Office for Student Support Programs and Services

Office for Student Support Programs and Services

Request for Off-Campus Instruction

Complete ALL sections and e-mail to Melissa Mangino ()for approval with a cc: to Angela Coleman() and your regional compliance specialist.

*This request form does not have to be completed if the OCI dates were already indicated as an outcome of a manifestation determination meeting.

Student’s Name: / Student’s ID #: / Date:
School: / DOB: / Grade:
Primary Eligibility: / Other Eligibilities:
Requested By: / Location: / Extension:
Case Manager: / Location: / Extension:
Reason for OCI:
Provide detailed description of situation to justify why the most restrictive setting is being requested.
Interventions/Alternatives to Suspension Previously Attempted
If this request is related to behavior, all boxes to the right that could be applied for the same pattern of behavior must be checked before OCI will be approved. Evidence of each action must be attached to the request (i.e., meeting notes, schedule, lesson, developed or updated plans, email, other relevant documentation). / After-school program / Counseling / Other:
Additional adult on bus for supervision / Develop/update Brief FBA/BIP / Parent meeting
Behavior agreement/ monitoring / Develop/update Comprehensive FBA/BIP / Request district level support
Bus plan / Evaluation/Reevaluation Requested / Restrict passing/unstructured time
Change from basic to self-contained classroom / Individualized social skills instruction / Saturday school
Change of schedule/teacher / ISS / Supervision plan
Change of school / Modified day / Threat Assessment
Check-in/check-out / Monitoring of FBA/BIP for fidelity of implementation / T/IEP revision
Community service / N/A (Not behavior related) / TOOLS program
For OCI requests over 10 days, has an Informed Notice of Change (MIS #797) been provided to the parent? The informed notice must explain the change of frequency and location of services for the timeframe. / Yes Date:
N/A (Non-ESE)
N/A (Under 10 days)
OCI Start Date: / OCI End Date: / Total # of: / Days:
Hours:
Duration To Be Determined? / Yes
No / If Yes, Explain:
Is student being placed on a modified schedule for this quarter? / Yes
No / Duration of modified schedule: Not to exceed the end of current quarter.
Is student being placed on full-time OCI for this quarter? / Yes
No / Duration of full-time OCI: Not to exceed the end of current quarter.
OCI Teacher(s) Information:
All assigned teachers must be listed prior to approval, unless a reason is provided and the teacher names are sent as soon as possible. For requests over 10 days, highly qualified teachers must be assigned for each course. / Name / Base School / Ext.
If teachers are not identified, please explain:

District Use Only: Date Received: ______Date Response Provided: ______Date Approved: ______