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 students last name and first name.

 

2.      Birth Date / Age: Enter the students birth date and age.

 

3.      Grade: Enter the student’s current grade.

 

4.      Gender: Enter the students gender (M or F).

 

5.      Parent: Enter the parent / guardian/surrogate name.

 

6.      Home Phone: Enter the parents / guardians home phone and cell number, if known.

 

7.      Address: Enter the parents / guardians home address, city and zip code.

 

8.      Native Language: Enter the students 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 students 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 Childrens 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 students last school.

 

18.    Contact Person: Enter the name of an appropriate contact person at the students 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]