STUDENT NAME: SIMS: PARENT/GUARDIAN NAME: PHONE: ADDRESS: WK PHONE: SCHOOL DISTRICT: SCHOOL: DOB: AGE: GRADE: GENDER: RACE: Purpose of Meeting Meeting Date: Initial Eligibility, IEP, Placement Date Services Begin: Annual Review of IEP Three Year Reevaluation Annual Review Date: Dismissal from Services - Date Effective: Date of Eligibility Determination: Parent Request Other: Three Year Reevaluation Due By: Discussed evaluation results/progress/assessment Student is eligible for special education or special education method Yes and related services as determined by the IEP team (Parent/Guardian initial) Yes No Copy of evaluation results received Yes An annual copy of Parent/Guardian Rights was received and (Parent/Guardian initial) reviewed (Date) (Parent/Guardian Initial) Transition Planning Needed No Yes A copy of the IEP was provided to parent/guardian Yes (*If yes, attach applicable transition pages.) (Parent/Guardian Initial) Primary Disability: IEP Team Membership Signature Date Parent/Guardian Parent/Guardian Student School Representative General Education Teacher Special Education Teacher or Provider Speech/Language Pathologist Individual who can interpret evaluation results Other: Other:
STUDENT NAME: SIMS: PARENT/GUARDIAN NAME: PHONE: ADDRESS: WK PHONE: SCHOOL DISTRICT: SCHOOL: DOB: AGE: GRADE: GENDER: RACE: Meeting Date: Purpose of Meeting Initial Eligibility, IEP, Placement Annual Review of IEP Three Year Reevaluation Dismissal from Services - Date Effective: Parent Request Other: Date Services Begin: Annual Review Date: Date of Eligibility Determination: Three Year Reevaluation Due By: Discussed evaluation results/progress/assessment method Yes (Parent/Guardian initial) Student is eligible for special education or special education and related services as determined by the IEP team Yes No Copy of evaluation results received Yes (Parent/Guardian initial) An annual copy of Parent/Guardian Rights was received and reviewed (Date) (Parent/Guardian Initial) Transition Planning Needed No Yes (*If yes, attach applicable transition pages.) A copy of the IEP was provided to parent/guardian Yes (Parent/Guardian Initial) Primary Disability: IEP Team Membership Signature Date Parent/Guardian Parent/Guardian Student School Representative General Education Teacher Special Education Teacher or Provider Speech/Language Pathologist Individual who can interpret evaluation results Other: Other:
IEP_pln13.docx