Final SELPA Forms Manual August 2015
Final SELPA Forms Manual August 2015
Final SELPA Forms Manual August 2015
FORMS MANUAL
WRITING IEPs
FOR EDUCATIONAL BENEFIT
August 2015
0
Introduction
This manual and accompanying IEP Forms were developed by members of the State SELPA
Association to address the legal requirements of IDEA, state law, and the State Performance
Plan as appropriate. This IEP is a recommended template to provide greater consistency for
districts around California. The California Department of Education, Special Education Division
also posts it on their website.
The items denoted in bold font on the IEP Forms and in the manual are required
CASEMIS fields and must be completed.
IEP Form Present Levels of Academic Achievement & Functional Performance (3) .........................................
............................................................................................................................InstructionsPresentLevelsForm
View Form ..................................................................................................................... ViewPresentLevelsForm
IEP Form Annual Goals & Objectives/Benchmarks (6B & 6C) .............InstructionsAnnualGoals&Obj/BenForm
View Form ........................................................................................................ ViewAnnualGoals&Obj/BenForm
IEP Form Signature and Parent Consent (8A & 8B) ........................ InstructionsSignatureParentConsentForm
View Form .......................................................................................ViewSignatureParentMediCalConsentForm
View Form .....................................................................................................ViewSignatureParentConsentForm
1. Student Name: Enter the student last name and first name.
4. Last IEP: Enter the date of the last IEP. This will be the same date as the IEP date
above.
5. Next IEP: Enter the next IEP date that will be one year from the present date in most
cases.
6. Original SpEd Entry Date: Enter the date the student first received special education
services, including IFSP (0-3 infant services).
7. Last Eval: Enter the date of the most recently completed comprehensive assessment to
determine or re-determine eligibility for special education and related services (triennial
or initial IEP date).
8. Next Eval: Enter the date when the next triennial evaluation is due.
13. Native Language: This field was previously known as home language. This is the
students home language or birth language.
14. EL: Check if the student is an English learner or check if the student has been re-
designated. (R-FEP)
16. Student ID and SSID: The student ID number is automatically assigned through
CASEMIS. The SSID, formerly CSIS, is assigned by the State. Each student must have
a SSID. Social Security Number is optional.
18. Parent/Guardian Information: Enter the contact information for the parent/guardian. If the
student resides in an out-of-home placement through a non-educational agency, put the
parent contact information in the second contact area, if known.
21. Ethnicity: Answer the two part question and then check the appropriate ethnicity(s).
Note: Only four ethnicities can be listed. This should be the ethnicity designated by the
parent on the student enrollment form at the school site.
23. Disability: Mark primary disability with P and secondary disability with S. The primary
disability should be the one that has the most significant impact on the students ability to
access the general education environment. Note: For funding purposes, low incidence
disabilities marked as primary or secondary will generate low incidence funding.
24. If the student is not eligible or no longer eligible for special education:
Document reason for decision and other options to address the students
educational needs on IEP Team Comments Page (Form 7).
IEP team members sign as appropriate on (Form 6).
If parent(s) do not agree that the child is not eligible for special education services,
note their concerns, discuss options for resolving their concerns, and review Notice
of Procedural Safeguards.
25. How Disability Affects Educational Performance: Write a statement which describes the
disability and its impact, i.e. auditory processing deficits adversely impact the students
ability to complete activities within the general education setting, significant speech and
language deficits interfere with the students ability to interact with other students in the
preschool setting
1. Has the Student Received Coordinated Early Intervening Services (CEIS) under the
IDEA in the Past Two Years: Coordinated Early Intervening Services (CEIS) are
coordinated interventions for students not currently identified as requiring special
education who need additional academic and behavior support to succeed in a general
education environment. NOTE: Do not confuse this with early intervention. NOTE:
This is required for districts that have been found to be significantly disproportionate by
the CDE and optional for other districts. Districts can choose to use up to 15% of IDEA
Local Assistance dollars for CEIS. Districts that are found to be significantly
disproportionate by CDE must use 15% of IDEA Local Assistance dollars for CEIS.
Coordinated early intervening services include educational and behavioral evaluations,
services and supports including scientifically based literacy instruction. If the student
received coordinated early intervening services (CEIS) during the past two years, check
yes. If you check yes then it is assumed that the district has moved 15% of their
Federal Local Assistance (IDEA) funds to general education and that data is being
collected on the students who have are receiving CEIS. Coordinated early intervening
services are only required for districts who have been identified as significantly
disproportionate. Otherwise, check no.
2. Date of Initial Referral for Special Education Services: Enter the date of the initial referral
to assess and determine eligibility for education services (ages 3-22). Note: This date
can change if a student is found eligible, then exits, and then is re-assessed and found
eligible again.
3. Person Initiating the Referral: Select the person initiating the referral (Parent, Teacher,
SST, Other School/District Personnel, Other).
4. Date District Received Parent Consent: Enter the date the district received parent
signature/consent for initial evaluation.
5. Date of Initial Meeting to Determine Eligibility: Enter the date of IEP Team meeting to
review initial evaluation and determine eligibility for special education.
Ed u c a tio n a l Be n e fit Re m in d e r
Is all of the information complete and correct?
How will the manager of the school MIS system be informed of any changes?
Does the IEP clearly specify the childs disability(s)?
Did the IEP Team identify how the childs disability affects his or her involvement and
progress in the general curriculum or participation in appropriate activities for the
preschool child?
Is the purpose for the meeting identified and clearly defined?
Are all dates accurate and complete?
Is ethnicity and race properly identified, matches CalPads and accurately
completed?
This form must be completed in time to be in effect when the student reaches 16 years of age
or sooner if appropriate or will reach 16 years of age before the next annual review.
1. Student was invited: The student is to be invited on the meeting notification form. When
the student is invited mark YES on the transition page. Keep the documentation of the
meeting notification in the students file.
2. Agency was invited: When appropriate support agencies need to be invited on the
meeting notification, with the parent/guardian/students permission. If an agency is invited
mark YES, when it is not appropriate mark N/A. You should never need to mark NO.
Keep the documentation of the meeting notification in the students file.
3. How the Student Participated in the Process: Describe how the student participated in the
process by choosing the best answer. Note: IEP teams may choose more than one
option.
Describe what the student is interested in and wants to pursue in areas of education,
career and living based on the information you get from the transition assessments. Be
sure this is documented on Form 1A.
5. Students Postsecondary Goals: The team must include measurable postsecondary goals
in Training or Education, Employment and if appropriate, Independent Living.
Document what the student plans on doing upon exiting school (post-secondary goals) in
each of these areas.
EXAMPLES
Education/Training:
Upon completion of school, I will join the Army.
Upon completion of school, I will enroll in the local Community College.
Upon completion of school, I will learn independent living skills from the Regional
Center.
Employment:
Upon completion of school, I will work as a mechanic.
Upon completion of school, I will work as a teacher.
Upon completion of school, I will work at the Opportunity Center.
Upon completion of school, I will work in competitive employment.
Upon completion of school, I will work in supported employment.
A. Make sure you link the post-secondary goal to an annual goal that will support the
skills needed to reach the students post-secondary goals.
B. Person/agency responsible: Put in the students name and then whoever else will
also be responsible.
6. Transition Services Codes: Chose an appropriate Transition Service Code that will be
used to support the students post-secondary goal. (Please see 800 code descriptions).
7. Activities to Support Transition Service: Identify different activities that will be employed
to help the student achieve his/her post-secondary goals. (Ex. career research paper,
college application, job applications, resume writing, self-help unit on cooking, Workability
training etc.)
9. Related Services/DIS as Appropriate: Include any related services the student may need
based on their disability that will help the student achieve his/her post-secondary goals.
(ex. Speech and Language, Deaf and Hard of Hearing services, Orientation and Mobility
Transportation, Career Counseling, etc.)
EXAMPLE 1
EXAMPLE 2
Diploma: Attach a form with all diploma coursework presently being completed and all
required future coursework that needs to be completed. Be sure to include the
names of the specific electives that are being taken and will be taken.
Certificate: Describe the functional areas being worked on currently and future areas to
be addressed prior to Exit from school.
2. Units/Credits: Update the units/credits the student has completed up to this meeting and
then the units/credits the student still has to complete or has pending for a
diploma/certificate including what the student will take in the next IEP cycle.
3. Course of Study leads to: The IEP Team indicates by checking which option - a
Certificate of Completion or a Diploma will the courses the student is currently enrolled
in lead to a certificate of completion or a diploma.
4. California High School Exit Exam: Enter the date and score on the ELA and Math
section of the CAHSEE and indicate if the student passed or failed. In the CAHSEE
Other section you can put if the student is getting an exemption, waiver, or taking the
CAPA.
5. Transfer of Rights: On or before the students 17th birthday, the teacher is to explain that
he and/or she will assume all special education rights and protections upon turning 18
(unless a conservator has been appointed by the court). Review the Notice of
Procedural Safeguards with the student. Have the student and parent sign this section.
Is there an appropriate measurable post-secondary goal or goals that covers education or training,
employment, and as needed, independent living?
Are the post-secondary goals updated annually?
Are the post-secondary goals based on age appropriate transition assessments?
Are there transition services in the IEP that will reasonably enable the student to meet his/her post-
secondary goals?
Does the course of study reasonably enable the student to meet their post-secondary goals?
Is there an annual IEP goal related to the students transition services needs?
Was the student invited and involved in their transition planning?
Was a representative of any participating agency invited to the IEP Team meeting with prior
consent from parent, guardian, or student?
Except for the Concerns of the Parent, a draft of this portion of the IEP may be prepared prior
to the meeting. Each section should be discussed at the meeting and changes made as
appropriate based on input by members of the IEP team.
1. Strengths, Preferences, and Interests: Identify the students strengths, preferences, and
interests.
3. Test Scores: Scores reflecting the students performance on state, district wide and
other assessments may be gathered prior to the meeting. Review results of the
assessments including (as appropriate):
California Assessment of Student Performance and Progress (CAASPP) for
English/Language Arts and Mathematics Standard Exceeded Standard Not Met
California Standards Test (CST) for Science Standard Exceeded Standard Not
Met
California Modified Assessment (CMA) for Science Standard Exceeded Standard
Not Met
California Alternate Assessment (CAA)
CELDT: Write in the CELDT scores.
Physical Fitness Test
Other Assessment Data, including results of district wide and/or individually
administered assessments. For preschoolers include DRDP access.
Hearing and Vision Screening: Enter date and if the student passed or failed the
hearing and vision screening. This data may be from a prior year IEP. Note the
reason for other, such as parent exemption.
6. Gross/Fine Motor Development: For a student, who has been identified with motor
development concerns, describe his or her specific skills and/or needs. If none, indicate
no concerns noted at this time.
9. Adaptive/Daily Living Skills: For those students with needs in self-help, specify skills
such as dressing, toileting, feeding, etc. Indicate age appropriate if no concerns are
noted.
10. Health: Describe pertinent medical information that relates to the students educational
progress. If none, indicate no concerns noted at this time.
11. Areas of Need: Indicate areas of educational need that have been identified by the IEP
Team based on assessments and present levels of academic achievement and
functional performance and/or special factors. For every identified area of need there
must be a goal.
1. Assistive Technology: Does the student require assistive technology devices and
services or low incidence services, equipment and materials to meet educational goals
and objectives? Check yes or no. If yes, specify the type of devices, services,
equipment, and/or materials needed.
2. Low Incidence: This applies only to the students with the following eligibility categories:
DB, VI, OI, HH, and Deaf. Low incidence equipment is indicated only if it is required to
meet specific educational needs. Check yes or no. If yes, specify.
Note: Best practice assistive technology should be addressed in the Supplemental
Aids and Services section and/or in a goal.
3. Blindness or Visual Impairment: Is the student blind or visually impaired? If the student is
visually impaired, indicate whether instruction in Braille will be provided, and if not, why?
If the student will not be using Braille he/she may use large print text or other modified
input.
