Planning Form Regarding Placement into a
Separate Continuum Class
Programs for Exceptional Children
(School team completes form through first meeting. Every section of this form must be completed prior to the IEP meeting to discuss the possible change.)
I. Student Information
Student Name: ______DOB: ______
School: ______ID#:______Grade: ______
Teacher/Case manager:______
Parent/Guardian Name: ______e-mail: ______
(if available)
Contact numbers: Home ______Work ______
Cell ______
EC Eligibility: ______Current EC setting/first date of this placement:______/______
Other Direct Services: ______
Related Services: ______
Current IEP dates: ___/___/___ to ___/___/___ * Re-evaluation due date: ___/___/___
*If student’s 3 yr. re-evaluation is due within the current school year, the IEP team must complete the 3 yr. re-evaluation process
Note: In order to consider a more restrictive placement, each of the following criteria must apply.
Post High School / High SchoolDiploma Pathway / Curriculum / Continuum of Service / State Assessment
Competitive/Supported
Employment
Volunteer / Graduation Certificate / North Carolina Extended Content Standards /
Separate
(39% or less with non disabled peers or individually supervised 70% of the day) / Instructed on extended content in all assessed areas
Has a significant cognitive deficit in all areas of conceptional, linguistic and academic development and also in adaptive behavior areas, such as communication, daily living skills and self-care
EXTEND1
II. Areas of Concern
Areas of Concern: / Provide a brief narrative of the current level of performance./ EOG performanceReading
Math
Writing
Communication
Adaptive skills
Social skills
Behavioral
____ Other: (describe)______
______
Current Assessments:
· “Current” is defined as within approximately one year if the child is 6 years old or younger and within approximately two years if the child is 7 years or older.
· Standard scores will most likely be 59 or below in all developmental areas for consideration of Life Skills classes.
· Scores on tests of autism will likely be in the moderate to severe range for consideration of a separate continuum Autistic classroom.
Name of test / Date / ScoreCognitive
Adaptive
Educational
Speech Language/Communication
Emotional/Behavioral
Autism Assessment
OT
PT/Adaptive PE/Other
III. Review of Programmatic Issues
Describe the classroom management, programmatic/instructional and/or behavioral strategies (Behavior plan, FBA) and interventions being implemented (4-6 weeks) with the student and the outcome for each. (Include modifications, extra assistance, class or schedule changes, frequency, setting, consistency of use, and fidelity of implementation.)
Intervention(s) per Area of Concern / Implementation Dates Place / Outcome(s)Please answer the questions below to ascertain if changing a student’s setting to a self-contained class placement is appropriate at this time.
1. Has the parent/guardian been notified of these concerns and the need for interventions and
observations? ___ Yes ___No
If no, notify parent/guardian. Date of notification: ______
2. Is the student able to grasp the essential elements of the general education curriculum and
achieve academically (even if performing below grade level) through the use of appropriate
supplementary aids and services in the current setting? ___Yes ___ No
Explain: ______
______
Documentation: ______
3. Is the student making progress towards meeting IEP goals and objectives? ___Yes ___ No
Explain: ______
______
4. Is the student able to participate appropriately in the social and non-academic aspects (language,
behavior) in the current setting? ___Yes ___ No
Explain: ______
______
______
IV. First Meeting:
Review the following documentation:
Data collection sheets, including fidelity information
Work samples
Anecdotal records and summary
Classroom management plan
Individualized student behavior management plan and data
o Interventions successful, maintain current placement.
or
o Revise and/or continue intervention process. Observations will be scheduled. A second meeting will be required.
The following people met and completed the above planning form:
Name / Position / DateV. Observation Recommendation(s) by Program Placement Specialist, School Psychologist, or receiving teacher.
______
VI. Second Meeting: Summary of intervention data.
______
______
o Maintain current placement, with the following interventions:
Intervention(s) per Area of Concern / Implementation Dates Place / Person(s) Responsible / Fidelity CheckInitial Date / Outcome(s)
or
o IEP team may proceed with change of placement process.
Support AnalysisDirections: Based on a review of all the information, check most appropriate indicator for each category. Total each column. Recommendation of the level of support (last row) is based upon the total number of checks in the each column.
Appropriate Curriculum / Standard Course of Study, including Occupational Course of Study / Extended Common Core Standards: Level 1, Level 2, or Level 3 **
Transition / Ability to transition with minimal prompts for class activities and within the school environment / Requires prompting and/or supervision for transitions for class activities and within the school environment
Behavior/Social Skills / Ability to interact with groups; similar to non-disabled peers / Responds to social skills training based on FBA/BIP
Self-Help / Ability to perform self-help skills with minimal assistance or prompts / Requires interventions to be successful in self-help and adaptive skills
General Education Participation / Benefits from participation in academic areas with non-disabled peers given appropriate support / Benefits from participation in general curriculum with non-disabled peers
Communication / Ability to communicate within a classroom setting with or without minimal intervention. / Initiates communication with/without assistive technology device
Medical Issues / Medical issues similar to non-disabled peers but do not impact education / Medical issues similar to non-disabled peers, but impacts education
Total: / Total:
Recommended Level of Support / Targeted Skills
Services/supports provided to students who require specific instruction in targeted skills areas (to include but not limited to: reading, math, written expression, social skills) outside the general education classroom from 21%-60% of the day. Special targeted skills groups can range from 1-14 students with consideration given to any specific guidelines governing group size composition for any methodologies adopted by the LEA. / Sustained Support
Services/supports outside the general education classroom for greater than 60% of the day, to students who require extensive and explicit instruction to acquire, maintain, and generalize multiple skills. Students may have documented health, communication, sensory, and/or behavior problems. Periodic, immediate support and supervision are required throughout the day.
**
Level 1 / Level 2 / Level 3Access skills: / Uses vocabulary of signs, pictures, and words to communicate. Recognizes very few sight words, numbers, etc. Some symbols may be abstract (e.g., yesterday, happy, 9:00). May vary based on the age and educational experience of the student / Beginning to use pictures or other symbols to communicate within a limited vocabulary, primarily concrete symbols (e.g., eat, drink, outside, play). / Communicates with gestures, eye gaze, purposeful moving to object, sounds; communication is purposeful (e.g., hold up cup for drink).
Browder, Spooner, Wakeman, Trela, & Baker, 2006
The following people met and completed the above planning form:
Name / Position / Date1 Rev 10/12