PLEASANTS COUNTY SCHOOLS WVEIS DATA COLLECTION FORM
All information regarding a student with a disability and his/her eligibility and services must be entered into the WVEIS system. The Pleasants County special education secretary, Trish Miller, is responsible for data entry. All information entered is found on one or more of the special education forms required by the WVDE and Pleasants County Schools. A WVEIS Data Collection Form completed by the special education case manager of each student ensures that the most current and accurate data is compiled and submitted to Trish for entry into the WVEIS system. The form is typically printed on green paper.
WHEN TO COMPLETE THE WVEIS DATA COLLECTION FORM:
Initial referrals/eligibility (must be completed even if a student does not qualify for services)
Reevaluation determinations/eligibility
Annual IEP
IEP revisions (if these revisions change an area reported in WVEIS, such as MPW, transportation, extended school year, testing accommodations, etc.)
DIRECTIONS FOR COMPLETION:
1)Fill out all student information including student’s full name, WVEIS number, birthdate, current grade and current school. Accuracy of this information is vital!
2)Indicate the Purpose of the Meeting by circling all that apply and documenting the date that the meeting occurred. For example, the meeting might have been a reevaluation determination/eligibility meeting on February 20th followed by an IEP revision that same day. In this case, you would circle both of these options and write the date 2/20/2011 on the lines.
3)Determine which section(s) are required for completion. There are three sections:
- Initial Referrals and Eligibility
- Reevaluations and Eligibility
- IEPS
4)Fill out the required section(s) entirely. Specific guidance for each of these is detailed on pages 2-4 of this section of your handbook.
5)Attach all supporting special education forms and paperwork to the completed WVEIS form and send to Trish at the county office inyour special education envelope. This information should be submitted in a timely manner (within two weeks of the meeting is preferred.)
DIRECTIONS FOR COMPLETING SECTION FOR
INITIAL REFERRALS AND ELIGIBILITY
1)Referral Source –this describes who referred the child to the MDET for evaluation. Only a number from 1-8 should be written in the space. The following referral sources may be cited:
a)1-Part C-WV Birth to Three
b)2-Parent
c)3-Teacher/SAT (School Assistance Team)
d)4-Other (any that are not listed here)
e)5-Health Care Professional (this can include doctors, outside counselors or psychologists, nurse practitioners, etc.)
f)6-Head Start
g)7-Public Child Care
h)8-Private Preschools
2)Referral Date – record the date on the referral source documentation. If the referral came from WV Birth to Three, record the date from the notice received from them. If the referral came from a teacher/SAT, record the date that the SAT team actually recommended evaluation.
3)Consent for Testing Date – record the date that the permission to evaluate was received by school personnel. This is found at the bottom of the Notice of Individual Evaluation/Reevaluation Request form in the box: *REQUIRED*
Received by School/County:
___/___/______
DATE PERSONNEL
4)Method – describe how consent for evaluation was obtained using one of the following codes:
a)01=Regular mail
b)02=Phone request
c)03=Hand delivered
d)04=Certified mail
5)Date Eligibility Determined - record the date that the Eligibility Meeting was held and the Eligibility Committee report was completed. This date should be filled in even if the student WAS NOT Eligible.
6)Eligibility Status – record the decision of the EC:
a)1=Eligible (student is eligible for services)
b)2=Not Eligible (student did not qualify)
7)Reevaluation Due Date – record the date that the student’s next reevaluation will be due. This is determined by taking the eligibility meeting date and adding three years. Example: If the eligibility meeting was held on 2/25/2011, then the new reevaluation due date is 2/25/2014.
8)E/R Code – document the area in which the student was made eligible. Although the student may have multiple disabilities, the EC must determine which is the primary handicapping condition. Only the codes listed on the Data Collection form and those that are highlighted below may be listed in this area. These codes are also used in the IEP section of the WVEIS Data Collection Form to list services including related services. Related service codes are in the unhighlighted boxes. These codes MAY NOT be used to describe eligibility.
E/R CODES TO BE USED ON WVEIS DATA COLLECTION FORM
AU / Autism / DF / Deafness / LD / Specific Learning DisabilityBD / Emotional/Behavior Disorder / EG / Exceptional Gifted (Gr. 9-12) / MD / Moderately Mentally Impaired
CD / Speech/Language Impairment / GF / Gifted (Gr. 1-8) / MM / Mild/Moderate Ment. Impair
DB / Deaf/Blind / HI / Hard of Hearing / MP / Profoundly Mentally Impaired
MS / Severe Mental Impairment / OH / Other Health Impairment / PH / Orthopedic Impairment
PS / Developmental Delay / RA / Audiology / RB / Rehabilitation Counseling
RH / School Health Services / RI / Interpreting Services / RL / Speech/ Language Path. Svs.
