Interim Special Education Services (30)
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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 Pick a date   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 Pick a date
Err Pick a date
Err Pick a date
Err Pick a date
 
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