INTERIM SPECIAL EDUCATION SERVICES
This form is used for placement of a student coming from
another SELPA or from out-of-state.
1.
Student Name: Enter the student’s last name and
first name.
2.
Birth Date / Age: Enter the student’s birth date and
age.
3.
Grade: Enter the student’s current grade.
4.
Gender: Enter the student’s gender (M or
F).
5.
Parent: Enter the parent / guardian name.
6.
Home Phone: Enter the parent’s
/ guardian’s home phone and cell number, if known.
7.
Address: Enter the parent’s
/ guardian’s home address, city and zip code.
8.
Native Language: Enter the student’s home language
or birth language.
9.
EL: Check if the student is an English
Learner and whether or not they have been redesignated.
10.
Ethnicity: Enter the student’s ethnicity as
it has been entered on the school enrollment form for the school.
11.
Residency: Check whether the student resides
with a Parent / Guardian, in a Foster Family Home, in a Licensed Children’s
Institution, is an Adult Student, or Other.
12.
Indicate Disability: Check the appropriate disability
as reflected on the IEP from the sending SELPA.
13.
Special Education Entry Date: Enter the date the student first
received special education services, including IFSP (0-3 infant services).
14.
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.
15.
Triennial Date: Enter the date when the next
triennial evaluation is due to be completed.
16.
Last Placement: Enter the name of the School /
District / County where the student was last enrolled.
17.
Phone: Enter the phone number of the
student’s last school.
18.
Contact Person: Enter the name of an appropriate
contact person at the student’s last school or district. This could be the
Special Education Teacher, Program Specialist, Special Education Director, etc.
19.
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).
20.
% of Time OUTSIDE: Enter the % of time the student is
out of the general education classroom receiving special education services.
21.
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.