RN / Counseling Services / RO / Occupational Therapy / RP / Psychological Services
RT / Transportation / RV / Orientation and Mobility / RY / Physical Therapy
TB / Traumatic Brain Injury / VI / Blindness and Low Vision / RZ / Other
DIRECTIONS FOR COMPLETING SECTION FOR
REEVALUATIONS AND ELIGIBILITY
1)Reevaluation Det. Plan Mtg. Date – document the date that you had the reevaluation determination planning meeting. You should have a matching meeting notice for this date. This is the date that you actually held the meeting to go over the reevaluation plan and determine which, if any, assessments were needed.
2)Consent for Testing Date - record the date that the permission to evaluate was received by school personnel. This is found at the bottom of the Notice of Individual Evaluation/Reevaluation Request form in the box: *REQUIRED*
Received by School/County:
___/___/______
DATE PERSONNEL
3)Response – record the response of the reevaluation planning committee. C = consent (parent signed the request for evaluation); or N = no response (parent did not respond to the request for evaluation); R = refused (parent responded to request and refused any evaluations); Z= No testing was required (if all areas are marked NO on the reevaluation plan). NOTE: If parent does not provide consent for evaluation, you MAY NOT conduct the evaluations.
4)Date Eligibility Determined – record the date that the Eligibility Meeting was held and the Eligibility Committee report was completed. This may be the same day as the reevaluation planning meeting IF no further evaluations were requested. When evaluations are requested, this meeting will be held after all evaluations are completed. There should be a Meeting Notice for this meeting also, with the date matching the date on the eligibility form.
5)Eligibility Status– record the decision of the EC: 1=Eligible (student is eligible for services); 2=Not Eligible (student did not qualify)
6)Reevaluation Due Date – record the date that the student’s next reevaluation will be due. This is determined by taking the eligibility meeting date and adding three years. Example: If the eligibility meeting was held on 2/25/2011, then the new reevaluation due date is 2/25/2014.
7)E/R Code –(SEE BOX AT THE TOP OF PAGE 3 OF THIS SECTION FOR SPECIFIC CODES)
Although the student may have multiple disabilities, the EC must determine which is the primary handicapping condition. Only the codes listed on the Data Collection form and those that are highlighted may be listed in this area.
DIRECTIONS FOR COMPLETING SECTION FOR
ALL IEPS
1)Case Manager – Put the teacher’s name that is case managing this student.
2)Completing the Special Education Service Table and Remainder of Info - See Examples Below:
E/R / U/DService / MPW
Indirect/Consult / MPW
Reg Ed Inclusion / MPW
Pullout/Sep Class / MPW
Total / TEACHER
Last Name
(4 letters)
First initial / SUBJECT AREA / STS / INITIAL DATE
(Des. In E/R) / EXIT DATE
(Mo/Da/Yr)
LD / U / 20 / 20 / KEHR K / Behavior / 30 / 3/30/2004
/ 400 / 400 / KEHR K / Math / 30
/ 225 / 225 / SCOT K / English / 30
RL / D / 60 / 60 / MILL T / Speech Therapy / 30 / 8/31/2002
RO / D / 30 / 30 / XXXCON / Fine Motor / 30 / 3/30/2004
TOTAL / ------ / 20 / 400 / 315 / 735 / ------ / ------ / ------ / ------ / ------
NOTICE OF MEETING (Date Sent): 3/3/2011 / METHOD (Circle One):
1=Regular Mail 2=Phone Request
3=Hand Delivered 4=Certified Mail / RESPONSE (Circle One):
W=Will Attend
N=Will Not Attend / LRE (From Placement Page):
0 1 2 3 4 5 6 7 8 9
W X Y Z M N P R S
EXTENDED SCHOOL YEAR Yes No / DIPLOMA TYPE
Regular Modified / SPECIALIZED TRANS.
Yes No
TESTING / YES/NO / CODE(S)/DESCRIPTION
Standard Conditions / Yes No / None Needed
Standard Conditions with Accommodation(s) / Yes No / P02 P26
Alternate Assessment/Standard Conditions / Yes No / None Needed
Alternate Assessment with Accommodations / Yes No
*MEDICAID*
Medicaid Number (if known):02020305061 Diagnosis Code:3152
***Medicaid Diagnosis Codes are as follows (please select the code that most accurately describes the E/R of the student):
31500 / Reading Disorder / 31502 / Developmental Dyslexia3151 / Specific Arithmatical Disorder / 3152 / Other Specific Learning Difficulties
31531 / Developmental Exp/Rec Language Disorder / 31532 / Receptive Language Disorder (Mixed)
31539 / Other Developmental Speech or Language Disorder / 3155 / Mixed Developmental Disorder
3158 / Other Specified Delays in Development / 3159 / Learning Disorder NOS
317 / Mild Mental Impairment / 3180 / Moderate Mental Impairment
3181 / Severe Mental Impairment / 3182 / Profound Mental Impairment
319 / Unspecified Mental Retardation
Pleasants County Schools Procedures Handbook –WVEIS FORMPage 1