Student’s Name: __________________________ Grade: __________ School: _________________
DOB: _________ Resident District: _____________ Ward of State: Yes No
IEP Manager: ______________________________________
Please check one: ___ Initial IEP (parent consent) / Start Date: __________
___ IEP change (Status, Setting, or disability) / Date: ______________
Special Education Evaluation Status (Please circle one below):
1 Not evaluated non-disabled, no IEP/IFSP/IIIP regular education only
2 K-12 evaluated – does not need services
3 Evaluated – requires services but not yet in a program
4 Evaluated – receiving special education services
5 Evaluated – qualifies for services, parent refused
6 Evaluated – receiving services through IIIP and receiving services through a public agency
7 Student’s IEP/IFSP/IIIP was terminated during school year
8 Student in Early Intervening Services
Special Ed Federal Instructional Settings (Please circle one below):
School age Instructional Setting Age 6 - 12
00 No IEP/IFSP/IIIP
01 Outside of regular class room less than 21% of school day
02 Resource room between 21% and 60% of school day
03 Separate classroom more than 60% of school day
04 Public separate day school facility greater than 50% of school day
05 Private separate day school facility greater than 50% of school day
06 Public residential facilities greater than 50% of school day
07 Private residential facility greater than 50% of school day
08 Homebound/hospital placement
Primary Disability Classification (Please circle one below):
00 No IEP/IFSP/IIIP, non-disabled student
01 Speech/Language Impaired
02 Developmental Cognitive Disabilities: Mild-Moderate
03 Developmental Cognitive Disabilities: Severe-Profound
04 Physically Impaired
05 Deaf – Hard of Hearing
06 Visually Impaired
07 Specific Learning Disabilities
08 Emotional/Behavioral Disorders (EBD)
09 Deaf – Blind
10 Other Health Disabilities
11 Autism Spectrum Disorder
12 Developmental Delay
14 Traumatic Brain Injury Disabled
16 Severely Multiply Impaired
54 504 Plan
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