Form 30 - Interim Special Education Services
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1STATE SELPA IEP TEMPLATE
INTERIM SPECIAL EDUCATION SERVICES
This form must be used for placement of a student from another SELPA or for a student from out of State
Student Name _____________________
Date of Birth ___/___/________
Age
_____________________
Grade
_____________________
Gender
_____________________
Parent / Guardian _____________________
Home Phone _____________________
Cell Phone _____________________
Home Address
_____________________
City
_____________________
State, Zip _____________________
Native Language ____________________
EL
Yes
No
Redesignated
Yes
No
Ethnicity___________________________
Residency
Parent/Guardian
FFH
LCI
Adult Student
Other
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
SPED Entry Date ___/___/_______
Interim Placement to be Reviewed ___/___/_______ 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
Service
Education
Frequency
Duration
Location
Start Date
End Date
Provider
Service
__________________ % 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 ________________________________________________________
Date ___/___/______
Position ________________________________________________________
Revised 07/2013
Form 30
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