Notice Of Eligibility Committee And/or Individualized Education Program Team Meeting Form
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1NOTICE OF ELIGIBILITY COMMITTEE AND/OR INDIVIDUALIZED
EDUCATION PROGRAM TEAM MEETING
_______________County Schools
Date _______________________________
Student Full Name __________________________________________
School ____________________________________________________
Date of Birth ________________________
Parent(s)/Guardian(s) _______________________________________
Grade ______________________________
Address ___________________________________________________
WVEIS # ___________________________
City/State/Zip ______________________________________________
Telephone __________________________
Dear Parent(s)/Adult Student:
A meeting will be held on _______________________________ at _______
a.m.
p.m. at___________________________.
The purpose of the meeting is checked below:
Eligibility Committee (EC) Meeting - The EC will review information to determine eligibility for special education. If the EC
determines the student is eligible, an Individualized Education Program (IEP) Team meeting will be held. (See description
below.) If found not eligible, recommendations from the EC will be provided to a school team for consideration, and no IEP
Team meeting will be held. If the EC determines further information is needed, you will be informed.
Individualized Education Program (IEP) Team Meeting - An IEP Team meeting will be convened to develop, review and/or
revise the IEP. Additionally, the IEP Team may:
identify transition services for the student (beginning with 1
st
IEP to be in effect at age 16)
identify preschool transition needs
plan for reevaluation
determine if the student’s conduct is a manifestation of a disability
document transfer of student’s rights
other _______________________________________________
(age of majority)
We invite you to participate in this meeting so we may plan an educational program together. Please be informed you and the county
school district have the right to invite other individuals who have knowledge or special expertise regarding the student.
Enclosed
Provided earlier this school year
Procedural Safeguards Brochure:
If an agency representative is to be invited, date consent was obtained: ____________________
Copy to Invited Members:
Administrator
General Education Teacher
Evaluator
Special Education Teacher or Provider
Birth to Three Representative
Other _____________________
Student
Agency Representative(s)______________________________________
(required when transition will be addressed)
IEP Team Member Excusal(s): The following IEP Team members will be excused from attending the IEP Team meeting. Members
whose academic and nonacademic areas will be discussed will provide a written summary for consideration in developing the IEP.
Name/Position: ______________________________
Name/Position: ___________________________
Sincerely,
____________________________________________________________
_______________________
Name/Position/Date
Phone Number
Parent(s): Please return this form to school within 5 days.
STUDENT RESPONSE
PARENT RESPONSE
(when transition will be addressed)
(check one)
I will attend the meeting as scheduled.
I will attend the meeting as scheduled.
I do not wish to attend.
I do not wish to attend.
I wish to have the meeting rescheduled.
I cannot attend in person, but will participate by phone.
I can be reached at _______________________.
I wish to have the meeting rescheduled.
Student Signature
Date
DOCUMENTATION OF PARENT NOTICE
PARENT/ADULT STUDENT OPTIONS
(check all that apply)
I agree to waive the 8-day notification requirement
Telephone
I consent to excuse the IEP Team members above.
Hand Delivered
I request the district to invite the Birth to Three
representative.
NOTE: Meeting may be rescheduled due
____________________________________________________
to a school delay or cancellation.
Parent/Adult Student Signature
Date
West Virginia Department of Education
March 2017
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