Interim Placement
Student Name
D.O.B
D.O.B
Age
Sex
Sex
CSIS/ID Code
Grade
Grade
Parent/Surrogate Guardian
Phone: Home
Phone: Home
Phone: Work
Phone: Work
Phone: Cell
Phone: Cell
Address
Address (2)
City
Zip
Current Dist. of Residence
Current Dist. of Residence
Current School of Res.
Current School of Res.
Home Language
Home Language
Student's Language
Student's Language
Migrant Ed
Yes
No
Yes
No
English Language Learner
English Language Learner
Yes
No
Yes
No
Interpreter Required
Yes
No
Yes
No
English fluency
English fluency
Ethnicity
Hispanic indicator
Hispanic indicator
(Selecting "yes" causes Hispanic to be the primary ethnicity)
1
1
2
2
3
3
4
4
5
5
6
6
Primary Disability
Primary Disability
Secondary Disability
Secondary Disability
DATES
Today's Date
Today's Date
Implementation Date
Implementation Date
30-Day Review
30-Day Review
SPED entry
SPED entry
Last Triennial
Last Triennial
Last IEP
Last IEP
AGENCY SERVICES
California Child. Services (CCS)
Dep't of Rehabilitation
Community Mental Health
Regional Center
Dep't. of Social Services (DSS)
Other agency services (specify):
Residency
Residency
Foster or LCI #
Other type:
Program
SAI/SC
SAI
Speech
Primary Placement
(edit on "8 Services" tab)
Service
Prmy
Duration
Frequency
Location
Start Date
End Date
[DNR]
Y
- /wk
-
(D) (Eval)
(there are no student services to list)
% of time student is OUTSIDE the general education environment
% of time student is IN the general education environment
Testing (from previous IEP): ELA
Math
Science
History/SS
Writing
Extended year
Yes
No
Yes
No
PARENTAL CONSENT
(Please initial areas that are acceptable)
I received a NOTICE OF PROCEDURAL SAFEGUARDS and understand them.
I agree with the interim placement and service recommendations.
Signature of Parent/Guardian/Surrogate/Student
Date
In addition to the parents, the following were participants in the Interim Placement decision:
Completed by
Date
School District Representative
Date
Other
Date
Additional information:
(NOTE: On the printed form, the "Additional Information" area does not expand to accommodate any amount of text entered here. Thus, it may appear truncated when printed.)
Special ed transportation
Yes
No
Yes
No
HEALTH
Significant health/medical problems (including medication, if any):
VERIFICATION OF PREVIOUS PLACEMENT
Made with
School & District
Phone
Date of verification request
Date of verification request
Verified by
Assigned school
Assigned school
(enter below if not listed:)
Assigned teacher
Intra-SELPA transfer
from VCPU, Ramona, Julian, Warner Springs, Borrego Springs, Spencer Valley, San Pasqual (3D-day Review NOT Required).
Current IEP (attached)
If not attached, develop "Goals and Objectives" and obtain copy of last IEP from prior district.
Evaluation data current (attached)
Evaluation plan developed (attached)