4. Deaf or Hard of Hearing: If the student is deaf or hard of hearing, consider the students
language and communication needs, opportunities for direct communications with peers
and professional personnel in the students language and communication mode,
academic level, and full range of needs including opportunities for direct instruction in
the students language and communication mode. If the student is not deaf or hard of
hearing, indicate N/A.
5. English Learner: If the student is an English Learner complete the sections listed below.
6. Behavior: Does the students behavior impede learning? Check yes or no. If yes,
describe how the behavior impedes learning. Specify positive behavior interventions,
strategies, and supports to address the behaviors. Check if there is a Behavior Support
Plan or Behavior Intervention Plan and attach a copy. If there is a behavior goal check
the box to indicate a goal is in the IEP. Check which type of plan is attached.
NOTE: The form will mirror options offered through the TIDE link found on the forms
menu which has been helpful for teachers to understand what are the new
accommodations being implemented.
All required grade levels for each test is specifically identified after the title of each
test subject.
Outside of testing range will be noted under the options for each test category Check
this box if applicable to the student.
For the areas of English Language Arts, and Math document any allowable
Designated Supports or Accommodations. Check the appropriate boxes for
Designated Supports or Accommodations and determine if these are Embedded or
Non-Embedded. In the area provided fully described any Designated Supports or
Accommodations necessary for student participation. If the student has a significant
cognitive impairment, indicate participation in the Alternative Assessment.
For the areas of Science, document if the student will be taking the assessment
using the CST or CMA. Document if the student also needs Designated Supports or
Accommodation. In the area provided fully described any Designated Supports or
Accommodations necessary for student participation. California Alternate
Assessment (CAA). If the student has a significant cognitive impairment, indicate the
CAA Level that is most appropriate to measure student progress.
Check the box if the student is taking the CMA, CAA or ALTERNATIVE
ASSESSMENT and provide a written description of the reasons why the student is
not participating in SBAC. The second area is provided to describe why the IEP
team believes that alternate assessment is appropriate f or the student.
Physical Fitness Test (Grades 5, 7, & 9 only): Specify if the student will be taking the
Physical Fitness Test with accommodations or modifications.
California High School Exit Exam (CAHSEE): Document if the student will be taking
CAHSEE with or without accommodations. If the student will participate in CAHSEE
using modifications a waiver is required after the student takes CAHSEE with
modifications and passes. Currently there is an exemption for students with
disabilities. Check the exemption box if the student will be using the exemption.
Document the reason for an exemption. If the student is taking CAPA check the
appropriate box. If the student is outside the testing range check the appropriate
box.
Specify the name of any assessment and accommodations or modifications the
student may need to participate in Other State/District-Wide Assessments/Alternative
Assessments.
For 3, 4, & 5 preschoolers note if the child will take DRDP (Desired Results
Developmental Profile). If the child needs adaptations in the preschool setting, then
the IEP Team should document the adaptations. (Refer to http://www.draccess.org
website for a list of adaptations
Check the appropriate assessment that the student will be taking. For the CELDT,
check the area of assessment and for the Standards Based Spanish Test, check the
appropriate area of assessment and if the student will need accommodations and/or
modifications.
Ed u c a tio n a l Be n e fit Re m in d e r
Has the IEP Team addressed all the special considerations the student may require?
Does the student demonstrate behavior(s) that impede learning, and if so, how will
positive interventions, strategies, and supports be provided?
Does the IEP Team agree on the areas of need to be addressed in goals as
identified in the Present Levels of Academic Achievement and Functional
Performance and in Special Factors?
Is participation on state and district wide assessments, including accommodations
and modifications, in accordance with state guidelines?
Are alternate assessment(s), including the reasons, clearly noted and described?
If a student requires any waivers or exemptions to the CAHSEE, is this clearly
documented?
IEP Form ^B is required for students who take the CAA. These students require annual goals
AND objectives. Best practice would be to use Form 6B for any students who are working on
pre-academic or functional skills.
1. Areas of Need: Indicate areas of educational need that have been identified by the IEP
Team based on assessments and present levels of academic achievement and
functional performance and/or special factors. For every identified area of need there
must be a goal.
2. Baseline: Specify the students baseline performance. The baseline should describe the
childs current performance on the skills identified in the goal. The baseline should be a
quantifiable description of classroom performance in the specified area. (i.e., reads 20
sight words, writes a simple paragraph of 2-4 sentences, etc.)
4. Standard: First consider standards at the students chronological grade level. Also
consider pre-requisite skills, levels of the cognitive domain, accommodations,
modifications, and assistive technology. NOTE: If the student is taking CMA there must
be a grade level standards based goal for each area where the student is taking the
CMA.
5. Annual Goal: Annual goals must be measurable and relate to the baseline data. Goals
must include:
Who student
Does What observable behavior (will add single digit
numbers)
When by reporting date
Given What conditions (when given a paragraph to read)
How Much mastery, criteria (90% accuracy, 3
consecutive days)
How Will It Be Measured performance criteria (as measured by teacher
data)
6. Enables the student to be Involved and Progress in the General Curriculum: Select if
student is working on the goal written to California content standards.
7. Addressed other Educational Needs Resulting from Disability: Select if the student is
working on other educational needs (i.e., behavior, social skills, self-help, etc.).
Remember, to be linguistically appropriate, the goals should align to the students
assessed level on the CELDT (if appropriate) and the CDE English Language
Standards.
8. Secondary Transition Goal: If the goal is related to secondary transition, check the box
and then check the appropriate area: Education/Training, Employment, or Independent
Living.
9. Progress Reports: Document the date and the summary of the progress.
Use IEP Form 6A for students who are not taking CAA. Objectives or benchmarks are no
longer required for students who are accessing the general curriculum. Draft goals (and
objectives or benchmarks, if required) may be developed prior to the meeting and reviewed
with the team for changes. Annual goals must be measurable, and at least one annual goal
must be written for each area of identified need.
Follow the directions for Form 6A above and include measurable objectives for each goal.
Objectives are sub skills leading towards goal mastery (i.e. multiply 2 digits by 3 digits;
analyze word problem to identify data needed to determine area of a rectangle).
Special education and related services are determined at the IEP meeting only after goals and
if appropriate objectives / benchmarks have been finalized. Placement decisions must be
made in conformity with the least restrictive environment (LRE) provisions. These provisions
direct that to the maximum extent appropriate, students with disabilities be educated with
typically developing peers, and that special classes, separate schooling or other removal of
students from the general education environment occurs only if the nature or severity of the
disability is such that education in general education classes with the use of supplementary
aids and services cannot be achieved satisfactorily. The placement must be made in the
school that the student would attend if the student did not have a disability unless unique
circumstances prevent this placement. Special education and related services and
supplementary aids and services, should be based on peer-reviewed research to the extent
practicable.
1. Service Delivery Options Considered: Discuss and document service delivery options
considered. The team must first consider placement in the general education classroom
with supports prior to recommending a more restrictive setting all or part of the day.
2. Supplementary Aids, Services and Other Supports for Student and/or School Personnel:
Delineate the specific supplementary aids and services and/or supports offered for the
student and offered for school personnel (consultation to teachers, preferential seating,
enlarged text, etc.). Indicate if the supports are for the student or for school personnel by
checking the appropriate box in the grid, along with the specific start and end dates for
each area.
Team must also document modifications and/or accommodations that will be needed in
order for the student to progress toward annual goals while participating in the general
curriculum. Accommodations do not fundamentally alter or lower expectations or
standards in instructional level, content, or performance criteria (extended time on a
timed task, enlarged text, etc.). Modifications fundamentally alter or lower expectations
3. Transportation: Check No if the IEP team determines that the student does not need
special education transportation. Check Yes if the student will require special education
transportation and specify the type of transportation (e.g. door to door, wheel chair bus,
etc.)
4. Special Education and Related Services: The team needs to determine the special
education and related services that will provide educational benefit and facilitate progress
on the goals for the student (e.g. specialized academic instruction, health and nursing,
language and speech, etc.). Identify the type of service. Indicate if the service will be
individual or group. NOTE: Specialized Academic Instruction (SAI) is the core special
education service that most students receive. The duration and frequency for SAI is
based on the amount of time the Special Education Specialist/Full Inclusion Specialist is
adapting curriculum and/or working with the student. SAI is not based on the amount of
time a general education teacher may spend adapting curriculum for a student. SAI is a
service not a location. If the service is to support secondary transition, check the
secondary transition box. See CASEMIS codes below:
SPECIALIZED INSTRUCTION
330 Specialized academic instruction Adapting, as appropriate to the needs of the child with a disability
the content, methodology, or delivery of instruction to ensure
access of the child to the general curriculum, so that he or she
can meet the educational standards within the jurisdiction of the
public agency that apply to all children. (RSP- school based,
RSP, SDC inclusion services, SDC-public integrated, SDC-public
segregated, SDC-non-public school.)
340 Intensive individual instruction IEP Team determination that student requires additional support
for all or part of the day to meet his or her IEP goals. Such as the
use of an one-on-one instructional assistant.
350 Individual & small group Instruction delivered one-to-one or in a small group as specified in
instruction an IEP enabling the individual(s) to participate effectively in the
total school program. (FOR PRESCHOOL ONLY)
RELATED SERVICES
415 Language and Speech Includes receptive and expressive language, articulation, voice,
and fluency.
425 Adapted physical education Direct physical education services provided by an APE.
435 Health & nursing specialized Specialized physical health care services means those health
physical health care services services prescribed by the childs licensed physician and surgeon
requiring medically related training of the individual who performs
the services and which are necessary during the school day to
enable the child to attend school. SPHCS include but are not
limited to suctioning, oxygen administration, catheterization,
nebulizer treatments, insulin administration, and glucose testing.
436 Health & nursing other This includes services that are provided to students by qualified
services personnel pursuant to an IEP when a student has health
problems, which require nursing intervention beyond basic school
health services. Services include managing the health problem,
consulting with staff, group & individual counseling, making
appropriate referrals and maintaining communication with
Note: Those districts that have historically reported bundled services only and have
not listed each separate IEP services (SAI, DIS counseling, etc.) may continue to do so
for the June 2012 reporting cycle. Beginning in December 2012, each related service
must be identified in the IEP rather than bundled together as day treatment or
residential services.
4. Provider: Note the title of the provider of the service (do not put the persons name).
5. Frequency: Indicate the frequency of the service being provided, such as daily, weekly,
monthly, yearly, or any other frequency.
6. Duration: Indicate number of times per frequency (see CASEMIS for examples).
7. Location: Select the location of where the service is provided to the student from the
following:
210 Home instruction based on IEP team determination (not medical)
220 Hospital
310 Head Start center
320 Child development or childcare facility
330 Public preschool
340 Private preschool
350 Extended day care
360 Residential facility
510 Regular classroom/public day school
Includes students who are fully included in general education classrooms. Also
includes students who are seen under a push in model in the general education
classroom and students who receive DIS services in the general education
classroom. Additionally, students who receive services in a setting that includes
other students with special needs are included here if there are general
education students who are reverse mainstream students in that class for that
portion of the day.
520 Separate class in public integrated facility
Includes students receiving special education pullout services, including RSP
and DIS, or in a special day class model, etc.
530 State Special School
540 Separate school or special education center or facility
550 Public residential school
560 Other public school or facility
570 Charter school operated by a LEA/district
580 Charter school operated as a LEA/district
610 Continuation school
620 Alternative work education center/work study facility
630 Juvenile court school
640 Community school
650 Correctional institution or facility
710 Community college
720 Adult education facility
810 Nonpublic day school
820 Nonpublic residential school-in California
830 Nonpublic residential school-outside California
840 Private day school (not certified by CDE Special Education Division)
850 Private residential school (not certified by CDE Special Education Division)
860 Parochial school
890 Service provider location
8. Extended School Year (ESY): Discuss if the student needs ESY to receive FAPE. Check
yes or no. If yes, specify in the grid the services the student will receive, the start and
end date, provider, frequency, duration, and location. An explicitly defined rationale
must be included in determining whether a student does or does not need ESY.
Attaching the ESY form provides this rationale. If the ESY form is not attached a written
description must be contained in the text box following Rationale.
