Northern Lights Special Education Cooperative

Quality Education Through Cooperation and Partnership

Hermantown staff only - Fill out this form for EC students that do not qualify for services. The evaluation hours are still reportable.

Questions in Bold and with an * are required

IEP/IFSP/IIIP Manager Name

Your email (if you want a copy of the data submitted sent to you via email):

Student First and Last Name*

Resident District

Evaluation Start Date  (mm/dd/yyyy)

Evaluation End Date  (mm/dd/yyyy)

Evaluation Hours

End Status Code for Sp. Ed.   04 - Student moved   20 - Student transferred to another district, but did not move  21 - EC withdrawal IFSP/IIIP/IEP goals met   25 - Evaluated - did not qualify   26 - EC withdrawl by parent   27 - EC transition at age 3, Part B eligible, exiting Part C   28 - Not Part B eligible, exiting Part C with referrals   29 - Not Part B eligible, exiting Part C with no referrals   30 - Part B eligibility not yet determined   34 - EC attempts to contact unsuccessful (considered a drop out code)   N/A

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