Interim Special Education Services (30)
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  Incomplete Incomplete
 
 
Student ,   Birthdate   Age   Grade   Gender  
 
   
   
   
   
 
 
Parent/Guardian   Home phone   Cell  
 
   
   
 
 
Address   City   Zip  
 
   
   
 
 
Native language  -    EL Yes No   English fluency  
 
   
   
 
 
Ethnicity   Hispanic ind.   Residency  -   
 
   
   
 
Disabilit(ies)  
 
   
 

 
SPED entry date   Initial placement to be reviewed Initial placement to be reviewed   Triennial due
 
Last placement      
    School/District/County   Phone   Contact person
 
SPECIAL EDUCATION PROGRAM AUTHORIZATION

Temporary placement in the following special education service(s) is authorized, pending action at the next Individualized Education Program Team meeting:
 
Special education & related services Start date Frequency Duration Location Service provider
 
Err
Err
Err
Err
 
Pct. of time outside general ed. class for sp. ed services Pct. of time outside general ed. class for sp. ed services  
 
 

 
Whenever a pupil transfers into a district from a district not operating services under the same local plan in which he or she was last enrolled in a special education services within the same academic year, the local educational agency shall provide the pupil with a free appropriate public education, including services comparable to those described in the previously approved individualized education program, in consultation with the parents, for a period not to exceed 30 days, by which time the local educational agency shall adopt the previously approved individualized education program or shall develop, adopt, and implement a new individualized education program that is consistent with federal and state law. (EC 56325)
 
 
Name of LEA Representative Making Interim Placement:
 
 
             
 
 
 
 
  Signature   Position   Date