Note: ESY shall be provided to a student with a disability who the IEP deems requires
special education and related services in excess of the regular academic year. Such
students shall have disabilities which are likely to continue indefinitely or for a prolonged
period of time, and interruption of the students educational programming may cause
regression, when coupled with limited recoupment capacity, rendering it impossible or
unlikely that the student will attain the level of self-sufficiency and independence that
would otherwise be expected in view of his or her disability. (5 CCR 3043)
Ed u c a tio n a l Be n e fit Re m in d e r
Was the determination of the appropriate supplementary aids and services, and
special education and related services completed after the goals were finalized?
Are the appropriate services identified to support progress toward all goals including:
progress in the general curriculum, participation in extracurricular activities, and other
nonacademic activities?
Are the special education, related services, and supplementary aids and services
based on peer-reviewed research to the extent practicable?
Are the start/end dates, provider, frequency, duration, and location specified for
supplementary aids and services as well as special education and related services?
2. District of Service: Specify district providing the majority of services to the student.
00 No school (0-5)
10 Public day school
11 Public residential school
15 Special education center or facility
19 Other public school or facility (i.e., store front transition program)
20 Continuation school
22 Alternative work education center/work study program
24 Independent study
30 Juvenile court school
31 Community school
32 Correctional institution or facility
40 Home instruction based on IEP team determination
45 Hospital facility
50 Community college
51 Adult education program
55 Charter school operated by an LEA/district
56 Charter school operated as an LEA/district
61 Head Start program
62 Child development or childcare facility
63 State preschool
64 Private preschool
65 Extended day care
70 Nonpublic day school
71 Nonpublic residential school-in California
72 Non-public residential school- outside California
75 Private day school (not certified by CDE Special Education Division)
76 Private residential school (not certified by CDE Special Education Division)
79 Nonpublic agency
80 Parochial school
5. Federal Setting (ages 6-22): Indicate the type of school setting the student attends. If the
student turns 6 years old on or before December 2 of the current school year, this
category is completed.
400 Regular classroom/public day school
Select if the student attends classes on a general education school campus regardless
of the type of program
450 Separate school
460 Residential facility
470 Homebound/hospital
480 Correctional facility
490 Parentally placed in private school
7. All Special Education Services Provided at Students School of Residence: Check yes or
no to the question all special education services provided at the students school of
residence. If the team determines no, rationale must be documented.
8. Percentage of Time Outside and In Class & Extracurricular & Non Academic Activities:
Document the percentage of time the student is outside the regular environment and
document percentage of time the student is in the regular education environment.
Consider the full day including lunch, recess, passing periods, etc.
9. Student Will Not Participate in the Regular Class & Extracurricular & Non Academic
Activities: Document the regular education environments where the student will not
participate with typically developing peers: Provide rationale for non-participation.
10. Other Agency Services: Note other agency services the child is receiving.
11. Promotion Criteria: Check appropriate box. District criteria are the same for students
without disabilities. Progress on goals or other should be noted if the childs curriculum
has been modified to meet his/her unique needs.
12. Parents will Be Informed of Progress and How: Check the frequency and how the
progress will be reported. NOTE: Progress reporting should match frequency of report
card schedule.
13. Activities to Support Transition: If the student is going through a transition (preschool to
kindergarten, special education to general education, etc.), document the activities to
support the transition.
14. Graduation Plan: This needs to be done for students in grade 7 and higher.
Ed u c a tio n a l Be n e fit Re m in d e r
Is there a clear description of the location of services, including why some services
may not be provided at the childs school of residence, if appropriate?
Is there a clear description of the amount of time the student is outside the general
education environment, including an explanation of why the student will not
participate in general education for all or part of the day?
If appropriate, are the activities clearly identified to support transition from preschool
to kindergarten, from special education and/or NPS to general education, 8th-9th
grade, etc.?
If appropriate, is the graduation plan identified for students Grade 8 or higher?
1. IEP Meeting Participants: Have all meeting participants sign and date that they were in
attendance. Make sure to include titles of each participant.
3. Not Eligible: If team determines child is not eligible for special education, check the
appropriate box.
5. No Longer Eligible: If team determines child is no longer eligible for special education,
check the appropriate box.
6. As a means of improving services and results for your child did the school
facilitate parent involvement? When in the Future IEP be sure to uncheck the box
prior to the IEP meeting. During the IEP meeting, check the appropriate box. This is a
required CASEMIS data field. One of the boxes must be checked. Note: you need to
ask this question annually, and the parent needs to check the box. No response does
not mean we forgot to ask. If the parent(s)/guardian/surrogate/adult student checks
no, then the team needs to agree on a plan to address the issue in the coming year.
11. Students Enrolled in Private Schools by Their Parents: If the student is enrolled in
private school by his/her parent(s)/guardian/surrogate/adult student, check the box and
develop a Services Plan, if appropriate.
IDEA Section 614(d) (3) (D) In making changes to a childs IEP after the annual IEP meeting
for a school year, the parent(s)/guardian/surrogate/adult student of the child with a disability
and the LEA may agree not to convene an IEP meeting for the purposes of making such
changes, and instead develop a written document to amend or modify the childs current IEP.
IDEA Section 614(d) (3) (F) Changes to the IEP may be made either by the entire IEP Team
by amending the IEP rather than by redrafting the entire IEP. Upon request, a
parent(s)/guardian/surrogate/adult student shall be provided with a revised copy of the IEP
with the amendments incorporated.
Serves as the option for making minor amendments to the IEP if the
parent(s)/guardian/surrogate/adult student and district agree that a meeting is not
needed (adding additional DIS LSH minutes after a phone conversation with the
parents and agreement with school staff, etc.)
Attach this form to current IEP after getting signature from
parent(s)/guardian/surrogate/adult student.
Districts need to designate who can serve as the LEA representative. LEA
representative is authorized to approve the amendments.
Parent(s)/guardian/surrogate/adult student will receive a copy of the IEP with the
amendments incorporated. The box at the bottom of the page will be initialed by the
parent, etc. to indicate they have received this amendment.
Ed u c a tio n a l Be n e fit Re m in d e r
Is the amendment clear?
Do the parent(s)/guardian/surrogate/adult student and staff agree on the
amendment?
Are all affected staff (special education teacher(s), DIS provider(s), general
education teacher(s), etc.), including the LEA representative, informed of the
amendment/change?
Is there documentation to indicate that the parent has received the copy of the IEP
with the amendments incorporated?
Form 11A - Specific Learning Disability Team Determination of Eligibility Instructions / Form
Form 11B - Specific Learning Disability Discrepancy Documentation Report IEP Team
Certification. Instructions / Form
Form 11D - Specific Learning Disability Patterns of Strengths and Weaknesses IEP Team
Certification. Instructions / Form
Form 21 - Referral for Special Education and Related Services.. Instructions / Form
Form 22 - Notice of Receipt of Referral for Special Education Assessment.. Instructions / Form
Form 25A - Notice of Meeting Individualized Education Program (School District Titles) Instructions / Form
Form 25B - Notice of Meeting Individualized Education Program (Personnel Names) Instructions / Form
Form 27 Page 1 - Summary of Academic Achievement and Functional Performance Instructions / Form
Form 27 Page 2 - Summary of Academic Achievement and Functional Performance Instructions / Form
Form 29 (Pages 1 & 2) - Prior Written Notice When Parent Revokes Consent to Special Education and Related
Services Instructions / Form
Form 30 - Individual Service Plan for Parentally Placed Private School Students Instructions / Form
Form 36 Prior Written Notice Graduation from High School Instructions / Form
This form documents the requirements for identifying a student as having a specific learning
disability (SLD).
A draft of this form is typically completed prior to the IEP meeting with a discussion and final
decision reached by the IEP team during the meeting.
The Case Manager completes the form with input from the appropriate IEP team members
(School Psychologist, Special Education Teacher, General Education Teacher, etc.)
Fill out the appropriate information based on the evaluations indicating the area of
achievement that is severely discrepant from the level of intellectual ability and the processing
disorder associated with this discrepancy.
Include any medical findings that are educationally relevant and the other information required
on this form.
If there is a team decision that is not based on the standard measures indicated, support that
decision.
Obtain signatures from all participants in the IEP meeting on this form.
This form documents the presence of a specific learning disability in instances when the students
standardized testing results do not exhibit a severe discrepancy between ability and achievement.
A draft of this form may be completed prior to the IEP meeting, but more typically is completed
during the IEP meeting with extensive discussion and final decision reached by the IEP team
during that meeting.
The Case Manager completes the form with input from the appropriate IEP team members
(School Psychologist, Special Education Teacher, General Education Teacher, etc.)
Fill out the appropriate information based on the evaluations including intellectual ability and
academic achievement.
As the testing results did not indicate a severe discrepancy the decision is based on
information provided by the parent, information provided by the students teacher,
observations, work samples, state testing results or other group testing scores.
The students chronological age is taken into consideration and any other relevant supporting
information is documented.
This form documents the requirements for identifying a student as having a specific learning
disability (SLD) based on determinations through a Response to Intervention process.
A draft of this form is typically completed prior to the IEP meeting with a discussion and final
decision reached by the IEP team during the meeting.
The Case Manager completes the form with input from the appropriate IEP team members
(School Psychologist, Special Education Teacher, General Education Teacher, etc.)
Fill out the appropriate information based on the evaluations indicating whether or not the area
the student has made sufficient progress to meet age or state-approved grade-level standards
based on the pupils response to scientific, research-based intervention.
Indicate whether the learning disability is or is not caused by poor attendance, environmental,
emotional, sensory or the other reasons listed in Section III.
Include any medical findings that are educationally relevant and the other information required
on this form.
If there is a team decision that is not based on the standard measures indicated, support that
decision. (Form 11B)
Obtain signatures from all participants in the IEP meeting on this form.
This form documents the requirements for identifying a student as having a specific learning
disability (SLD) based on determinations through a process indicating the students pattern of
strengths and weaknesses.
A draft of this form is typically completed prior to the IEP meeting with a discussion and final
decision reached by the IEP team during the meeting.
The Case Manager completes the form with input from the appropriate IEP team members
(School Psychologist, Special Education Teacher, General Education Teacher, etc.)
Fill out the appropriate information based on the evaluations indicating whether or not the
student exhibits a pattern of strengths and weaknesses in performance, achievement, or
both, relative to age, state-approved grade-level standards, or intellectual development.
Include any medical findings that are educationally relevant and the other information
required on this form.
If there is a team decision that is not based on the standard measures indicated, support
that decision. (Form 11B)
Obtain signatures from all participants in the IEP meeting on this form.
This form is used by school personnel when requesting an assessment for eligibility for special
education and related services.
A pupil shall be referred for special educational instruction and services only after the resources of
the regular education program have been considered and, where appropriate, utilized. EC 56303
Name of parent or legal guardian: Enter first and last name of parent or legal guardian.
Date parent notified of intent to refer: Enter exact date parent notified.
Method of notifying parent of intent to refer: Check method used to notify parent.
Parents native language: If other than English enter language or primary mode of
communication.
Primary Concern Regarding Student: This should be the specific reason or area where you
suspect a disability.
Specific Reason for Referral: Check the appropriate box or enter a description of the reason
next to other.
Name of Referring Person: Enter the name of referring person and title.
The bottom part of the form For District Use Only is helps keep track of the assessment
timelines.
This form serves as a notice to parent or guardian that their child has been referred for
assessment. It is in a letter format and should be put on district letterhead.
Enter the name of the people who will be attending the IEP meeting.
The assessment plan is to be completed by the assessment team and approved by the
parent(s)/guardian/surrogate/adult student in writing at the initial referral for special education
and/or request for assessment and each time the Local Education Agency (LEA)/District proposes
to conduct assessment. There are two versions of the Assessment Plan Form. Form 23A
includes the Medi-cal statement authorizing billing , appropriate parent signature and receipt of
written notification.
NOTE: For initial assessments, Some SELPAs use a Prior Written Notice Form 24.
