West Clermont Data Collection Form for Students with Suspected/Identified Disabilities

Use for Events From June 1, 2014 Through May 31, 2015

Name: ______Student ID#: ______DOB: ______Date: ______

Resident District: ______District of Attendance: ______Building of Attendance: ______Autism Scholarship? ______

Grade Level: ______Race: ______Disability Category: ______Teacher: ______

A. Date Type Codes: Activity / Event Date from PR-XX form / Outcome (circle) / Begin
Date / End Date / Compliance
1. PSTC (Preschool Transition -transition from Help Me Grow) / Date______/ N/A / N/A
2. RFRL (Referral for Evaluation - after the child is suspected of having a disability) / Date______/ N/A / N/A
3. CNST (Parent Consent for Evaluation -on or after referral date) / Date______/ CNGT (consent granted) / GNGI (Initial Eval) / CNRF (consent refused) / CNNR (consent not returned) / CNDP (consent moved to due process) / N/A
# days between CNST & IETR: ______
4. IETR (Initial Evaluation Team Report -Completion due 60 days from consent) / Date______/ ETNE (not eligible) ETDP (ETR resulted in due process) / Code:_____
Disability Category (circle):
ET01(MD) ET02(Deaf/Blindness) ET03(HI) ET04(VI) ET05(speech) ET06(Orth) ET08(ED) ET09(ID) ET10(SLD) ET12(AU) ET13(TBI) ET15(OHI)ET16(DD) preschool
5. IIEP (Initial IEP - 30 days from ETR Completion; by third birthday if PSTC)
****FILL OUT STEPS 2,3, and 4 ABOVE!!!!!!! / Date______/ IEPR (parent refusal / FAPE) IEDP (resulted in due process) / Date
_____ / Date
____ / Code:_____
LRE CODES (circle)
IE13-spec ed outside reg. class less that 21% of day
IE14-spec ed outside reg. class 21% to 60 % of day
IE15-spec ed outside reg. class more than 60% of day
IE16-public separate school greater than 50%
IE17-private separate school greater than 50%
IE18-public residential facility
IE19-private residential facility
IE20-homebound/hospital
IE39-nonpublic, placed by parent, service plan
PRESCHOOL CODES (circle)
IE51-WC itinerant w/regular early childhood program +10 hours
IE53-WC itinerant w/regular early childhood program -10 hours
IE55-WC program w/regular early childhood program +10 hours
IE56- WC program w/regular early childhood program -10 hours
IE62-special education program – separate school
IE64-special education program – residential facility
IE70-home
8. RETR (Reevaluation Team Report - 3 years from prior ETR)
***Fill out at every IEP meeting / Date______/ ETDP(resulted in due process) ETEX(exiting special education) / Code:_____
Disability Category (circle):
ET01(MD) ET02(Deaf/Blindness) ET03(HI) ET04(VI) ET05(speech) ET06(Orth) ET08(ED) ET09(ID) ET10(SLD) ET12(AU) ET13(TBI) ET15(OHI) ET16(DD) preschool
9. RIEP Periodic Review of IEP
(1 year from previous IEP) / Date______/ IEPR (parent refused / FAPE) IEDP (resulted in due process) / Date
_____ / Date
____ / Code:_____
LRE CODES (circle)
IE13-spec ed outside reg. class less that 21% of day
IE14-spec ed outside reg. class 21% to 60 % of day
IE15-spec ed outside reg. class more than 60% of day
IE16-public separate school greater than 50%
IE17-private separate school greater than 50%
IE18-public residential facility
IE19-private residential facility
IE20-homebound/hospital
IE21-correctional facility
IE39-nonpublic, placed by parent, service plan
PRESCHOOL CODES (circle)
IE51-WC itinerant w/regular early childhood program +10 hours
IE53-WC itinerant w/regular early childhood program -10 hours
IE55-WC program w/regular early childhood program +10 hours
IE56-WC program w/regular early childhood program -10 hours
IE62-special education program – separate school
IE64-special education program – residential facility
IE70-home
8. TETR (Transfer Student ETR Adoption) / Date______/ Disability Category (circle):
ET01(MD) ET02(Deaf/Blindness) ET03(HI) ET04(VI) ET05(speech) ET06(Orth) ET08(ED) ET09(CD) ET10(SLD) ET12(AU) ET13(TBI) ET15(OHI) ET16(DD) preschool / Date
_____ / Date
____
C. Secondary Planning Element (Transition Plan reported for students who turn 14 prior to end of this IEP) / Circle One:
TFYG – Transition Statement and/or Plan in Place. Student plans to meet
graduation requirements entering ninth grade
TPCE – Transition Plan in Place. Met Grad requirements and will continue as
Grade 23
**** Not Applicable
D. Related Services (2150XX)
(Record only those related services described on IEP) / Service: / Start / End Date
215002Aide Services
215003Attendant Services
215004Audiology
215006Interpreter Services
215007Medical Services
215008Occupational Therapy Services
215009Orientation and Mobility Services
215010Physical Therapy Services
215011Reader Services
215012School Psychological Services
215013Speech and Language Services
215015Rehabilitation Counseling
215017Parent Counseling and Training
215018Counseling Services
215020Recreational Services
215021Special Transportation
215022Social Work Services
215023Other (Work Study, Adapted PE, Adapted Equipment)
215026School Health Services
215027School Nurse Services
E. Preschool Itinerant Services (a teacher) / 220100 Provider:
F. Testing Requirements / TEST TYPE required by IEP:
ALT - Alternate Assessment STR – NO accommodations STA – with accommodations / Accommodations required:
** not applicable NO
Y1 – yes, 504 plan
Y2 – yes, IEP
Y3 – yes, LEP / OGT Required for Graduation?
Yes No NA
Met Participation Requirements? Yes No
date:______

IEP Meeting Date:______IEP Effective Dates From ______To ______

District Representative: ______Date:______

FY09

Codes for Compliance Column

**Not out of compliance 04Schedule conflicts with family 05Parental choice 06Parent refused consent 07Child’s health 08Student incarcerated