FORM 1 INDIVIDUALIZED EDUCATION PROGRAM INFORMATION/ELIGIBILITY

Items above the solid line may be completed prior to the meeting, based on information contained in the student information system.

 

1.      Student Name: Enter the student last name and first name.

 

2.      IEP Date: Enter date of the IEP meeting.

 

3.      Last IEP: Enter the date of the last IEP. This will be the same date as the IEP date above.

 

4.      Next IEP: Enter the next IEP date that will be one year from the present date in most cases.

 

5.      Original SpEd Entry Date: Enter the date the student first received special education services, including IFSP (0-3 infant services).

 

6.      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).

 

7.      Next Eval: Enter the date when the next triennial evaluation is due.

 

8.      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 studentÕs course of study.

¥      Pre-expulsion means an IEP meeting that is being held as part of or following a manifestation determination.

¥      Interim means if the child has an IEP and transfers into a district from another

SELPA.

¥      Expanded IEP means an IEP meeting, which includes CMH representatives.

¥      Other

 

9.      Birthdate: Enter the exact birthdate.

 

10.    Age: The studentÕs age as of the IEP meeting date.

 

11.    Gender: Enter M or F.

 

12.    Grade: Enter the appropriate grade designation.


 

13.    Migrant: Check Yes or No to reflect the studentÕs Migrant status.

 

14.    Native Language: This field was previously known as home language. This is the studentÕs home language or birth language.

 

15.    EL: Check if the student is an English learner or has been re-designated. (R-FEP)

 

16.    Interpreter: Check if an interpreter is needed for the IEP meeting.

 

 

17.    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.    Residency: This is the studentÕs residential status.

 

19.    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.

 

20.    District of Residence: This is the studentÕs district of residence.

 

21.    Residence School:  Enter the childÕs neighborhood school.

 

22.    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 ÒPÓ and secondary disability withÓSÓ. The primary disability should be the one that has the most significant impact on the studentÕs ability to access the general education environment.  Note:  For funding purposes, low incidence disabilities marked as secondary will generate low incidence funding.

 

If team determines the student has a specific learning disability, complete

Specific Learning Disability Team Determination of Eligibility. Evaluation team members sign form as appropriate.

 

24.    If the student is not eligible or no longer eligible for special education:

¥       Document reason for decision and other options to address the studentÕs 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. Òauditory processing deficits adversely impact the studentÕs ability to complete activities within the general education settingÓ, Òsignificant speech and language deficits interfere with the studentÕs ability to interact with other students in the preschool settingÓ


27.     Triennial (3 Year) Re-Evaluation:  Check the appropriate box. If the triennial evaluation is due prior to the next IEP meeting; check one of the following: Summary of Progress and Current Educational Performance, Full Evaluation, or Other.  If other is check specify measurement.

 

For Initial Placements Only               (Ages 3 to 22 only Do not include infant referral dates)

 

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 ÒyesÓ. If you check ÒyesÓ 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.

 

 Educational Benefit Reminder

-   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 childÕs disability(s)?

-   Did the IEP Team identify how the childÕs 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 and accurately completed?

 

[Excerpted from the State SELPA IEP Manual, July, 2013]