1. Student Name: Enter the student last name and first name.
2. Date of Birth: Enter the exact birthdate.
3. Date: Enter date the form was created and sent to parent/guardian/surrogate/adult student.
4. Purpose of Meeting: Select purpose of meeting.
Initial is the IEP to determine eligibility after initial assessment.
Annual is the IEP meeting to be held within one year of prior IEP.
Triennial is the IEP meeting to be held after reassessment. This meeting may also
include the Annual IEP Meeting.
Transition means transition from infant to preschool, preschool to kindergarten,
elementary to middle, middle to high school, high school to transition placements, from
public school setting to NPS or reverse, etc.
Transition also means for students who are 16 or older, or who will turn 16 when this IEP
is in effect, the IEP team must address needed post-secondary transition services.
These services must include the results of age appropriate transition assessments,
measurable post-secondary goals related to training/education, employment and
independent living skills (as appropriate) and describe the focus of the students course
of study.
Interim means if the child has an IEP and transfers into a district from another SELPA.
Other
5. Parent/Guardian Information: Enter the name of the parent/guardian/surrogate.
6. District : This is the students district of residence.
7. School: Enter the childs neighborhood school.
8. Grade: Enter the appropriate grade designation.
9. Native Language: This field was previously known as home language. This is the students home
language or birth language.
10. English Proficiency/CELDT Level: Enter the appropriate level of English proficiency based on the
scores obtained through CELDT testing.
"Assessment plan" means a written statement that delineates how a pupil will be
evaluated and meets the requirements of Section 56321 of the Education Code.
Note: An assessment plan must be completed and signed and agreed to by the
parent(s)/guardian/surrogate/adult student if the district plans to administer testing to the student
that is not part of an assessment being administered to all or a group of students.
Mark the reason the assessment plan is being sent: Initial, Annual, Triennial, Transition, or
Interim (or other such as Manifest Determination, Special Requested, etc.).
The assessment plan is to be completed by the assessment team and approved by the
parent(s)/guardian/surrogate/adult student in writing at the initial referral for special education
and/or request for assessment and each time the Local Education Agency (LEA)/District proposes
to conduct assessment. Form 23B is the second of the two versions of the Assessment Plan
Form. Form 23B does not include any Medi-cal information. All requirements of Form 23A in
regards to assessment plan procedures are also required and included in Form 23B
The Prior Written Notice form must be completed and sent with the Assessment Plan for all initial
referrals for assessment.
Student Name: Enter the student last name and first name.
Date: Enter date the form was created and sent to parent/guardian/surrogate/adult student.
Evaluation procedure(s) List the types of assessment data that were used in making the
decision to assess the student (i.e., observation, standardized testing, statewide assessment,
etc.).
Assessments List the assessments used to make the determination to engage in further
assessment
Record(s) List any records that are or are not part of the students cumulative file to make
the determination to assess.
Alternatives considered/rejected List any other options that were considered and
rejected such as intervention programs offered, curriculum adaptations, etc.
Other factors list any other relevant factors to be considered such as: the student has
been retained, the student is working far below grade level, and the student has received
scientific-based intervention and has not responded, etc.
The State SELPA Form has two meeting notification forms, one listing school district titles and the
other with the title and a line to write in specific staff names. It is up to your local district//SELPA
to determine which form to use.
Type of Meeting: Check the box to indicate what type of meeting is being proposed.
Example: Initial, Annual, Transition etc.
Parents Name: Enter the name of the person you are inviting to the meeting
(Parent/Guardian/Surrogate)
Meeting Schedule: Enter Date, Time and location of the proposed meeting.
Anticipated Team Members: Check appropriate boxes to indicate IEP team members that may
attend the meeting. Form 23A would include the members name next to their title. Specialist type:
indicate any related service providers that may be attending, such as SLP, OT, APE etc. NOTE: This
gives the parents notice that if they wish to audiotape the meeting, they must give 24-hour notice and
the school would be taping also. The notice in paragraph (a) of 34 CFR Section 345 also allows a
District/LEA to inform parents that they may bring other people to the meeting that have specific
knowledge of their child or expertise about the childs disability.
Further Information: Enter Name, Title and contact information for your District Director or
contact person.
Return To: Enter the name of the case carrier. Note; It is often helpful to highlight this so the
parent realizes they should complete the form and return it to school.
Parent Response: Parent is to check the appropriate boxes, indicating attendance, sign, date
and return the form to school
The State SELPA Form has two meeting notification forms, one listing school district titles and the
other with the title and a line to write in specific staff names. It is up to your local district//SELPA
to determine which form to use.
Type of Meeting: Check the box to indicate what type of meeting is being proposed.
Example: Initial, Annual, Transition etc.
Parents Name: Enter the name of the person you are inviting to the meeting
(Parent/Guardian/Surrogate)
Meeting Schedule: Enter Date, Time and location of the proposed meeting.
Anticipated Team Members: Check appropriate boxes next to the district title indicating the IEP team
members that may attend the meeting. NOTE: This gives the parents notice that if they wish to
audiotape the meeting, they must give 24-hour notice and the school would be taping also. The notice in
paragraph (a) of 34 CFR Section 345 also allows a District/LEA to inform parents that they may bring
other people to the meeting that have specific knowledge of their child or expertise about the childs
disability.
Further Information: Enter Name, Title and contact information for your District Director or
contact person.
Return To: Enter the name of the case carrier. Note; It is often helpful to highlight this so the
parent realizes they should complete the form and return it to school.
Parent Response: Parent is to check the appropriate boxes, indicating attendance, sign, date
and return the form to school.
The Manifest Determination form is used to report findings for a Manifest Determination Review
each time the Local Education Agency (LEA) / recommends a student in special education (or on
a 504 Plan) for expulsion and/or when the student is removed from his/her current educational
placement (is suspended for more than 10 consecutive days or suspended for more than 10 days
in a school year if the behavior constitutes a pattern).
Date of the Current IEP is the date of the last agreed upon, signed IEP (by the
parent/guardian)
Date of Last Assessment List the date of the last three-year triennial or complete psycho-
educational assessment conducted (it may be an assessment that was conducted as part of
the Manifest Determination).
Disability State the primary disability of the student. It is recommended that the IEP team
also include information for their determination that would come from any other disability of the
student.
Current Educational Setting List the current placement (i.e., special class, regular
education class, etc.)
Description of the Behavior Write a brief statement about the behavior that occurred (it is
best to list factual information or investigation findings/outcomes)
Disciplinary Action Taken and Date This refers to suspension and the first date of the
suspension
Part II. In determining whether the student's behavior was a manifestation of his/her
disability, the manifestation determination team considered the following:
Evaluation and diagnostic results Check this box if formal assessment results helped the
team to make the decision regarding whether or not the behavior was a manifestation of the
students disability. List the specific evaluations/dates used).
Observations Check this box if student observation data was used to help the team make
the decision regarding whether or not the behavior was a manifestation of the students
disability. List who observed and when.
Student's IEP, services, and placement Check this box if the IEP, services or placement
of the student at the time of the behavior incident were used to help the team make the
decision regarding whether or not the behavior was a manifestation of the students disability.
Describe how used (relevant information from IEP).
Other relevant information List any other information that contributed to the decision such
as past discipline history of the student, reports from staff, etc.
Check yes if the team feels the behavior was caused by or had a direct or substantial
relationship to the disability. Check no if team feels it did not.
Check yes if the team feels the behavior was the direct result of a failure to implement the
IEP (for example, if all the supports and services listed on the IEP were not taking place as
outlined as the time of the incident)
Part IV. The Manifestation Determination team decided that the student's behavior (check
one of the following two boxes as appropriate based on the boxes check above:
Check the first box was a manifestation of his/her disability if the answer to the two
questions above (steps 12 and 13) were yes if this box is check the discipline proceedings
may not go forward (in most cases this will mean that the case cannot go forward to the Board
of Education for to recommend expulsion)
Check the second box if one of the answer to both of the two questions above was no. This
means the behavior was not a manifestation of his/her disability.
The SOP must be completed during the final year of a students high school education. The timing
of completion of the SOP may vary depending on the students postsecondary goals. If a student
is transitioning to higher education, the SOP, with additional documentation, may be necessary as
the student applies to a college or university. Likewise, this information may be necessary as a
student applies for services from state agencies such as vocational rehabilitation. In some
instances, it may be most appropriate to wait until the spring of a students final year to provide an
agency or employer the most updated information on the performance of the student.
Cognitive Abilities: Check the appropriate box. If checked other, briefly describe.
Communication Skills: Check the appropriate box. If checked other, briefly describe.
Motor Skills (Fine/Gross): Check the appropriate box. If checked other, briefly describe.
Agency Linkages: Check the agencies known to be working with student or could be a
resource to the student. Include the agency contact person and phone number, if known.
Related To Support: Check the areas that apply and other items as appropriate.
Related to Health Concerns: Check the areas that apply and other items as appropriate.
Presentation of Materials & Instructions: Check the areas that apply and other items as
appropriate.
Response to Materials & Instruction: Check the areas that apply and other items as
appropriate.
Settings: Check the areas that apply and other items as appropriate.
Date of Contact: Note date when contact can made no later than.
Note: The completion of this section may require the input from a number of school personnel including
the special education teacher, regular education teacher, school psychologist or related services
personnel. It is recommended, however, that one individual from the IEP Team be responsible for
gathering and organizing the information required on the SOP
For a child whose eligibility terminates due to aging out or receipt of a diploma, the district/LEA
must provide the child with a SOP, which shall include recommendations on how to assist the
child in meeting the childs post-secondary goals. The SOP must be completed during the final
year of a students high school education. The timing of completion of the SOP may vary
depending on the students postsecondary goals. If a student is transitioning to higher education,
the SOP, with additional documentation, may be necessary as the student applies to a college or
university. Likewise, this information may be necessary as a student applies for services from
state agencies such as vocational rehabilitation. In some instances, it may be most appropriate to
wait until the spring of a students final year to the child with the most updated information on the
performance of the so that this information may be passed on to relevant post-secondary
agencies and/or employers.
Related to Support:
Mark each item within this section that assists the student with the organization of assignments
and behaviors related to successful completion of assignments.
Mark each item within this section that provides information necessary to the medical well-being
of the student.
Mark each item within this section that benefits the student with the successful completion of
assignments or tests that directly relate how an assignment or test is presented to the student.
Mark each item within this section of items necessary for the student to effectively complete
assignments or tests presented.
Settings:
Mark each item that provides the most favorable area for the student to successfully complete
tasks.
Timing/Scheduling of Tasks/Assignments/Tests:
Mark each item that supports the student with the best timelines for completion of assignments,
tasks and tests.
Complete this section with the name of the district of service, address, phone number and name
of the contact person who can provide the parent, student or outside agency with educational
information.
This form is provided to parents prior to the district initiating or refusing to change the
identification, evaluation, educational or placement or provision of a free appropriate public
education.
If the district is proposing to do something, check the box Proposal to initiate or change and
then check the appropriate box that applies to the situation that has required a Prior Written
Notice.
If the district is refusing a request made by the parent, check the corresponding box and then
check the box that applies to the situation that has required a Prior Written Notice.
Description of proposed or refused action: Briefly describe the proposed action or the action
that the district is refusing to take.
Reason(s) for proposed or refused action: Note the specific reasons why the district is
refusing to take a proposed action or a refused action.
Description of other options considered and reasons for rejecting them: Document other
options that were considered and the reasons for rejecting the options.
Other factors relevant to the proposal or refusal: Document any other factors that were
relevant to the districts decision to propose or refuse to do an action.
If at any time subsequent to the initial provision of special education and related services, the
parent of a child revokes consent in writing for the continued provision of special education related
services, the LEA:
May not continue to provide special education and related services to the child, but must
provide Prior Written Notice before ceasing the provision of special education and related
services;
Will not be considered in violation of the requirement to make FAPE available to the child
because of the failure to provide the child with further special education and related services;
and
Is not required to convene an IEP team meeting or develop an IEP for the child for further
provision of services.
Fill out the appropriate blanks in the template letter (see sample on following page).
