SIMS (Student Information Management System-Infinite Campus) Required Data Elements Updated 9/11 by TKC

Student Name:
Case Facilitator:
Medicaid Eligible? Yes No
If Yes, complete form if student has SLT, OT or PT services / Purpose of Meeting
Initial Eligibility/Placement into Special Education
Annual IEP
Continuing – no changes in any data elements
New Student to District
Addendum/Change
Three Year Reevaluation
Dismissal from Services Date: ______
Effective Date of Services: (if new to district-1st date of enrollment)
Special Education Placement Category (Ages 6-21) / Preschool – Ages 3-5 (even in Kindergarten!)
310-Reg Ed Program at least 10 hrs/wk-Sped in Reg Ed
315-Reg Ed Program at least 10 hrs/wk-Sped in other location
325-Reg Ed Program less than 10 hrs/wk-Sped in Reg Ed
330-Reg Ed Program less than 10 hrs/wk-Sped in other location
335-Separate Class
345-Separate School
355-Residential Facility
365-Home
375-Service Provider Location

Multiple Disability Areas: Multiple Dis 1 ______
0505 - Emotional Disturbance Multiple Dis 2 ______
0510 - Cognitive Disability Multiple Dis 3 ______
0535 - Orthopedic Impairment Multiple Dis 4 ______
0540 - Vision Loss Multiple Dis 5 ______
0545 - Deafness
0550 - Speech/Language Impairment
0555 - Other Health Impairment
0565 - Traumatic Brain Injury

Instructional Program Type
(This is determined by the coding used for the Cost Analysis completed by business manager or special ed. director)
(Please circle one)
A. Programs for Mild to Moderate Disabilities (under 900 min)
B. Programs for Severe Disabilities (over 900 min)
C. Speech Only
D. Early Childhood (ages 3-5)
E. Day Program
F. Residential Program
G. Homebound Program

Transportation: (circle one) Yes / No
If transported on Palace Transit please complete:
When/Where/Address/Phone Number:
IEP Program Exit Reason
01 - No longer received Sped Service
02- Graduated with regular high school diploma
03 - Received a certificate
04 - reached maximum age
05 - died
06 - moved known to be continuing
07 - moved not known to be continuing
08 - dropped out
09 - refused services
10 - Completed ISFP prior to reaching maximum age for Part C
11 - Change in IEP
12 – Student Continues
0100 - Regular Classroom with modifications 80-100%
0110 - Resource Classroom 40-79%
0120 - Self-Contained Classroom 0-39%
0130 - Separate Day School
0140 – Residential Facility
0150 - Home/Hospital Program
Special Education Primary Disability Areas:
(Please circle one)
0500 - Deaf-Blindness
0505 - Emotional Disturbance
0510 - Cognitive Disability
0515 - Hearing Loss
0525 - Specific Learning Disability
0530 - Multiple Disabilities
0535 - Orthopedic Impairment
0540 - Vision Loss
0545 - Deafness
0550 - Speech/Language Impairment
0555 - Other Health Impairment
0560 - Autism
0565 - Traumatic Brain Injury
0570 - Developmental Delay
Special Education Services:
(Please indicate the amount of time)
Physical Therapy ______
Speech/Language Therapy ______
Occupational Therapy ______
Psychological Services ______
School Nurse Services ______
Orientation & Mobility Services ______
Counseling Services ______
Other Therapy Services ______(explain)
Assistive Technology Yes / No (circle one)
Significant Cognitive Disability (student takes STEP-A)
Yes / No (circle one)