Coop Id Mercedes Special Education Cooperative

COOP ID MERCEDES SPECIAL EDUCATION COOPERATIVE

P.O. BOX 419/ 200 S. Ohio St.

District ID: MERCEDES, TX. 78570

NOTICE OF IEP START DATE

Name: DOB: Gender: FemaleMale Grade: EEPre-KK123456789101112

Campus: C. E. VailChacon Middle SchoolDAEPDominguezGreenHarrell Middle SchoolHinojosa JJAEPKennedyLF AcademyLFHSMAAMECAMHSSam HoustonSanchezSMHSSMMSTaylorTony GonzalezTravisOther* to C.E. VailChacon Middle SchoolDAEPDominguezGreenHarrell Middle SchoolHinojosaJJAEPKennedyLF AcademyLFHSMAAMECAMHSSam HoustonSanchezSMHSSMMSTaylorTony GonzalezTravisOther** * Other School & District:

ARD Date: Start Date (first date student receives new service):

For Initial Referrals/Transfer students only: Enrollment Date:
Parent’s Name: / Address:
City: / Telephone Number:
SSN: / Medicaid #: / Ethnicity:
Type of ARD: / AmendmentAnnualAnnual/REEDInitialRevisionTransfer
Reason for ARD: / Add DisabilityAdd Related ServiceChange of Campus*Change of CodeDisciplineDismissalDrop DisabilityDrop Related ServiceSchedule Change / Add DisabilityAdd Related ServiceChange of CampusChange of CodeDisciplineDismissalDrop DisabilityDrop Related ServiceSchedule Change / Add DisabilityAdd Related ServiceChange of CampusChange of CodeDisciplineDismissalDrop DisabilityDrop Related ServiceSchedule Change
Disabilities/Report Dates (Rank each disability by number and indicate report date.) / FIE Date:
Primary: 01 OI02 OHI03 AI04 VI05 DB06 ID07 ED08 LD09 SI10 AU13 TBI14 NCEC Rpt. Date: / Tertiary: 01 OI02 OHI03 AI04 VI05 DB06 ID07 ED08 LD09 SI10 AU13 TBI14 NCEC Rpt. Date:
Secondary: 01 OI02 OHI03 AI04 VI05 DB06 ID07 ED08 LD09 SI10 AU13 TBI14 NCEC Rpt. Date: / Quaternary: 01 OI02 OHI03 AI04 VI05 DB06 ID07 ED08 LD09 SI10 AU13 TBI14 NCEC Rpt. Date:
Multiply Disabled: NoYes / Medically Fragile: NoYes
Instruc. Setting: / 00 Speech Only01 Homebound08 Vocational Adjustment Class31 Early Childhood Instruction ECI40 Mainstream41 Resource (<21%)42 Resource (21%-49%)43 Life Skills (50%-60%)44 Life Skills (61%+)45 Early Childhood (100% Ages 3-5) / Indicate if instructional setting will change Yes No
SPEECH Code: / 01 Speech Only2 Speech & Other SPED Setting / FOSTER CARE Code / 08 Vocational Adjustment Class81 Mainstream82 Resourece (<21%)83 Resource (21%-49%)84 Life Skills (50%-60%)85 Life Skills (61%+)89 Early Childhood (100% Ages 3-5)
RELATED/Other Services Indicate if student is receiving direct/consultation services / None at this time
Adapted PE ConsulationAdapted PE DirectAI ConsulationAI DirectAT Device/ServiceCounseling ConsultationCounseling DirectO&M ConsultationO&M DirectOT ConsultationOT DirectPersonal CarePT ConsultationPT DirectSpecial TransportationVI DirectVI Indirect / Adapted PE ConsultationAdapted PE DirectAI ConsultationAI DirectAT Device/ServiceCounseling ConsultationCounseling DirectO&M ConsultationO&M DirectPersonal CarePT ConsultationPT DirectSpecial TransportationVI DirectVI Indirect / Adapted PE ConsultationAdapted PE DirectAI ConsultationAI DirectAT Device/ServiceCounseling ConsultationCounseling DirectO&M ConsultationO&M DirectOT ConsultationOT DirectPersonal CarePT ConsultationPT DirectSpecial TransportationVI DirectVI Indirect
Adapted PE ConsultationAdapted PE DirectAI ConsultationAI DirectAT Device/ServiceCounseling ConsultationCounseling DirectO&M ConsultationO&M DirectOT ConsultationOT DirectPersonal CarePT ConsultationPT DirectSpecial TransportationVI DirectVI Indirect / Adapted PE ConsultationAdapted PE DirectAI ConsultationAI DirectCounseling ConsultationCounseling DirectO&M ConsultationO&M DirectOT ConsultationOT DirectPersonal CarePT ConsultationPT DirectSpecial TransportationVI DirectVI Indirect / Adapted PE ConsultationAdapted PE DirectAI ConsultationAI DirectAT Device/ServiceCounseling ConsultationCounseling DirectO&M ConsultationO&M DirectOT ConsultationOT DirectPersonal CarePT ConsultationPT DirectSpecial TransportationVI DirectVI Indirect
EXIT Dates (Indicate service to be exited and last date of service) / None at this time
OTPTSpeechAdapted PESpecial TransportationCounselingHomeboundAT Device/ServiceSpecial Education Program
Date: / OTPTSpeechAdapted PESpecial TransportationCounselingHomeboundAT Device/ServiceSpecial Education Program
Date: / OTPTSpeechAdapted PESpecial TransportationCounselingHomeboundAT Device/ServiceSpecial Education Program
Date:

Person Completing IEP Start Date Form Date

***THIS FORM MUST BE EMAILED TO THE MSEC SPED OFFICE WITHIN 3 BUSINESS DAYS OF THE ARD***

For La Feria & Santa Maria: Email a copy of this form to the Campus PEIMS Clerk.

For SEMS/PEIMS Clerk Only: Date Received