IEP Form – Individualized
Education Program – 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.
4.
Next IEP: Enter the next IEP date that will be one year
form 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.
·
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 district.
·
Expanded IEP means an IEP meeting which includes CMH
representatives.
·
Other
9.
Birthdate: Enter the exact birthdate.
10.
Age: The student’s 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 student’s
Migrant status.
14.
Native Language: This field was previously known as home
language. This is the student’s home language or birth language.
15.
EL: Check if the student is an English learner or has been
redesignated. (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 student’s 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 student’s district of
residence.
21.
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 “P” and
secondary disability with ”S”. The primary
disability should be the one that has the most significant impact on the
student’s 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 form 9.
Evaluation team members sign form as appropriate.
24.
Severe/Non Severe: Check appropriate box.
56030.5. "Severely disabled"
means individuals with exceptional needs who require intensive instruction and
training in programs serving pupils with the following profound disabilities:
autism, blindness, deafness, severe orthopedic impairments, serious emotional disturbances,
severe mental retardation, and
those individuals who would have been eligible for enrollment in a development
center for handicapped pupils under Chapter 6 (commencing with Section 56800)
of this part, as it read on January 1, 1980.
25.
If the student is not eligible or no longer eligible for
special education:
·
Document reason for decision and other options to address
the student’s 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.
26.
How Disability Affects
Educational Performance: Write a statement which
describes the disability and it’s impact, i.e. “auditory processing deficits
adversely impact the student’s ability to complete activities within the
general education setting”, “significant speech and language deficits interfere
with the student’s ability to interact with other students in the preschool
setting”
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 Pre-Referral Early Intervening
Service in the Past Two Years: Pre-Referral Early Intervening Services 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. They include educational and behavioral
evaluations, services and supports including scientifically based literacy
instruction. If the student received pre-referral early intervening services
during the past two years, check yes. 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).
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
o
Is all of the
information complete and correct?
o
How will the manager
of the school MIS system be informed of any changes?
o
Does the IEP clearly
specify the child’s disability(s)?
o
Did the IEP Team
identify how the child’s disability affects his or her involvement and progress
in the general curriculum or participation in appropriate activities for the
preschool child?