FORM
30 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/surrogate 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 re- designated.
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.
[Excerpted
from the State SELPA IEP Manual, July, 2013]