CASEMIS/Action Plan |
|
(This form can generate more than one printed page) |
|
|
Student |
, |
|
DOB |
|
|
Gender |
|
|
Grade |
|
|
SSID |
|
|
IEP date |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
School of
residence |
|
|
District of
residence |
|
|
School of
attendance |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Ethnicity |
|
|
Hispanic or Latino |
|
|
Not Hispanic or Latino |
|
X
|
Migrant ed |
|
X
|
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 |
X
|
CA Child Services |
|
X
|
Dept of Social Services |
|
X
|
Regional Center |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
X
|
Community Mental Health |
|
X
|
Dept of Rehabilitation |
|
X
|
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) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Services |
|
|
[DNR]
[Primary]
|
|
|
-
/wk
|
G
I
|
- |
- |
|
|
|
|
|
|
Case manager |
|
|
% OUTSIDE Gen Ed |
|
|
% IN Gen Ed |
|
|
X
|
Sp Ed support exceeds 50% of school day |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Testing: Test |
Accommodations/modifications |
|
Transition questions |
|
|
CASHEE |
|
|
1 |
|
|
|
|
|
|
|
|
|
Math |
|
|
2 |
|
|
|
|
|
|
|
|
|
Science |
|
|
3 |
|
|
|
|
|
|
|
|
|
ELA |
|
|
4 |
|
|
|
|
|
|
|
|
|
History |
|
|
5 |
|
|
|
|
|
|
|
|
|
Writing |
|
|
6 |
|
|
|
|
|
|
|
|
|
|
7 |
|
|
|
|
|
|
|
|
8 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Initial referral (for assessment) |
|
|
Referral date |
|
|
|
|
|
|
|
Referred by |
- |
|
|
|
|
|
|
Parent consent date received |
|
|
|
|
|
|
|
Coordinated early intervening services |
Yes
No
|
|
|
|
|
|
|
Initial evaluation date |
|
|
|
|
|
|
|
|
|
|
Grad plan |
- |
|
X
|
MHS eligible |
|
X
|
MHS language |
|
|
|
|
|
|
|
|
|
|
|
X
|
BSP |
|
X
|
BIP |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|