1. Student Name: Enter the students last name and first name.
4. Date: Enter the date of which the Service Plan was held.
6. Address: Enter the students current address. If the student is living in a residential school,
enter the address of the parent.
8. Cell Phone: Enter the cell number of the parent(s) or guardian(s), if known.
9. Work Phone: Enter the work phone of one of the parent(s) or guardian(s), if known.
10. District where private school is located: Enter the name of the district where the private
school is located (unless other agreements have been made. This would be the district
drafting and implementing the Service Plan.
11. District of residence: Enter the name of the district where the students parent(s) or
guardian(s) reside.
12. Home School: Enter the name of the school the student would attend if they were living at
the address of their parent(s) or guardian(s) and not attending a private school.
13. Private School: Enter the name of the private school where the student is currently
attending.
14. Private School Phone: Enter the phone number of the private school.
15. District of Residence Phone: Enter the phone number of the District of Residence listed on
the Service Plan (item 10 above).
Students parent(s), guardian(s), surrogate or the adult student have declined the
districts offer of a Service Plan check this option if the parent(s) or guardian(s) have
declined wanting a service plan. This would be applicable if they want no services or if at
some time they choose to enroll the student in a public school program in the district of
residence.
Students parent(s), guardian(s), surrogate or the adult student have accepted the
districts offer of a Service Plan.
16. Services: Enter the special education service(s) below for the student while enrolled in
private school or until the proportionate share of federal funds have been expended for the
current school year.
17. Area(s) or need: Enter the area(s) of need based on the assessment results.
19. Enter the service(s): Enter the service(s) being offered. Remember, the services offered
must be based on the final decisions the SELPA / District have made with respect to private
school services. (300.320)
20. Frequency: Enter how often the service will take place or how many sessions, etc.
21. Duration: Enter how long (minutes, hours, etc.) each service will take place.
22. Location: Enter the location where services will take place.
23. Start Date: Enter the date when services will begin.
24. End Date: Enter the date when services will end.
25. Service Provider: Enter the title, not the name, of the service provider.
LEA Representative enter the name of the person who is representing the district / LEA.
Remember this person must have the authority to allocate services.
Other have any other persons in attendance sign the Service Plan.
27. Next Annual Review Due By: Enter the next annual review date (approximately one year from
the date of the date of the current service plan meeting)
28. Triennial Review Due By: Enter the triennial review date. This is three years from the date of the
last assessment review or the initial assessment review
This form is used for placement of a student coming from another SELPA or from out-of-state.
1. Student Name: Enter the students last name and first name.
8. Transportation: Check No if the IEP team determines that the student does not need special
education transportation. Check Yes if the student will require special education transportation
and specify the type of transportation (e.g. door to door, wheel chair bus, etc.)
10. Home Phone: Enter the parents / guardians home phone number, if known.
11. Cell Phone: Enter the parents / guardians cell number, if known
12. Address: Enter the parents / guardians home address, city and zip code.
13. Native Language: Enter the students home language or birth language.
14. EL: Check if the student is an English Learner and whether or not they have been re-
designated.
15. Redesginated: Check the appropriate box indicating if the student has or has not been re-
designated. (R-FEP)
16. Ethnicity: Enter the students ethnicity as it has been entered on the school enrollment form
for the school.
17. Residency: Check whether the student resides with a Parent / Guardian, in a Foster Family
Home, in a Licensed Childrens Institution, is an Adult Student, or Other.
18. Indicate Disability: Check the appropriate disability as reflected on the IEP from the
sending SELPA.
19. Special Education Entry Date: Enter the date the student first received special education
services, including IFSP (0-3 infant services).
20. Interim Placement to be Reviewed: Enter the date of the next meeting to determine
appropriate special education placement. This date must be within 30 calendar days.
21. Triennial Date: Enter the date when the next triennial evaluation is due to be completed.
22. Last Placement: Enter the name of the School / District / County where the student was last
enrolled.
24. Contact Person: Enter the name of an appropriate contact person at the students last
school or district. This could be the Special Education Teacher, Program Specialist, Special
Education Director, etc.
25. Special Education Program Authorization: Enter the appropriate, comparable special
education services, starting date of the services, frequency of that service, duration,
location, and the service provider (the title, not the name).
26. % of Time OUTSIDE: Enter the % of time the student is out of the general education
classroom receiving special education services.
27. Name of LEA Representative: The LEA representative, who looked at the incoming IEP
and determined the appropriate placement, prints their name, signs the form, indicates their
position, and dates the form.
The Aging Out and Graduation letters match the 7 requirements of PWN, after a few revisions
the letter will be brought back for final approval next month. SELPA can choose to use the
letters.
This form is to be used when the LEA is requesting the parent or guardian to excuse a required
IEP team member from an IEP in whole or in part. Separate columns and check boxes have been
added to clearly identify the area of curriculum or related service not being discussed as well as
the submission of written input provided to the parent/guardian/surrogate or adult student for the
area of curriculum or related services of the missing IEP Team member.
3. Check the Box in Whole or in Part: If the IEP team member is being excused for the
entire meeting check in whole and check in part if the team member is only being
excused for part of the meeting.
4. Individual Education Program Team Member(s): List the members that will be excused
from the IEP team meeting in whole or in part.
5. Area of Curriculum or Related Services: List the area of curriculum or related services
that pertain the IEP team member being excused.
6. Area of Curriculum or Related Services is Not Being Discussed: Check the column if
the area of curriculum or related services is not being discussed at the IEP team meeting.
7. Written Input has Been Submitted to the Parent and the IEP Team Prior to the Meeting
Regarding Area of Curriculum or Related Services: If the area of curriculum or related
services pertaining to the IEP team member is going to be discussed at the IEP team
meeting, then IEP team member must submit his/her in writing to the parent and the IEP
team prior to the meeting.
This form is to be completed prior to each triennial IEP in order to document the LEAs process for
determining if further assessment is needed to inform the IEP Team at a triennial IEP meeting (See 30
EC 56381). Remember, parent/guardian/surrogate or adult student input regarding whether or not
further assessment is required.
Indicate the students name, date of birth, date of form/ date form sent out, school (current school of
attendance), date of determination (date triennial reevaluation need was determined), the due date of
the NEXT triennial IEP, and the students case manager as indicated in SEIS.
Mark Yes if it is determined that some level of formal assessment is needed (even if it is only
academic, or another area). If the answer is Yes mark the appropriate boxes below this section to
indicate exactly what types of formal assessment will be completed.
Mark No if the IEP has determined that no additional formal assessment will be completed in any
domain, to include academics.
Lastly, if the Yes box was check and it was determined that additional assessment was needed,
indicate why by checking the appropriate boxes.
Likewise, if the No box was checked that indicated no additional formal assessment was needed write a brief
statement as to why (for example, it is deemed that current, appropriate assessment data is available to
inform the IEP Team regarding the educational or related service needs, including approved academic
achievement and functional performance, of the pupil).
The ESY worksheet was formally adopted by the Forms Committee in February, 2013 as an optional form in
order to assist IEP Teams when making Extended School Year (ESY) determinations. The worksheet is to
describe and properly document the recoupment and regression that determines the need for ESY.
Definitions: Explains exactly what ESY is and how/why it is determined to be needed by the student. This
section also provides the definition for Rate of Recoupment and Regression and Recoupment in order for the
IEP to completely discuss the needs of the student.
Question Section: Each of the questions 1 through 5 must be discussed and determined to be Yes or No for
each item.
Question 1: The IEP Team must determine if the student is unable to regain skills in the same manner and
timeline as their general education peers. If the student is not able to regain skills in such a manner the IEP
Team must identify the area(s) in which the student is does not make progress in a manner similar to his/her
peers.
Question 2: This question documents the loss of skills a student exhibits during short breaks throughout the
school year which may determine the need for ESY services. If a student shows a loss of skills during s short
break the IEP Team must identify the area(s) which is affected.
Question 3: This question identifies essential skills or crucial areas of improvement a student is achieving that
would otherwise be lost should the student have a lengthy break of service. The IEP Team is to identify the
skills or areas that would be adversely affected should the student have a significant break in service.
Question 4: This questions summarizes the above information indicating the loss of skills that would occur
without ESY services.
Question 5: This questions documents the relationship between the students disabling condition and the need
for ESY services.
Should any of the 5 Questions receive a Yes answer, Page 2 of the Worksheet must be completed.
Page 2 of the ESY Worksheet describes in more detail the need for services. The IEP committee is responsible
for ensuring that a student receives a free appropriate public education (FAPE), and must determine the special
education and related services necessary to meet the student's unique needs. This section provides this
justification.
Failing to master IEP goals does not automatically make a student eligible for ESY services
This form is provided to inform parents and/or adult student prior to the district initiating to change
the educational placement or provision of a free appropriate public education based on the criteria
of completing their high school requirements for a Certificate of Completion.
.
The form describes requirements mandated of a Prior Written Notice. The form is an optional
form.
Fill out date letter is being sent to parent and/or adult student.
Enter the date of the last IEP that describe the last agreed upon offer of FAPE and the date
this IEP will conclude.
In the final paragraph, print the name of district contact person should the parent and/or adult
student disagree with the decision of promotion based on a Certificate of Completion with the
phone number and/or email address to make contact.
This form is provided to inform parents and/or adult student prior to the district initiating to
change the educational placement or provision of a free appropriate public education based on
the criteria of completing their high school requirements with a Regular High School Diploma.
.
The form describes requirements mandated of a Prior Written Notice . The form is an optional
form.
Fill out date letter is being sent to parent and/or adult student.
Fill in the name of the student within the body of the first paragraph.
Enter the specific reason why options other than a regular high school diploma is not
appropriate for the student.
In the final paragraph, print the name of district contact person should the parent and/or
adult student disagree with the decision of promotion based on a Certificate of Completion
with the phone number and/or email address to make contact.
This form is provided to document the necessary data points for the CASEMIS collection. This form is for
internal use only and is not necessary to be given to parents.
4. District of Service: Specify district providing the majority of services to the student.
5. Student SSID/CSIS: The SSID, formerly CSIS, is assigned by the State. Each student must have
a SSID. Social Security Number is optional.
7. Student Last Name: Enter the students last name as documented on the official birth certificate.
8. Student First Name: Enter the students first name as documented on the official birth certificate.
9. Grade: The grade is for Infants only and this is a pre-filled field.
12. Case Manager: The person indicated on the students IFSP forms to manage the students
program.
13. Student Address/City/State/Zip: Enter the parents / guardians home address, city, state and zip
code.
14. Parent/Guardian Address/City/State/Zip: Enter the parent / guardian/surrogate name. Enter the
contact information for the parent/guardian. If the student resides in an out-of-home placement
through a non-educational agency, put the parent contact information in the second contact area,
if known.
15. Phone #1: Enter the parents / guardians home phone number, if known.
16. Phone #2: Enter the parents / guardians cell or work number, if known
17. Ethnicity: Check the appropriate ethnicity(s). Note: Only one ethnicity can be listed. This should
be the ethnicity designated by the parent on the student enrollment form.
18. Race: Enter a code from the federally identified list, must select one or more, regardless of
Ethnicity. This is required for those students whose ethnicity was listed as 501 or 900.
19. EL: Check if the student is an English Learner and whether or not they have been re-
designated.
21. Native Language: Enter the students home language or birth language.
Revised July 2015 62
22. Early Intervention: Check No. Early Intervention cannot be Yes for Infants.
23. Disability: Mark primary disability with P and secondary disability with S. The primary disability
should be the one that has the most significant impact on the students ability to access the general
education environment. Note: For funding purposes, low incidence disabilities marked as secondary will
generate low incidence funding.
24. Referral Date: Enter the date of the initial referral to assess and determine eligibility for education
services (ages 0-3). Note: This date can change if a student is found eligible, then exits, and then is re-
assessed and found eligible again.
25. Parent Consent: Enter the date the district received parent signature/consent for initial evaluation.
26. Initial Evaluation: Enter the date the IFSP team determined the student is eligible for services.
27. Date of Original Special Education Entry: Enter the date of IFSP Team meeting to review initial
evaluation and determine eligibility for special education.
