Students Ages 3-5
Student’s Name: / District ID: / State ID: / Grade: / Sex:
Native Lang: / Ethnicity: / Birth Date: / Age:
District: / School:
1. lEAST RESTRICTIVE ENVIRONMENT (LRE)
Check one:
[] The student will participate entirely in the general education classroom, the general education curriculum, and nonacademic and extracurricular activities with nondisabled peers.
[] The student will participate in the general education classroom and curriculum, except for the following:
Check and explain all that apply.
[] General education classroom
[] General education curriculum
[] Nonacademic and extracurricular activities with nondisabled peers
2. DECEMBER 1 FEDERAL REPORT: EDUCATIONAL ENVIRONMENT FOR AGES 3-5
The student attends a public or private Regular Early Childhood Program that includes at least 50% non-disabled children.
[] (41) In a Regular Early Childhood Program at least 80% of the time.
[] (42) In a Regular Early Childhood Program at least 40% but not more than 79% of the time.
[] (43) In a Regular Early Childhood Program less than 40% of the time.
Children attending regular early childhood programs should be reported in one of the environments above even if they receive special education services in other environments.
The student DOES NOT attend a Regular Early Childhood Program but DOES attend a public or private Special Education Program.
[] (44) Separate Class: Student attends a special education program in a class with less than 50% nondisabled children.
[] (45) Separate School: Student receives education programs in public or private day schools designed specifically for children with disabilities.
The student DOES NOT attend a Regular Early Childhood Program and DOES NOT attend a Special Education Program.
[] (46) Residential: Student receives special education and related services in the residential facility.
[] (47) Service Provider Location: Student receives all special education and related services from a service provider.
[] (48) Home: Student receives special education and related services in the principal residence of the child’s family or caregivers. Include students who also receive services in a service provider location.
January 2007 Form 430a
Copy to the confidential folder, each service provider, and the parent or adult student.