Interim Special Education Services (30)
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Student ,   Birthdate   Age   Grade   Gender  
 
   
   
   
   
 
 
Sch of attendance   Sch of residence   Sp ed transportation Yes  
 
   
   
 
 
Parent/Guardian   Home phone   Cell  
 
   
   
 
 
Address   City   Zip  
 
   
   
 
 
Native language  -    EL Yes No   English fluency  
 
   
   
 
 
Ethnicity   Hispanic ind.   Residency  -   
 
   
   
 
Disabilit(ies)  
 
   
 

 
SPED entry date   Initial placement to be reviewed Initial placement to be reviewed   Triennial due
 
Last placement      
    School/District/County   Phone   Contact person
 

 
The following items appear only on the 2013-2014 "alternate" form (printable from the first page):
 
Current placement      
    Program   School   Case Manager
 

 
 
SPECIAL EDUCATION PROGRAM AUTHORIZATION

Temporary placement in the following special education service(s) is authorized, pending action at the next Individualized Education Program Team meeting:
 
Special education & related services Frequency Duration Location Start date End date Service provider
 
Err Err
Err Err
Err Err
Err Err
 
Pct. of time outside general ed. class for sp. ed services Pct. of time outside general ed. class for sp. ed services  
 
 

 
Whenever a pupil transfers into a district from a district not operating services under the same local plan in which he or she was last enrolled in a special education services within the same academic year, the local educational agency shall provide the pupil with a free appropriate public education, including services comparable to those described in the previously approved individualized education program, in consultation with the parents, for a period not to exceed 30 days, by which time the local educational agency shall adopt the previously approved individualized education program or shall develop, adopt, and implement a new individualized education program that is consistent with federal and state law. (EC 56325)
 
 
Name of LEA Representative Making Interim Placement:
 
 
             
 
 
 
 
  Signature   Position   Date