28. Referred By: Select the box that identified the appropriate person initiating the referral (Parent,
Teacher, SST, Other School/District Personnel, Other).
29. Plan Type: Select the box the identifies the plan determined to best meet the needs of the student.
30. Residential Status: Select the box that best identifies the students residential status.
31. Solely Low Incidence: Mark Yes or No if the student is eligible under a category identified as a
low incidence disability. A Yes answer would apply only to the students with the following eligibility
categories: DB, VI, OI, HH, and Deaf.
32. Infant Setting: Discuss and document service delivery options considered. Select the appropriate box
that identifies the type of setting the student will receive service.
33. Federal Infant Setting (Ages 0-2): After the discussion of placement options, identify the location the
student will receive services.
34. Transportation: Check No if the IFSP team determines that the student does not need special
education transportation. Check Yes if the student will require special education transportation and specify
the type of transportation (e.g. door to door, wheel chair bus, etc.)
35. Services Chart: The team needs to determine the special education and related services that will
provide educational benefit and facilitate progress on the goals for the student (e.g. specialized academic
instruction, health and nursing, language and speech, etc.). Identify the following information within the
chart:
36. Special Education Exit Date: Document the date the student was exited from their special education
program and mark within the chart below the date line as to the exact reason for the students exit.
INDICATE DISABILITY/IES (P = Primary, S = Secondary) Note: For Initial and triennial IEPs, assessment must be done and discussed by
IEP Team before determining eligibility.
_______ 210 ID _______ 220 HH * _______ 230 Deaf * _______ 240 SLI _______ 250 VI *
_______ 260 ED _______ 270 OI* _______ 280 OHI _______ 290 SLD _______ 300 DB *
_______ 310 MD _______ 320 AUT _______ 330 TBI _______ 281 Est. Med. Dis. (0-5)
* Low Incidence Disability
_______Not Eligible for Special Education _______Exiting from Sp. ED. (returned to reg. ed/no longer eligible)
Describe how students disability affects involvement and progress in the general curriculum (or for preschoolers, participation in
appropriate activities) _________________________________________________________________________________________
_____________________________________________________________________________________ ___
Student Invited Yes No If appropriate, and agreed upon, agencies invited Yes No NA
Describe how the student participated in the process Present at meeting Interview Prior
Interest Inventories Questionnaire
Is there an appropriate measurable post-secondary goal(s) that covers education or training, employment, Yes No
and, as needed, independent living.
Is the Post-secondary goal(s) addressed/updated in conjunction with the development of the Annual IEP. Yes No
Are there transition services included in the IEP that will reasonably enable the student to meet his or her Yes No
post-secondary goals.
Are there annual goal(s) included in the IEP that are related to the students transition services needs. Yes No
Form 2
STATE SELPA IEP TEMPLATE
TRANSITION PLAN (ITP) Page 2
Age of Majority
On or before the students 17th birthday, he/she has been advised of rights at age of majority (age 18)
When you reach the age of 18, the age of majority, you have the right to receive all information about your educational program and
make all decisions related to your education. This includes the right to represent yourself at an IEP meeting and sign the IEP in place of
your parent or guardian.
Strengths/Preferences/Interests _________________________________________________________________________________
Concerns of parent relevant to educational progress ________________________________________________________________
SBAC
English/Language Arts Standard Exceeded Standard Met Standard Nearly Met Standard Not Met
Math Standard Exceeded Standard Met Standard Nearly Met Standard Not Met
CA Standards Test
Science Adv. Proficient Basic Below Basic Far Below Basic
CMA
Science Adv. Proficient Basic Below Basic Far Below Basic
CAPA
Science Standard Exceeded Standard Met Standard Nearly Met Standard Not Met
CELDT
Listening ____________ Speaking ___________ Reading ________________ Writing ______________
Other Assessment Data (e.g., curriculum assessment, other district assessment, etc.) _______________________________________
Vocational___________________________________________________________________________________________________
Health ______________________________________________________________________________________________________
SPECIAL FACTORS
Does the student require assistive technology devices and/or services? Yes No
Rationale____________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Does the student require low incidence services, equipment and/or materials to meet educational goals?
Yes No (if yes, specify)
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
Behavior Intervention Plan (BIP) Attached Behavior Goal is part of this IEP
7/2015 Form 4
STATE SELPA IEP TEMPLATE
STATEWIDE ASSESSMENTS
Indicate students participation in the California Assessment of Student Performance and Progress (CAASPP) below:
Note: there would be drop down boxes showing all the allowable options in each category. Drop downs must allow for
multiple choices from each checked area. Matrix of choices in attached excel file.
If student is taking CMA or ALTERNATIVE ASSESSMENT the IEP team has reviewed the criteria for taking alternate
assessments.
The student will not participate in the SBAC because _________________________________________________
Participation in an alternate assessment is appropriate because ________________________________________
Desired Results Developmental Profile (DRDP) (For Preschoolers Ages 3, 4 and 5 years)
Adaptations Not Applicable Sensory support Functional positioning
Alternative response mode Assistive equipment or device Visual support
Alternative mode for written language Augmentative or alternative communication system
Linguistically appropriate
Goal __________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Comments _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Comments _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Comments _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Comments _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Linguistically appropriate
Goal __________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Benchmark 1 Within _______________ ________________, will achieve the above goal at __________________________
Benchmark 2 Within _______________ ________________, will achieve the above goal at __________________________
Benchmark 3 Within _______________ ________________, will achieve the above goal at __________________________
Comments _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Comments _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Comments _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Comments _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Linguistically appropriate
Goal _______________________________________________________________________________________________
___________________________________________________________________________________________________
Comments__________________________________________________________________________________________
_________________ ___
Comments__________________________________________________________________________________________
_________________ ___
Comments__________________________________________________________________________________________
_________________ ___
Comments________________________________________________________________________________________
_________________________________________________________________________________________________
Form 6C
STATE SELPA IEP TEMPLATE
OFFER OF FAPE - SERVICES
The service options that were considered by the IEP team list all (In selecting LRE, describe the consideration is given to any potential harmful
effect on the child or on the quality of services that he or she needs) :
Supplementary Aids, Services & Other Supports for School Personnel, or For Student, Or On Behalf Of the Student
Aids, Services, Program
Accommodations/Modifications,
And/Or Supports Start Date End Date Frequency Duration Location
Student ___/___/_____ ___/___/______
Personnel ___/___/_____ ___/___/______
Student ___/___/_____ ___/___/______
Personnel ___/___/_____ ___/___/______
Student ___/___/_____ ___/___/______
Personnel ___/___/_____ ___/___/______
Special Education Transportation Yes No
Programs and services will be provided according to where student is in attendance and consistent with the district of service calendar
and scheduled services, excluding holidays, vacations, and non-instructional days unless otherwise specified.
All special education services provided at students school of residence? Yes No (rationale) _________________________
_______% of time student is outside the regular class & extracurricular & nonacademic activities
_______% of time student is in the regular class & extracurricular & nonacademic activities
Student will not participate in the regular class and/or extracurricular and/or nonacademic activities ________________________
because ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
ACTIVITIES TO SUPPORT TRANSITION (e.g., preschool to kindergarten, special education and/or NPS to general education class, 7th 9th grade)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CONSENT
_______ I agree to all parts of the IEP.
_______ I agree with the IEP, with the exception of ________________________________________________________________
_______ I decline the offer of initiation of special education services.
_______ I understand that my child is not eligible for special education.
_______ I understand that my child is no longer eligible for special education
As a means of improving services and results for your child did the school facilitate parent involvement? Yes No No Response
Signature____________________________________________________ ___/___/______
Parent Guardian Surrogate Adult Student Date
Signature____________________________________________________ ___/___/______
Parent Guardian Surrogate Adult Student Date
If my child is or may become eligible for public benefits (Medi-Cal): I authorize the LEA/district to release student information for
the limited purpose of billing Medi-Cal/Medicaid and to access Medi-Cal: health insurance benefits for applicable services.
Signature _____________________________________________________________
Parent Guardian Surrogate Adult Student
CONSENT
_______ I agree to all parts of the IEP.
_______ I agree with the IEP, with the exception of ________________________________________________________________
_______ I decline the offer of initiation of special education services.
_______ I understand that my child is not eligible for special education.
_______ I understand that my child is no longer eligible for special education
As a means of improving services and results for your child did the school facilitate parent involvement? Yes No No Response
Signature____________________________________________________ ___/___/______
Parent Guardian Surrogate Adult Student Date
Signature____________________________________________________ ___/___/______
Parent Guardian Surrogate Adult Student Date
(Initial) ______ I agree to the contents of the amendment to the IEP dated ____ / ____ / ____
Parent/Guardian/Date Other/Date
My assessment of this student differs from the above report as follows: Statement (attach additional pages as necessary)
b. Work Samples:
Section II. The discrepancy identified above is directly related to a processing disorder. Yes No
Check appropriate area(s): Sensory Motor Skills Visual Processing
Auditory Processing Attention
Cognitive Abilities, (including association, conceptualization and expression)
Section III. Specific learning disabilities do not include learning problems that are primarily the result of visual, hearing, or
motor disabilities, of intellectual disability, of emotional disturbance, or of environmental, cultural, or economic
disability. If any of the items below (A-H) are checked Yes, the student may not be identified as having a learning
disability.
I. Visual, hearing, or motor disability Yes No
J. Intellectual disability Yes No
K. Emotional disturbance Yes No
L. Cultural factors Yes No
M. Environmental or economic disadvantage Yes No
N. Limited English proficiency Yes No
O. Lack of appropriate instruction in reading or math Yes No
c. The IEP team considered data that demonstrate that prior to, or as a part of, the referral process, the pupil
was provided appropriate instruction in regular education settings, delivered by qualified personnel; and
d. The IEP team considered data-based documentation of repeated assessments of achievement at
reasonable intervals, reflecting formal assessment of student progress during instruction, which was
provided to the pupils parents
H. Limited school experience or poor school attendance
Section IV. Additional Relevant Information:
Basis for determination of eligibility:
Psychoeducational Evaluation utilizing multiple measures (see attached psychoeducational report).
Other (specify)
Section V. Relevant behavior related to academic functioning, noted during observation:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Parent/Guardian/Date Other/Date
My assessment of this student differs from the above report as follows: Statement (attach additional pages as necessary)
Section II. The specific learning disability identified above is directly related to a processing disorder. Yes No
Check appropriate area(s): Sensory Motor Skills Visual Processing
Auditory Processing Attention
Cognitive Abilities (including association, conceptualization and expression)
Section III. Specific learning disabilities do not include learning problems that are primarily the result of visual, hearing, or
motor disabilities, of intellectual disability, of emotional disturbance, or of environmental, cultural, or economic
disability. If any of the items below (A-H) are checked Yes, the student may not be identified as having a learning
disability.
P. Visual, hearing, or motor disability Yes No
Q. Intellectual disability Yes No
R. Emotional disturbance Yes No
S. Cultural factors Yes No
T. Environmental or economic disadvantage Yes No
U. Limited English proficiency Yes No
V. Limited school experience or poor school attendance Yes No
W. Lack of appropriate instruction in reading or math Yes No
e. The IEP team considered data that demonstrate that prior to, or as a part of, the referral process, the pupil
was provided appropriate instruction in regular education settings, delivered by qualified personnel; and
f. The IEP team considered data-based documentation of repeated assessments of achievement at
reasonable intervals, reflecting formal assessment of student progress during instruction, which was
provided to the pupils parents
Parent/Guardian/Date Other/Date
My assessment of this student differs from the above report as follows: Statement (attach additional pages as necessary)
___________________________________________________
Signature and Title/Date
Parents or adult students native language or other primary mode of communication if other than English ____________
Students native language or other primary mode of communication _________________________
General Education Interventions Attempts If this referral is by an educational representative, describe interventions
attempted prior to this referral and attach documentation. (EC 56303) __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Dear ____________________________
On ___/___/______, the school district received a referral to evaluate your child _______________________ to
determine whether he/she has a disability and need for special education. The school district is responsible for this
assessment and will conduct it at no cost to you. You are an important member of the IEP Team. You may include others
on the IEP Team who have knowledge or special expertise about your child.
