Individualized Education Program (Iep) - Information/eligibility - State Selpa Iep Template

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STATE SELPA IEP TEMPLATE
INDIVIDUALIZED EDUCATION PROGRAM (IEP) - INFORMATION / ELIGIBILITY
Student Name _____________________
Date of Birth ___/___/________
IEP Date
___/___/________
Last IEP
____ / ____ / ______
Next IEP
____ / ____ / ______
Original SpEd Entry Date ___/___/________
Last Eval
____ / ____ / ______
Next Eval
____ / ____ / ______
Purpose of Meeting
Initial
Annual
Triennial
Transition
Pre-Expulsion
Interim
Other_____________
Date of Birth ____/____/______
Age
_________________
Gender
__________________
Grade
______________________
Migrant
Yes
No
Native Language __________________
EL
Yes
No
Redesignated
Interpreter
Yes
No
Student ID ________________________
SSN
_________________
SSID
__________________
Residency
Parent/Guardian
Foster
LCI
Adult Student
Other
Parent / Guardian _________________________________
Home Phone
_________________________________
Home Address
_________________________________
Work Phone
_________________________________
City
_________________________________
Cell Phone
_________________________________
State, Zip
_________________________________
Email
_________________________________
Parent / Guardian _________________________________
Home Phone
_________________________________
Home Address
_________________________________
Work Phone
_________________________________
City
_________________________________
Cell Phone
_________________________________
State, Zip
_________________________________
Email
_________________________________
Ethnicity
(Select One)
Hispanic or Latino
Not Hispanic or Latino
Race (Enter Code, must select one or more, regardless of Ethnicity):
Race 1 ________ Race 2 ________ Race 3 ________
INDICATE DISABILITY/IES (P = Primary, S = Secondary)
Note: For Initial and triennial IEPs, assessment must be done and discussed by IEP
Team before determining eligibility.
_______ 210 ID
_______ 220 HH *
_______ 230 Deaf *
_______ 240 SLI
_______ 250 VI *
_______ 260 ED
_______ 270 OI*
_______ 280 OHI
_______ 290 SLD
_______ 300 DB *
_______ 310 MD
_______ 320 AUT
_______ 330 TBI
_______ 281 Est. Med. Dis. (0-5)
* Low Incidence Disability
_______Not Eligible for Special Education
_______Exiting from Sp. ED. (returned to reg. ed/no longer eligible)
Describe how student’s disability affects involvement and progress in the general curriculum (or for preschoolers, participation in
appropriate activities) ________________________________________________________________________________________
____________________________________________________________________________________________________________
FOR INITIAL PLACEMENTS ONLY
Has the student received IDEA Coordinated Early Intervening Services (CEIS) in the past two years?
Yes
No
Date of Initial Referral for Special Education Services
_____/_____/_____
Person Initiating the Referral for Special Education Services
_________________
Date District Received Parent Consent
_____/_____/_____
Date of Initial Meeting to Determine Eligibility
_____/_____/_____
Revised 07/2013
Form 1

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