Team Report

  IEP EAS  

  Change: 
 
Student ID#     Specify
 
       
 
Date     New Yes   MIS
 
       
 
Pupil   Date of birth   Grade   Gender
 
   
   
   
 
Address         Telephone no.
 
 
 
   
  Street   City   Zip      
 
Parent/Guardian   Residency -
 
   
 
Resident district   Resident school -   Attending school -
 
   
   
 
SSID#   Ethnicity (Hispanic indicator)   EL:  Yes No    Migrant:  Yes No
 
   
   
    Race             Native language -
     
 
 
 
       
 

 
ELIGIBILITY
  Primary disability -
 
  Secondary disability (No secondary disability) -
 
 
INSTRUCTIONAL SETTING
    Obsolete items (these items print on the 2008-2009 form only)
  Reg Class   Sp/Lang
  DIS   APE
  RSP   PHS
  SDC (specify)    Vision
  Hope (SS)   MOB
  OCDE   Hearing
  Home/Hospital   Behavior
  Other:    Vocational
    Counseling
    Nursing
    OCMH
    Other
     

 
SERVICES (To add or edit services, click on the "1 General" tab)
 
Services Start/End Date Duration Frequency I/G Provider Location
[DNR]  /wk Grp Ind ST - -
(there are no student services to display)
 

 
School:  Review Date if Different from Annual: Review Date if Different from Annual:
 
Case Carrier 
 
Continue Original Start Date:
 
% IN General Ed  BSP Plan Review: BSP Plan Review:
 
If Changed: Current IEP w/Obj & ITP: Current IEP w/Obj & ITP:
 
Date Entered Date Entered To (School and Program) Last Triennial: Last Triennial:
 
Date Dropped Date Dropped From (School and Program) Triennial Due:
 
  Parent involvement 
 
Reason for Leaving  Initial Referral (for assessment)
 
TESTING - CAHSEE   Math    Science    ELA  Referral Date
  History       Writing 
 
Grad Plan  - Tran goal Tran goal  Referred by  -
 
MHS Eligible:  Yes No Tran goal Tran goal  Parent consent date received 
 
MHS Language:  Yes No Tran goal Tran goal  Initial evaluation IEP date 
 
  Tran goal Tran goal  Pre-referral early intervening services:  Yes No
 

 
FURTHER ACTION REQUIRED RESPONSIBLE INDIVIDUAL
 
Consent for Assessment
 
Individual Educational Program Signed
 
Testing 
 
Change of Classes/School
 
Referral To
 
ESY:  Yes No
 
General Ed summer school
 
Transportation:  Yes No   Dist. Home/School
 
   To Therapy OCTA Pass ROP
 
Translation:  Spanish Vietnamese Other
 
Workability
 
State/District Assessments 
 
 
 
 
  Signature of Case Carrier/Chairperson  
 
 
GA 102 Sept 2008