REQUEST FOR INDIVIDUAL STUDENT WAIVER FOR MECHANICAL RESTRAINT(S) OR SECLUSION STUDENT INFORMATION Student Name: BD: School: Address: Address: Primary/Secondary Disabilities: Communication System Indicate with (P) and (S) Mark all included in IEP ( ) Autism Receptive ( ) Deaf-blindness Touch Cues ( ) ( ) Deafness Objects ( ) ( ) Developmental delay Tangible Symbols ( ) ( ) Emotional disturbance Gestures ( ) ( ) Hearing impairment Sign Language ( ) ( ) Intellectual disability AAC device ( ) (specify ) ( ) Multiple disabilities Picture symbols ( ) ( ) Orthopedic impairment PECS ( ) ( ) Other health impairment Speech ( ) ( ) Specific learning disability ( ) Speech or language impairment Expressive ( ) Traumatic brain injury Touch Cues ( ) ( ) Visual impairment, including blindness Objects ( ) Tangible Symbols ( ) ( ) IEP ( ) 504 Plan Gestures ( ) Sign Language ( ) Needs Funding Category –Based AAC device ( ) (specify ) Picture Symbols ( ) ( ) Complex PECS ( ) Intensive ( ) Speech ( ) Basic ( ) ESL (English Second Language) Yes No Least Restive Environment/ Placement Current IEP (date) Regular Setting includes pullout related services and team classrooms. Student served inside the regular classroom greater than or to 80% of the day. Services Provided Both in Separate Special Education Classes and Regular Setting Student served inside the regular classroom greater than or equal to 40% of the day and no more than 79% of the day. Separate Special Education in an Integrated Setting Student served inside the regular classroom less than 40% of the day. Separate School Student served in public or private separate day school facility for greater than 50% of the school day or a residential facility if student does not live at the facility. Residential Facility where student resides during the school week. Homebound or Hospital Correctional Facilities (only used by DSCYF and Prison Education) Students placed in short-term detention or correctional facilities.
REQUEST FOR INDIVIDUAL STUDENT WAIVER FOR MECHANICAL RESTRAINT(S) OR SECLUSION STUDENT INFORMATION Student Name: BD: School: Address: Address: Primary/Secondary Disabilities: Indicate with (P) and (S) ( ) Autism ( ) Deaf-blindness ( ) Deafness ( ) Developmental delay ( ) Emotional disturbance ( ) Hearing impairment ( ) Intellectual disability ( ) Multiple disabilities ( ) Orthopedic impairment ( ) Other health impairment ( ) Specific learning disability ( ) Speech or language impairment ( ) Traumatic brain injury ( ) Visual impairment, including blindness ( ) IEP ( ) 504 Plan Needs –Based Funding Category ( ) Complex ( ) Intensive ( ) Basic Communication System Mark all included in IEP Receptive ( ) Touch Cues ( ) Objects ( ) Tangible Symbols ( ) Gestures ( ) Sign Language ( ) AAC device (specify ) ( ) Picture symbols ( ) PECS ( ) Speech Expressive ( ) Touch Cues ( ) Objects ( ) Tangible Symbols ( ) Gestures ( ) Sign Language ( ) AAC device (specify ) ( ) Picture Symbols ( ) PECS ( ) Speech ESL (English Second Language) Yes No Least Restive Environment/ Placement Current IEP (date) Regular Setting includes pullout related services and team classrooms. Student served inside the regular classroom greater than or to 80% of the day. Services Provided Both in Separate Special Education Classes and Regular Setting Student served inside the regular classroom greater than or equal to 40% of the day and no more than 79% of the day. Separate Special Education in an Integrated Setting Student served inside the regular classroom less than 40% of the day. Separate School Student served in public or private separate day school facility for greater than 50% of the school day or a residential facility if student does not live at the facility. Residential Facility where student resides during the school week. Homebound or Hospital Correctional Facilities (only used by DSCYF and Prison Education) Students placed in short-term detention or correctional facilities.
RS%20Waiver%20Request%203-30-15.docx