You and your child (if appropriate) are IEP Team participants. In addition, the following people will be representatives for
the district:
The district assessment team will review existing information available on your child, including information provided by
you. The assessment team will then determine what areas of suspected disability will be assessed. You will be sent an
Assessment Plan within 15 days of the school district receiving the referral to evaluate your child. The Assessment Plan
will inform you of the types of assessments that will be conducted. Upon completion of the evaluation you will be given a
copy of the report(s).
Within 60 days of receiving your consent for evaluation, an IEP Team meeting will be held to determine if your child is
eligible for special education and related services. If your child is eligible, an IEP will be developed to address your childs
needs and determine the appropriate services and placement for your child. The district needs your written consent
before initially assessing and/or providing special education and related services to your child.
You and your child have protections under the procedural safeguards (rights) of special education law. Please read the
enclosed Procedural Safeguards with this notice.
I consent to the assessment. I understand that the results will be kept confidential and that I will be invited to attend the IEP
team meeting to discuss the results. I also understand that no special education services will be provided to my child without my
written consent.
I do not consent to the proposed assessment described above.
I would like the following assessment information to be considered by the IEP team ________________________________
Signature__________________________________________________________________ ___/___/______
Parent Guardian Surrogate Adult Student Date
If my child is or may become eligible for public benefits (Medi-Cal): I authorize the LEA/district to release student information
for the limited purpose of billing Medi-Cal/Medicaid and to access Medi-Cal: health insurance benefits for applicable services.
Signature _____________________________________________________________
Parent Guardian Surrogate Adult Student
Parent/Guardian/Student has received written notification of protections available to parents when LEA requests to access
Medi-cal benefits
Address _________________________________________________ Phone number _____________________
Comments ______________________________________________________________________________________________
NOTE Prior Written Notice attached if this is an initial evaluation. Date Received by District/LEA ____/____/______
The district proposes to assess your child to determine his/her eligibility for special education services or continued eligibility and present levels of
academic performance and functional achievement. Your child will be assessed in all areas of suspected disability as needed.* To meet your childs
individual education needs, this assessment will consist of an evaluation in only the areas checked by the local educational agency (LEA)/district. *Tests
conducted pursuant to these assessments may include, but are not limited to classroom observations, rating scales, one-on-one testing or some other
types or combination of tests.
I consent to the assessment. I understand that the results will be kept confidential and that I will be invited to attend the IEP team
meeting to discuss the results. I also understand that no special education services will be provided to my child without my written
consent.
I do not consent to the proposed assessment described above.
I would like the following assessment information to be considered by the IEP team ________________________________
Signature__________________________________________________________________ ___/___/______
Parent Guardian Surrogate Adult Student Date
Address _________________________________________________ Phone number _____________________
Comments ______________________________________________________________________________________________
NOTE Prior Written Notice attached if this is an initial evaluation. Date Received by District/LEA ____/____/______
Form 23B
STATE SELPA IEP TEMPLATE
PRIOR WRITTEN NOTICE - INITIAL ASSESSMENT
The above alternatives were rejected for the following reasons ___________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
The following is a description of other factors that are relevant to the districts proposal for an assessment _______________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Assessments will be conducted by qualified staff and, when appropriate, utilizing qualified interpreters. You will be asked to participate
in a meeting of the Individualized Education Program (IEP) team following completion of the assessment. All information and
assessment results will be kept confidential. No special education services will be provided to your child without your written consent.
Please return this assessment plan within 15 calendar days of receiving it.
Included with this assessment plan is a copy of the Special Education Rights of Parents and Children that describes procedural
safeguards available to you.
If you have any questions about the proposed assessment or the procedural safeguards available to you, then please call
Address ______________________________________________________________________________________________________
Dear_____________________________________ Todays Date ____/____/________
An Individual Education Program (IEP) Meeting has been scheduled for the above student. Your participation is important in the
development of an appropriate education. The student could benefit from participation in the IEP Meeting and is invited to attend.
Secondary students age 15 or older should attend the IEP Team meeting as appropriate. You have the right to have other individuals
present who have knowledge or special expertise relating to the above student. If this is the initial IEP meeting and the student was
receiving services under Part C, through an IFSP you may request that the district invite the Part C Service Coordinator or other
representative. You are requested to attend this meeting as a participating member of the IEP team. The meeting is scheduled for:
Date ____/____/________ Time _____________________________________
School / Location _____________________________________ Room_____________________________________
We anticipate that the following members may also attend
Administrator/Designee ________________________________________________
Special Education Teacher ________________________________________________
General Education Teacher ________________________________________________
Student ________________________________________________
Psychologist ________________________________________________
Specialist (type) ________________________________ ________________________________________________
NOTICE: If you wish to audio tape this meeting, you must provide 24 hour notice; we will also audio tape the meeting.
If you would like further information about your Procedural Safeguards or the purpose of this meeting, please call:
NO, I cannot attend the meeting, but hereby give my permission for the meeting to be held without me (CFR 300.322d). I understand
the IEP and related documents from this meeting will be provided to me for my signature, and I agree to return them in a timely manner.
NO, I cannot attend, but I will send ________________________________ as my representative to speak for me. I understand the IEP
and related documents from this meeting will be provided to me for my signature, and I agree to return them in a timely manner.
NOTICE: If you wish to audio tape this meeting, you must provide 24 hour notice; we will also audio tape the meeting.
If you would like further information about your Procedural Safeguards or the purpose of this meeting, please call:
NO, I cannot attend the meeting, but hereby give my permission for the meeting to be held without me (CFR 300.322d). I understand
the IEP and related documents from this meeting will be provided to me for my signature, and I agree to return them in a timely manner.
NO, I cannot attend, but I will send ________________________________ as my representative to speak for me. I understand the IEP
and related documents from this meeting will be provided to me for my signature, and I agree to return them in a timely manner.
Disability____________________________________
Disciplinary Action taken / proposed __________________________ Date of decision of disciplinary action ___/___/______
In determining whether the student's behavior was a manifestation of his/her disability, the manifestation determination team
considered the following in relation to the behavior subject to discipline (check applicable items)
Teacher observations of the student List: _____________________________________________
The Student's IEP Describe:_________________________________________
Other relevant information supplied by the parents of the student List: _____________________________________________
Other List: _____________________________________________
The Manifestation Determination team determined that, in relation to the behavior subject to the disciplinary actions
The conduct in question was caused by or had a direct and substantial relationship to the disability. Yes No
Comments___________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Or
The conduct in question was the direct result of a failure to implement the IEP. Yes No
Comments___________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
was a manifestation of his/her disability. (Requires a yes or any 1 of the above 2 items)
Discipline proceeding(s) may not occur at this time.
Functional behavior assessment to be conducted (unless already conducted) and behavior plan to be implemented, or
If a behavioral intervention plan has been developed, plan will be reviewed and modified as necessary
Comments___________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
was not a manifestation of his/her disability. (Requires a no on both of the above 2 items)
Proceed with disciplinary proceedings, all conditions have been met. (Behavior not a manifestation of student's disability, student
understood impact and consequences of behavior, student could control behavior, and services and supports were correct at time of
incident)
Comments___________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Parent agrees disagrees with the determination of the Manifestation Determination team.
Comments___________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Parent received copy of Procedural Safeguards (Parent Rights) Yes No Date ___/___/______
SIGNATURES
_______________________________________________________ ____/____/_______
Parent Guardian Surrogate Adult Student Date
_______________________________________________________ ____/____/_______
Parent Signature Date
Note: These accommodations have been documented on the IEP date ___/___/______
Recommendations Of Accommodations, Supports And Resources
Related To Support Response to Materials & Instruction
Check for understanding Reduced/shortened tests/assignments/tasks
Instructions/directions repeated/rephrased _________________________________________________
Present one task at a time Extended time on in-class assignments/tests
Preferential/assigned seating; explain _________________________________________________
____________________________________________ Use of notes for tests/assignments
Use of assignment notebook or planner Open book for tests/assignments
Provided with progress reports Spelling errors will not impact grade when no opportunity
Supervision during unstructured time for editing assistance and/or spell-check is available
Cues/prompts/reminders of rules / procedures Special projects or alternate assignments in lieu of
Offer choices assignments given to non-disabled peers
Note taking assistance Use of a calculator
Access to computer on campus Proof-reader and redo assignment or writing mechanics
Use of a scribe/word processing not graded
Use of a calculator Other _________________________________________
Peer tutor/ staff assistance in
______________________________________________
Prior Behavior Support Plan (BSP) Settings
Home/job/school communication system; explain Access to study carrel for task/assignments/tests
_____________________________________________ Free from visual distractions
Other _________________________________________ Quiet environment free from excessive noise
In a small group environment
Other
_________________________________________________
Related to Health Concerns
Reminder to take medication(s) Timing/Scheduling of Tasks/Assignments/tests
Medication(s) given under supervision Extended time(s)
Other ______________________________________ ___ minutes for every
___ minutes given to non-disabled peers
Tests/assignments given in shortened time segments
Presentation of Materials & Instructions Extended time on in-class assignments/tests
Books on tape and/or CD Other__________________________________________
Assignments/tests modified to address identified needs of
learning styles
__________________________________________________
For Additional Information such as however not limited to;
Large print
last cognitive assessment results (psycho-educational report),
Closed caption
academic/functional assessment results, Individual
English language development materials
Educational Program Packet, or other k-12 schooling
Manipulative/study aids for
documentation contact
_________________________________________________
Test questions/assignments- given orally
Name of School District
Tests/assignments directions- read orally
______________________
Tests/assignments- shorten
School Districts Phone number
Questions on tests/assignments rephrased
_______________________
Preview of tests/assignments
Title of Contact Person
Tests/assignments given in smaller parts
_______________________
Visual aids flash cards, maps, posters, clues, etc.
Best if contact is made no later than ___/___/______
Other; explain __________________________________
Provided to parent prior to district initiation or refusal regarding change of identification, evaluation, educational placement, or
provision of free appropriate public education
This notice is to inform the parent(s) of the above named student regarding the school districts
Description of evaluation procedures, tests, records, or reports used in deciding to propose or refuse this action_____________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
You have protection under the procedural safeguards of Part B of the IDEA. If you would like a copy of the Procedural Safeguards
please contact the district and a copy will be sent to you. If you would like further information about your rights or the proposed
action and/or referral please contact
WRITTEN NOTICE TO PARENT WHEN PARENT REVOKES CONSENT TO SPECIAL EDUCATION AND RELATED SERVICES
[DATE]
[PARENTS NAME]
[PARENT ADDRESS]
Dear _____________:
On _________________ [DATE], the [___________ School District] (District) received your written notice revoking consent
to the Districts continued provision of special education services and placement for your [SON/DAUGHTER]. This letter
responds to your __________ [DATE] letter, wherein you revoked your consent for your child, [NAME], to receive special
education and related services from the District. Please consider this the Districts response to your request under Title 34
Code of Federal Regulations (CFR) sections 300.300 and 300.503.
The District believes that [NAME] continues to require special education and related services pursuant to the individualized
education program (IEP) meeting convened on [DATE] based upon the following information: (1) a review of [NAMEs]
student records; (2) input from the members of [NAMEs] IEP team; (3) observation of [NAMEs] school performance; and (4) a
review of [NAMEs] assessments, specifically, [SPECIFY EACH EVALUATION / ASSESSMENT/ REPORT], including independent
assessments; (5) [NAMEs] progress on her/his goals; and, (6) all other available information.
However, based on the receipt of your written revocation of consent, the District will discontinue all special education and
related services for [NAME] on [DATE]. After that date, [NAME] will no longer receive the educational services and supports
contained in [his/her] [DATE(S)] IEP, which include, but are not limited to: [LIST PLACEMENT, SERVICES, ACCOMMODATIONS,
MODIFICATIONS, AND/OR SUPPORTS, INCLUDING BEHAVIORAL SUPPORTS, STUDENT WILL NO LONGER RECEIVE].
