1. Physical Education: Check the type of physical
education, if applicable.
2.
District of
Service: Specify district
providing the majority of services to the student.
3.
School of
Attendance: This is the school
where the student is enrolled.
4.
School Type: Select one of the following:
00 No
school (0-5)
10
Public day school
11
Public residential
school
15
Special education
center or facility
19
Other public school or
facility (i.e., store front transition program)
20
Continuation school
22 Alternative
work education center/work study program
24
Independent study
30
Juvenile court school
31
Community school
32
Correctional
institution or facility
40 Home
instruction based on IEP team determination
45
Hospital facility
50
Community college
51
Adult education program
55
Charter school operated
by an LEA/district
56
Charter school operated
as an LEA/district
61
HeadStart program
62
Child development or
childcare facility
63
State preschool
64
Private preschool
65
Extended day care
70
Nonpublic day school
71
Nonpublic residential
school-in California
72
Non-public residential
school- outside California
75 Private
day school (not certified by CDE Special Education Division)
76 Private
residential school (not certified by CDE Special Education Division)
79
Nonpublic agency
80
Parochial school
5. Federal Setting (ages 6-22): Indicate the type of school
setting the student attends. If the student turns 6 years old on or before
December 2 of the current school year, this category is completed.
400
Regular
classroom/public day school
Select
if the student attends classes on a general education school campus regardless
of the type of program
450
Separate school
460
Residential facility
470
Homebound/hospital
480
Correctional facility
490
Parentally placed in
private school
6. Preschool Setting (ages 3-5): Indicate the type of school
setting the student attends. If the student turns 6 years after December
2 of the current year, this category is completed. If the student is dually
or concurrently enrolled in general education and a special education program
for an equal amount of time, consider the student as being in a regular early
childhood or kindergarten program.
400
Regular early childhood
or kindergarten program
440
Separate class
450
Separate school
460
Residential facility
470
Home
475
Service provider
location
7. All Special Education Services Provided at
StudentÕs School of Residence: Check yes or no to the question Òall special
education services provided at the studentÕs school of residence.Ó If the team
determines Òno,Ó rationale must be documented.
8. Percentage of Time Outside and In Class & Extracurricular & Non Academic
Activities: Document the percentage of time the student is outside the
regular environment and document percentage of time the student is in the regular education environment. Consider the full day including lunch, recess,
passing periods, etc.
9.
Student Will Not
Participate in the Regular Class & Extracurricular & Non Academic
Activities: Document the regular education environments where the student
will not participate with typically developing peers: Provide rationale for non-participation.
10.
Other Agency
Services: Note other agency services the child is receiving.
11.
Student Eligible
for Mental Health Services under Chapter 26.5: Check yes or no.
12.
Mental Health
Services Included on the IEP:
Check yes or no. (Be sure to list the service received from County Mental Health
on the Services page (Form 5A). (i.e. counseling, day treatment, etc.)
13.
Promotion Criteria:
Check appropriate box. District criteria are the same for students without disabilities.
Progress on goals or ÔotherÕ should be noted if the childÕs curriculum has been
modified to meet his/her unique needs.
14.
Parents will Be
Informed of Progress and How: Check the frequency and how the progress will
be reported.
15.
Transportation: Check appropriate box. If special education
transportation is indicated, specify the type (door-to-door, curb-to-curb,
wheelchair bus, etc.). Include parent provided transportation, if parent is
being reimbursed. Special education transportation is appropriate if special
provisions are required for the student to access special education services.
16.
Activities to
Support Transition: If the student is going through a transition (preschool
to kindergarten, special education to general education, etc.), document the
activities to support the transition.
17. Graduation Plan: This needs to be done for students in grade 8 and
higher.
NOTE: The IEP Team must use caution when
determining if the student will be working towards a diploma or a certificate
of completion. Students must have the opportunity to work toward a diploma if he/she
have the ability to do so. This must be considered on an annual basis. Check
appropriate box.
[Source: State SELPA IEP Manual, December, 2007]