STUDENT INFORMATION SYSTEMAppalachia Intermediate Unit 8

(Revised 3-8-16)Page 1 of 2

From: S.D.______Signature of Preparer

  • The following information is required for the Appalachia IU 8 Student Information System.
  • The Alphabetic Letters (A through P) Placed In Front Of Some Items Refer To Lists Of Choices From Which To Select.

These Lists are Printed In A Separate Document, “Supportive Information For S.I.S”.

Referral Date:______Did Not Qualify Date:______

PASecureID______Student Name

LastFirst Middle

Address:

City: State: Zip:

Phone: Unlisted: Building:

DOB ______Gender______(B)Grade: _____Kdg. Type:

(Half-day/Full-day)

(A) Ethnicity/Race______School Year:

(C)Entry Code: E01 Entry Date:

PIMS Eligibility (Complete SIS PIMS Supplement Form if Checked)

--Contact Data—

Parent or Grdn Name:

TitleNameRelationship

Receive Mailings

Address: (If Different from Above)

City: State: Zip:

Phone: Unlisted:

*****************************************************************************

Second Contact: (Opt.)

TitleNameRelationship

Receive Mailings

Address: (If Different from Above)

City: State: Zip:

Phone: Unlisted:

*****************************************************************************

County______(D) Withdrawal Code:______

(F)Educating School District: Withdrawal Date:______

(F)HomeSchool District:

(E)Residency: Student Type:Exceptional Public School Special Ed.: ____ LEP

SIS- School Age Student Name ______DOB______

(Revised3-8-16) Page 2 of 2

Date Special Education Processes Began: Date This Special Education Cycle Stopped:

(F)Student District:Perm. to Eval:Parent Req:

(F)Home District: Parent Consent: Sent:

(G)Eligibility: (Not Counted )ER/GWR:ReEvWaived:

MA Eligible Medicaid # : ER Issued/Completed:Reason Not 60 Days

Dually EnrolledEligible for Sp Ed/Gifted Services

NOREP/NORA Date:

Original Placement Date:Exit Date: (I)Exit Reason:______

IEP ******************************************************************************************************************

IEP Dev Date: IEP Imp Date: IEP Due Date:

Unofficial IEPService Plan: Y N (R) PCG Disability ______

Transition IEP (J) Transition Type:______(J) Transition Type:______(J) TransitionType:______

(H) Primary Disability:______Other Except: Other Except: Other Except:

(K) Ed. Environment ______Ed. Environment %______(P) Nbhd School:_____(Q)Planned Part______

Instructional Groups

Start Date:End
Major
(L)Type of Support:______
(M)Amt. of Sp Ed:
Loc. of Int: School Age______
Duration: Hours:_____ Minutes:______
Frequency ______Times Per ______
(F)Serv. Provider:
Building:
Teacher: / Start Date:End
(L) Type of Support:______
(M) Amt. of Sp Ed:
Loc. of Int: School Age______
Duration: Hours:_____ Minutes:______
Frequency ______Times Per ______
(F)Serv. Provider:
Building:
Teacher: / Start Date:End
(L) Type of Support:
(M) Amt. of Sp Ed:
Loc. of Int: School Age______
Duration: Hours:_____ Minutes:______
Frequency ______Times Per ______
(F)Serv. Provider
Building:
Teacher:
RELATED Services RELATED Services Support For School Personnel
Start Date:End
Serv. Prov:
(N)Related Serv.:
Duration: Hours:_____ Minutes:______
Frequency ______Times Per ______
Building:
Teacher:
Contact (Opt.) / Start Date:End
Serv. Prov:
(N) Related Serv.:
Duration: Hours:_____ Minutes:______
Frequency ______Times Per ______
Building:
Teacher:
Contact (Opt.) / Start Date:End
Serv. Prov:
(N) Related Serv.:
Duration: Hours:_____ Minutes:______
Frequency ______Times Per ______
Building:
Teacher:
Contact (Opt.)

Z:\School-Age SIS Form - Electronic (3-9-16).doc