Administrative Interim Placement
 
    Pick a date    

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
English Language Learner English Language Learner
Interpreter Required
 
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 Pick a date
 
  30 Day Review
(New Annual Date)
30 Day Review
(New Annual Date)
Pick a date
 
  Initial Placement in Sp. Ed. Initial Placement in Sp. Ed. Pick a date
 
  Last Eval (tri date) Last Eval (tri date) Pick a date
 
  Next Eval (tri date) Next Eval (tri date) Pick a 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
 
% 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   
 
  Days Days Minutes Minutes
 
MENTAL HEALTH SERVICE

 
Not applicable
 
Assessment completed Assessment completed Pick a date   Eligible
 
MH goals/language included in this IEP
 
 

 
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    Pick a date
 
Verified by  
 
 
Case manager/code Case manager/code   
 
Initial referral (for assessment)

 
Referral date Referral date    Pick a date
 
Referred by
 
Parent consent date received Parent consent date received    Pick a date
 
Initial evaluation IEP date Initial evaluation IEP date    Pick a date
 
Pre-referral early intervening services