARY REPORT
____ TRANSLATION OF DOCUMENTATION OF THE EVALUATION
PARENT’S SIGNATURE:
____________________________________
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