Administrative Interim Placement
Student Name
DOB
DOB
Age
Gender
Gender
Social Security #
Social Security #
SSID Code
Student ID
Student ID
Current Grade
Current Grade
Name of Parent/Surrogate Guardian
Phone: Home
Phone: Home
Phone: Work
Phone: Work
Address
Address (2)
City
Zip
District of Residence
District of Residence
School Res.
School Res.
Att. district
Att. district
Att. school
Att. school
Native Language
Native Language
Migrant Ed
Yes
No
Yes
No
English Language Learner
English Language Learner
Yes
No
Yes
No
Interpreter Required
Yes
No
Yes
No
Ethnicity
1
1
2
2
3
3
4
4
5
5
6
6
Primary Disability
Primary Disability
Secondary Disability
Secondary Disability
Other Disabilities (select all that apply)
DATES
Meeting Date
Meeting Date
30 Day Review
(New Annual Date)
30 Day Review
(New Annual Date)
Initial Placement in Sp. Ed.
Initial Placement in Sp. Ed.
Last Eval (tri date)
Last Eval (tri date)
Next Eval (tri date)
Next Eval (tri date)
AGENCY SERVICES
California Children's Services (CCS)
Department of Rehabilitation
County Mental Health (CMH)
Probation
Department of Social Services (DSS)
Regional Center
Other agency services (specify):
Residency
Residency
Other res. type:
Foster/LCI# or other desc.
Federal
preschool
setting
Federal
school
setting
A current IEP is attached:
(If no, develop goals and objectives (Form 4) and obtain copy of last IEP from prior district)
Special ed transportation
Yes
No
Yes
No
% of time student is OUTSIDE the general education environment
% of time student is IN the general education environment
STUDENT SERVICES
Service
Start/End Date
Duration
Frequency
I/G
Provider
Location
[DNR]
/wk
Grp Ind ST
-
-
(there are no student services to list)
OTHER PROGRAM INFORMATION
Physical education
(if other, specify type)
Extended school year
Extended school year
Yes
No
Yes
No
Days
Days
Minutes
Minutes
MENTAL HEALTH SERVICE
Not applicable
Assessment completed
Assessment completed
Eligible
Yes
No
Yes
No
MH goals/language included in this IEP
Yes
No
Yes
No
PARENTAL/STUDENT CONSENT
(Please initial areas that are acceptable)
I received a NOTICE OF PROCEDURAL SAFEGUARDS for Special Education and understand them.
I agree with this interim placement.
Signature of Parent __ Guardian __ Surrogate__ Student __
Date
Signature of Parent __ Guardian __ Surrogate__ Student __
Date
In addition to the parents, the following were participants in the development of the Administrative Interim Placement
Special Education Teacher/Provider
Date
LEA Representative/Administrative Designee
Date
Other
Date
Grad plan
Transition Goal 1
Transition Goal 1
Transition Goal 2
Transition Goal 2
Transition Goal 3
Transition Goal 3
Transition Goal 4
Transition Goal 4
ASSESSMENT PARTICIPATION
Math
ELA
Science
History
Writing
CAHSEE
Significant health/medical problems
Vision
Hearing
Medication if any
Verification of previous placement made with:
School
District
Address
Phone
Date of verification request
Date of verification request
Verified by
Case manager/code
Case manager/code
Initial referral (for assessment)
Referral date
Referral date
Referred by
Parent consent date received
Parent consent date received
Initial evaluation IEP date
Initial evaluation IEP date
Pre-referral early intervening services
Yes
No
Yes
No