Special Education Student Record Detail ________________________ DOB Student Name ____________________(mm/dd/yyyy) Grade Level Pre-K Type of Placement: Early Childhood Public Separate Day Elementary Full Inclusion Residential Middle Home-based Early Childhood Substantially Separate Secondary Partial Inclusion General Education Private Separate Day Low Communication Impairment Low Incidence Disabilities Level of Need Moderate Disability Type Emotional Impairment Specific Learning Disabilities High Intellectual Impairment NONE NONE Most Recent Annual Review Date of Most Recent ____________________(mm/dd/yyyy) Activity Initial Evaluation Activity Re-evaluation LEP Yes Home Language not Yes No English No Check all that apply Area Selection Criteria 1. Team Process 2. IEP, Placement, and Progress Reporting Initial Evaluation Re-evaluation Extended/Independent Ed. Evaluation 3. Assessments Early Intervention Program Other Referral Source Student Aged 14 15 – 4. Transition Student Aged 16 17 Student Aged 18+ – Interim Alternative Ed. Setting Positive Behavioral Interventions 5. Student Discipline Suspended at Least 10 Days Approved Program Collaborative Out of District Program ESIS 6. Out of District and Other Placements Private School at Private Expense Unapproved Program 7. Primary Language of the Home other than English 1
Special Education Student Record Detail Student Name ________________________ DOB ____________________(mm/dd/yyyy) Grade Level Pre-K Elementary Middle Secondary Type of Placement: Early Childhood Full Inclusion Home-based Early Childhood Partial Inclusion Private Separate Day Public Separate Day Residential Substantially Separate General Education Level of Need Low Moderate High NONE Disability Type Communication Impairment Emotional Impairment Intellectual Impairment Low Incidence Disabilities Specific Learning Disabilities NONE Most Recent Activity Annual Review Initial Evaluation Re-evaluation Date of Most Recent Activity ____________________(mm/dd/yyyy) LEP Yes No Home Language not English Yes No Check all that apply Area Selection Criteria 1. Team Process 2. IEP, Placement, and Progress Reporting 3. Assessments Initial Evaluation Re-evaluation Extended/Independent Ed. Evaluation 4. Transition Early Intervention Program Other Referral Source Student Aged 14 – 15 Student Aged 16 – 17 Student Aged 18+ 5. Student Discipline Interim Alternative Ed. Setting Positive Behavioral Interventions Suspended at Least 10 Days 6. Out of District and Other Placements Approved Program Collaborative Out of District Program ESIS Private School at Private Expense Unapproved Program 7. Primary Language of the Home other than English 1