Covered Bridge Special Education District / Rockville Community School Corporation
1320 Walnut Street / South Vermillion Community School Corporation
Terre Haute, Indiana47807 / Southwest Parke Community School Corporation
(812) 462-4364 / Vigo County School Corporation

CASE CONFERENCE REPORT AND INDIVIDUALIZED EDUCATION PROGRAM

DATE / PURPOSE(S) / Initial Case Conference
TIME / Case Review Conference
LOCATION / Annual Case Review
Causal Relationship Conference
36-Month Planning Conference
NAME
Last / First / Middle
PARENT
ADDRESS
CITY / IN / 478 / PHONE
SEX / Male Female / BIRTHDATE / GRADE: / (School Year / ) / GRADE: / (School Year / )
STN
HomeSchool / Code / Ethnic Background / Legal Custody Status / Local Program Level
Am.Ind/Nat.American / 01 - Parents / 02 - Early Childhood Program
Home School Corp. / Code / Asian or Pacific Islander / 02 - Maternal Parent / 03 - Elementary Program
Hispanic / 03 - Paternal Parent / 04 - Secondary Program
PlacementSchool / Code / African American / 08 - Foster Parents / 05 - Communication Disorder only
White (non Hispanic) / 09 - Other / - Homebound
Multiracial / - Surrogate

CASE CONFERENCE PARTICIPANTS

Case Conference Coordinator / Parent(s)
School Administrator
Gen. Ed. Teacher(s) / Student
Spec. Ed. Teacher(s) / Specialist(s)
Evaluation Team Member(s) / CBSED Representative
Other / Other

DESCRIPTION OF EVALUATION PROCEDURES

Intelligence / Achievement / Adaptive Behavior / Social /Emotional / Communication / Other
WISC IV / WJ-III / VABS / BASC II / CELF-4 / Medical Report
WAIS-III / WIAT-2 / ABI / Conners R / TOLD-3 / Agency Report
SB-V / PIAT-R / ABAS II / Achenbach / PLS-4 / Social/Dev. History
WJ-III / KTEA – II / Teacher Report / Teacher Report / SLP Report / ADOS
KBIT - II / Teacher Report / Teacher Report
Other evaluation procedures

36 month evaluation report sharedYesNot Applicable

ELIGIBILITY (Based on Article 7, Special Education Rules)

Does not meet eligibility criteria for special education and related services / Termination Code / Date / Program
The student meets eligibility criteria for the following disabilities: (Mark the primary disability with “1”)
Autism Spectrum Disorder / Hearing Impairment / Multiple Disabilities
Communication Disorder / Learning Disability / Orthopedic Impairment
Developmental Delay (Early Childhood) / Mild Mental Handicap / Other Health Impairment
Deaf-blind / Moderate Mental Handicap / Traumatic Brain Injury
Emotional Disability / Severe Mental Handicap / Visual Impairment
INDIVIDUALIZED EDUCATION PROGRAM / developed / reviewed / revised
INDIVIDUALIZED TRANSITION PLAN / developed / reviewed / revised / not applicable
SUMMARY OF PERFORMANCE(exiting students only) / developed / not applicable

Form 5A1 – September 2007 Original to CBSED, copy to parent, copy to school, copy to teacher