CASEMIS/Action Plan

 
 
 
  Change   Student ID  
 
 
Student ,   DOB   Gender   Grade   SSID   IEP date
 
   
   
   
   
   
Parent   Ph: Home   Ph: Work  
 
   
   
 
Address   Residency    
 
   
 
School of
residence
  District of
residence
  School of
attendance
 
 
   
   
 
 

 
Ethnicity   Hispanic or Latino   Not Hispanic or Latino   Migrant ed   EL   Native language    
                                 
Race   American Indian or Alaskan Native   Black or African American   White
                   
    Native Hawaiian or Other Pacific Islander   Asian  
               
 

 
Federal school setting     Federal preschool setting    
 
   
 
 
Agency Services CA Child Services   Dept of Social Services   Regional Center    
                     
  Community Mental Health   Dept of Rehabilitation   Other:  
                     
 

 
Eligibility (P=Primary, S=Secondary)
 
  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
 
   
   
   
   
 

 
Services
 
Service(s) Start/End Date Duration Frequency I/G Provider Location

[DNR]  [Primary]  - /wk G I - -

(No services are listed)
 

 
Case manager   % OUTSIDE Gen Ed   % IN Gen Ed      
 
   
   
     
If changed:   Original start date
     
Date entered Date entered   To (school and program)   Next annual IEP
             
Date dropped Date dropped   From (school and program)   Last eval (tri) date
             
Reason for leaving     Next eval (tri) date
           
 

 
  Parent input   X   Yes   X   No  
     
   
   
Testing: Test Accommodations/modifications  
 
  CASHEE  
   
 
  Math  
   
 
  Science  
   
 
  ELA  
   
 
  History  
   
 
  Writing  
   
 
 

 
Transition Questions
 
  1 (A-100)  
   
   
  2 (A-101)  
   
   
  3 (A-102)  
   
   
  4 (A-103)  
   
   
  5 (A-104)  
   
   
  6 (A-105)  
   
   
  7 (A-106)  
   
   
  8 (A-107)  
   
   
 
  DRDP-Access   DRDP-R  
             

 
Initial referral (for assessment)
 
  Referral date  
   
 
  Referred by -  
   
 
  Parent consent date received  
   
 
  Coordinated early intervening services Yes No  
   
 
  Initial evaluation date  
   
 
 

 
Grad plan -   MHS eligible   MHS language  
 
             
  BSP   BIP  
 
             

 
  Action items (if applicable)   Date   Responsible individual  
 
  Assessment Assessment      
 
  Referral to Referral to      
 
  Reconvening Reconvening      
 
  Other Other         
 
  None  
 
  Further steps  
 
  Transportation:        
 
  Transportation requested Transportation requested         
 
 
 
 
 
 
  Signature of administrator/designee   Signature of case carrier/chairperson