Beginning on [DATE] [INSERT THE SCHOOL DAY AFTER THE DAY THAT SPECIAL EDUCATION SERVICES STOP], [NAME] will be
placed in a general education classroom [IF NEEDED, INSERT DESCRIPTION OF GENERAL EDUCATION PLACEMENT]. At that
time, [NAME] will only have access to those supports, accommodations, and opportunities that are made available to general
education students.
Please be advised that after [DATE], [NAME] will become a general education student and will no longer be entitled to the
special education and related services, rights and procedural safeguards provided under the Individuals with Disabilities
Education Improvement Act of 2004 (IDEA) and related provisions in the California Education Code. [NAME] will be treated
as a general education student in all respects, including discipline as well as District-wide testing (such as STAR testing), [and
graduation, if appropriate]. As a result, [NAME]s disability will not be taken into consideration when determining appropriate
disciplinary action and [he/she] will not be entitled to the IDEAs discipline protections.
Your revocation of consent releases the District from its obligation to provide your child with a free appropriate public
education. If, in the future, you would like your child to receive special education and related services from the District, please
contact us. The District will treat such a request as a request for an initial evaluation.
The District has considered all available information in ceasing the provision of special education services to your
[SON/DAUGHTER.] The District would like to meet with you on [DATE] to discuss your decision and its potential impacts.
However, our invitation to meet is entirely voluntary. You are not obligated to meet with us and any meeting will not delay or
deny the discontinuation of special education and related services to your child. Please contact _____________ at [INSERT
I have enclosed a copy of the Districts parental rights and procedural safeguards. Please feel free to contact me with any
questions you may have at this time. You may also contact the following sources to obtain assistance in understanding your
rights:
Thank you for your time and careful consideration in this matter. If you have any questions or concerns, please do not hesitate
to contact me.
Sincerely,
[NAME]
[TITLE]
Services The District (LEA) will provide the special education service(s) below for the student while enrolled in private school or until
the proportionate share of federal funds have been expended for the current school year.
Area(s) of need
Special Education
Frequency Duration Location Start Date End Date Service Provider
Service
Student has been found eligible for special education services. By signing this document, the parent/guardian(s) have indicated
to the District of Residence (DOR) that they have chosen to unilaterally enroll or continue to enroll the student in a private school
without the consent of, referral by, or at expense of the District. It is further acknowledged that the DOR has offered to develop an
IEP when the students parent/guardian(s) express an interest in enrolling the student in public school. The parents understand in
accordance with IDEA 2004, their rights to due process do not apply in the private school setting.
_____________________________________________________
Parent Guardian Surrogate Adult Student Date ____/_____ /____
Parent _______________________________________________ Date ____/_____ /____
LEA Representative _____________________________________ Date ____/_____ /____
Other ________________________________________________ Date ____/_____ /____
Next Annual Review Due By ____/_____ /____ Triennial Review Due By ____/_____ /____
This form must be used for placement of a student from another SELPA or for a student from out of State
INDICATE DISABILITY/IES (P = Primary, S = Secondary) Note: For Initial and triennial IEPs, assessment must be done and discussed
by IEP Team before determining eligibility.
_______ 210 ID _______ 220 HH * _______ 230 Deaf * _______ 240 SLI _______ 250 VI *
_______ 260 ED _______ 270 OI* _______ 280 OHI _______ 290 SLD _______ 300 DB *
_______ 310 MD _______ 320 AUT _______ 330 TBI _______ 281 Est. Med. Dis. (0-5)
* Low Incidence Disability
SPED Entry Date ___/___/_______ Interim Placement to be Reviewed ___/___/_______ Triennial Due ___/___/_______
Last Placement
________________________________________ ________________________________ ___________________________
School / District / County Phone Contact Person
Special
Service
Education Frequency Duration Location Start Date End Date
Provider
Service
By mutual agreement between the parent/adult student, and designated representative of the local education agency, the
presence and participation of the Individual Education Program team member(s) identified below is/are not necessary and
has/have been excused from being present and participating in the meeting scheduled on _____/_____/_____ because (1) the
members area of the curriculum or related services is not being modified or discussed in the meeting or (2) the meeting
involves a modification to or discussion of the members area of curriculum or related services and the member submitted, in
writing to the parent and the IEP team, input into the development of the IEP prior to the meeting.
By mutual agreement the IEP team members identified above, have been excused from being present and participating in my
childs IEP meeting.
IDEA Section 614 (d) (1) (c) IEP TEAM ATTENDANCE- (i) ATTENDANCE NOT NECESSARY A member of the IEP team shall not
be required to attend an IEP meeting, in whole or in part, if the parent of a child with a disability and the local educational
agency agree that the attendance of such a member is not necessary because the members area of the curriculum or related
services is not being modified or discussed in the meeting, (ii) EXCUSAL- A member of the IEP Team may be excused from
attending an IEP meeting, in whole or in part, when the meeting involves a modification to or discussion of the members area
of curriculum or related services, if(I) the parent and the local educational agency consent to the excusal; and (II) the
member submits, in writing to the parent and the IEP team, input into the development of the IEP prior to the meeting. (iii)
WRITTEN AGREEMENT AND CONSENT REQUIRED- A parents agreement under clause (i) and consent under clause (ii) shall be
in writing.
As part of determining the need for reassessment the District/LEA has completed ALL of the following steps: (all must be checked)
Existing assessment data has been reviewed, including assessments provided by the parents.
Current classroom-based assessments have been reviewed.
Teacher and related services provider(s) observations have been reviewed.
Parent/legal guardian input has been reviewed and considered.
Based upon a review of the information referenced above, the LEA, in collaboration with parent, has determined that additional
assessment is needed yes no
If yes, it is recommended that assessment be completed in the following areas: (Check all that apply)
Academic Achievement Health
Cognitive Functioning Language/Speech Communication Development
Motor Development Adaptive/Behavior
Social/Emotional Post-Secondary Transition
Other _____________________________ Alternate Means of Assessment
(Describe alternate methods of assessing the student, if applicable) _________________________________________________
If yes, additional assessment data is needed to determine: (Check all that apply)
1. Whether the student has a particular category of disability and/or continues to meet the eligibility criteria as a child with a
disability.
2. The present level of performance of the student and the students educational needs.
3. Whether the student continues to need special education and related services.
4. Whether any additions or modifications to special education and related services are needed to enable the student to meet the
annual goals included in the students IEP and to participate, as appropriate, in the general curriculum.
If no, reason(s) the IEP team determined that no further assessment data was needed after reviewing legal requirements
_______________________________________________________________________________________________________________
________________________________________ _
The parent(s) has/have exercised the right to request an assessment to determine whether their child continues to meet special
education eligibility criteria and to determine his/her educational needs yes no
The signatures below are documentation that the LEA reviewed the data referenced above in making the determination of whether to
conduct further assessment and involved the parent / legal guardian in the process.
The IEP Team shall determine the following in order to designate a student as requiring ESY as part of FAPE
Using input from staff and parents, answer the following questions
1. At the start of the school year, with a review period equal to that of general education students, was the student unable to regain
skills lost over the break that would otherwise be expected in view of the students disabling condition?
Yes No If yes, specify what area(s) _____________________________________________________________________
________________________________________________________________________________________________________
2. Does this student display a loss of previously taught skills and an inability to regain those skills following interruptions in instruction
during the regular school year, i.e., Thanksgiving break, Winter Break, and Spring Break?
Yes No If yes, specify what area(s) _____________________________________________________________________
________________________________________________________________________________________________________
3. Is the current student at a crucial stage in learning a skill(s), such that an interruption in school program might cause loss of a skill(s)
that the student would not be able to re-learn in a reasonable period of time, in view of the students disabling condition?
Yes No If yes, specify what essential skill(s) _______________________________________________________________
_________________________________________________________________________________________________________
4. Is the student able to maintain the skills identified without Extended School Year?
Yes No If no, specify what skill _______________________________________________________________________
5. Does the student require ESY to continue to achieve at the level of independence that is expected in view of the students disabling
condition?
Yes No
Note: refer to criteria specified on the ESY Worksheet pg. 2 if answer is yes on #5 above
1. The student demonstrates a pattern of past regression in skills as evidenced by breaks of more than four weeks:
Yes No Unknown
Comments (describe the degree (minimal or serious) of actual or likely regression following a school break __________________
__________________________________________________________________________________________________________
2. What is the estimated amount of time it takes or it may take the student to regain the prior level of knowledge skills, benefits or
functioning following a school break One Month or less Up to 3 months 4 to 6 months Other
Comments ________________________________________________________________________________________________
_________________________________________________________________________________________________________
3. Describe the students rate of learning (as compared with the students ability to recoup after a break)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
4. Does the IEP team feel the students disability will continue indefinitely or for a prolonged period of time? Yes No Unknown
Comments (describe the degree (minimal or serious) of actual or likely regression following a school break _________________
__________________________________________________________________________________________________________
Describe the degree, nature and severity of the students disability__________________________________________________
__________________________________________________________________________________________________________
5. Does the IEP team feel it will be impossible or unlikely the student will attain self-sufficiency and independence expected in view of
the students disability following a break? Yes No Unsure
Comments (describe the degree (minimal or serious) of actual or likely regression following a school break:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
6. Is the student at a critical point of skill acquisition or readiness where their ability to acquire the skills will be lost or
greatly reduced as a result of an interruption of services? Yes No Unsure
If yes, describe ______________________________________________________________________________________________
__________________________________________________________________________________________________________
7. Are there any other issues concerning the students physical, medical condition, emotional, social, behavioral, mental health,
academic and/or vocational issues, and his/her ability to be with typically developing peers that may be adversely impacted if the
student does not receive ESY services? Yes No Unsure
If yes, describe ______________________________________________________________________________________________
__________________________________________________________________________________________________________
Congratulations! This letter serves as written notice that is currently meeting the high
school requirements for a certificate of completion. Your childs (or you if you are an adult student) promotion
with a Certificate of Completion is based on your child (or you if you are an adult student) meeting the
prescribed course of study requirements for promotion with a high school certificate.
It is the Districts determination that any other option (e.g. retention, regular high school diploma) is not
appropriate for ___________________ at this time.
As your child (or you if you are an adult student) _____________ is/are a student who is receiving special
education services, s/he continues to be eligible for special education supports and related services through
age 21 unless he/she received a high school diploma.
If your child (or you if you are an adult student) becomes 22 years of age during the months of January to
June, inclusive, and has a current IEP, your child or you may continue participation in the IEP program for the
remainder of the current fiscal year (Ed Code 56026).
The current offer of a free and appropriate public education (FAPE) as outlined in the IEP dated
_____________will conclude on ___________________.
Please be advised that your child (or you if you are an adult student) is entitled to procedural safeguards if you
disagree with this determination.
Enclosed is a copy of the procedural safeguards for your review. If you have any questions, please
call__________________at____________________.
Sincerely,
_________________________(Name, Title)
7/2014 Form 35
(DISTRICT LETTERHEAD)
Date: / /
Congratulations! This letter serves as written notice that is currently meeting the
requirements for graduation with a regular high school diploma. As is receiving
special education and related services, pursuant to Federal law the District must notify you of this proposed
change in placement. Your childs graduation with a regular diploma is based on his/her meeting both the
State of California and School Districts requirements for graduation with a regular high school diploma. Upon
his or her graduation, your child will no longer be eligible for special education services.
It is the Districts determination that other options, such as awarding of a certificate of completion, is not
appropriate for at this time.
Since your child is currently on track to satisfy the requirements to graduate with a high school diploma. Upon
request, an IEP meeting may be convened to discuss this recommendation.
Please be advised that your child (or you if you are an adult student) is entitled to procedural safeguards if you
disagree with this determination.
Enclosed is a copy of the procedural safeguards for your review. If you have any questions, please
call__________________at____________________.
Sincerely,
_________________________(Name, Title)
7/2014 Form 36
STUDENT DATA TRANSMITTAL FORM FOR IFSP
For internal use only
Plan Type: 15-IFSP 80- Eligible No IFSP, Other Reason 90-Not Eligible