IEP/IFSP/IIIP Manager Name
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Your email (if you want a copy of the data submitted sent to you via email):
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Student First and Last Name*
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Address
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City, State, Zip
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D.O.B. (mm/dd/yyyy) |
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Gender |
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Is the Student Latino?
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Race - Check ALL that apply Native American / Alaskan Native
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Ethnicity - Check only ONE Native Ame/Alaskan Native Asian/Pacific Islander Hispanic Black, Non-Hispanic White, Non-Hispanic N/A |
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MARSS # (13 digits)
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Grade |
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Class Placement? #1300 3-5 ECSE Non District #1500 3-5 Non District Speech #1700 3-5 District ECSE #1900 B-3 Home Visits #2000 B-3 Child Care Center #2100 B-3 Home Speech NA |
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Foster Student? Yes No NA |
If yes to foster student, are parent rights intact? Yes No NA | |
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Student New to District w/Current IEP Enrollment Date: (mm/dd/yyyy) |
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Type of Plan |
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Initial IEP/IFSP/IIIP Parent Signature Date (mm/dd/yyyy) |
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Primary Disability
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Federal Instructional Setting (Birth - Age 2)
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Federal Instructional Setting (Age 3 - Age 5)
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Federal Instructional Setting (School Age Students 6-21)
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Special Transportation? |
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Building
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Resident District
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Open Enrolled? |
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Foster Placement? |
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Parental Consent for Evaluation Date (mm/dd/yyyy) |
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Evaluation Status (SEES) | |
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Evaluation Start Date (mm/dd/yyyy) |
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Evaluation End Date (mm/dd/yyyy) |
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Total Evaluation Hours
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Parent Consent Date (mm/dd/yyyy) |
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Contact # 1 Name
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Contact # 1 Address
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Contact #1 City, State, Zip
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Contact # 1 Home Phone
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Contact # 1 Cell Phone
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Contact # 1 Email
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Relationship to Learner (Contact #1) |
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Contact #2 Name
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Contact #2 Address
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Contact #2 City, State, Zip
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Contact #2 Home Phone
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Contact #2 Cell Phone
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Contact #2 Email
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Relationship to Student (Contact #2) |
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Comments
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