Interim Placement
 
    Pick a date    

Student Name   D.O.B D.O.B   Age   Sex Sex
 
 

CSIS/ID Code   Grade Grade
 
     

Parent/Surrogate Guardian   Phone: Home Phone: Home   Phone: Work Phone: Work   Phone: Cell Phone: Cell
 
       

Address   Address (2)   City       Zip
 
   
        

Current Dist. of Residence Current Dist. of Residence   Current School of Res. Current School of Res.  
 
   

Home Language Home Language   Student's Language Student's Language  
 
Migrant Ed
 
English Language Learner English Language Learner
 
Interpreter Required  
 
English fluency English fluency
 
Ethnicity

 
  Hispanic indicator Hispanic indicator     (Selecting "yes" causes Hispanic to be the primary ethnicity)
 
  1 1   2 2

  3 3   4 4

  5 5   6 6

 
Primary Disability Primary Disability   
 
Secondary Disability Secondary Disability   
 
DATES

  Today's Date Today's Date Pick a date
 
  Implementation Date Implementation Date Pick a date
 
  30-Day Review 30-Day Review Pick a date
 
  SPED entry SPED entry Pick a date
 
  Last Triennial Last Triennial Pick a date
 
  Last IEP Last IEP Pick a date
 
 
AGENCY SERVICES

  California Child. Services (CCS) Dep't of Rehabilitation
 
  Community Mental Health Regional Center
 
  Dep't. of Social Services (DSS)  
 
    Other agency services (specify):  
 

 
Residency Residency
 
Foster or LCI #
 
Other type:
 
Program SAI/SC
 
  SAI
 
  Speech
 
 
Primary Placement  (edit on "8 Services" tab)
 
Service Prmy Frequency Duration Location Start Date End Date
[DNR]  Y    min  /  per wk -    (D)  (Eval)
(there are no student services to list)
 
 
% of time student is OUTSIDE the general education environment
 
% of time student is IN the general education environment
 

 
PARENTAL CONSENT
(Please initial areas that are acceptable)
 
    I received a NOTICE OF PROCEDURAL SAFEGUARDS and understand them.

   
 
    I agree with the interim placement and service recommendations.

   
 
 

Signature of Parent/Guardian/Surrogate/Student Date
 
In addition to the parents, the following were participants in the Interim Placement decision:
 
 

Completed by Date
 
 

School District Representative Date
 
 

Other Date
 

 
Additional information:
 
 
(NOTE: On the printed form, the "Additional Information" area does not expand to accommodate any amount of text entered here. Thus, it may appear truncated when printed.)
 
 
Special ed transportation
 
HEALTH
 
Significant health/medical problems (including medication, if any):
 
 
VERIFICATION OF PREVIOUS PLACEMENT
 
Made with
 
School & District
 
Phone
 
Date of verification request   Pick a date
 
Verified by

 

 
Assigned school Assigned school   
(enter below if not listed:)
 
Assigned teacher
 
Intra-SELPA transfer
 
  from VCPU, Ramona, Julian, Warner Springs, Borrego Springs, Spencer Valley, San Pasqual (3D-day Review NOT Required).
 
Current IEP (attached)
 
  If not attached, develop "Goals and Objectives" and obtain copy of last IEP from prior district.
 
Evaluation data current (attached)
 
Evaluation plan developed (attached)