Student service
Last Name
First Name
Date of birth
1. Items for all students:
Teacher*
Teacher*
If the teacher is not listed in the pop-up, try entering the name or code
here:
School*
School*
If the school is not listed in the pop-up, try entering the school name or code
here:
Service*
Service*
Primary
Primary
Yes
No
Yes
No
Report to CASEMIS
Yes
No
Yes
No
Start date*
Start date*
End (evaluation) date
End (evaluation) date
Location type*
Location type*
Extended school year
Extended school year
Yes
No
Yes
No
2. For infant (age 0-2) or mental health services:
The following items are required for infant and mental health services. However, they can also be used for non-infant services as well.
Provider type
Provider type
(*infant/MHS)
Frequency code
Frequency code
(*infant/MHS)
Duration, minutes per session
Duration, minutes per session
(*infant/MHS)
3. Other items:
Auxiliary service location
Auxiliary service code
(Other:)
Delivery model (individual/group)
Disabling condition
Disabling condition
(primary only)
Isolated site
Yes
No
Yes
No
Regional program
Yes
No
Yes
No
Consult
Yes
No
Yes
No
LEA district
LEA district
Session note
Infant agency
Infant agency
(obs.)
Infant location
Infant location
(obs.)
Associated student address
4. For non-infant, non-MHS services:
Duration (other description)
Duration (other description)
(Describe if other:)
Frequency (other)
Frequency (other)
(Describe if other:)
Sessions per week
Sessions per week
5. For discontinued services:
Drop date
Drop reason
Drop reason
(primary service only)
Drop code or reason
Drop code or reason
(non-primary service only)
CSIS exit reason
CSIS exit reason
*Required items