St. Lucie Public Schools
School: ___________
Data Input – Exceptional Student Education
Data Correction Only
Grade: ___________
Student Name: ______________ ________________________ Student ID#: _________________________
EVALUATION INFORMATION (student profile/ESE Details/Evaluation)
Student Placement Status:
Type of Evaluation:
Referral Date
(Circle one)
I N P
Initial Evaluation
R
Work in progress (If IEP update is included –Update IEP Info First then add evaluation)
T
Z
Reevaluation
Transfer (out of State)
(same as District Received Date):
Evaluation Start:
Eligibility Determination:
Case Manager:
Reevaluation:
Evaluation Completed:
Referral Reason: (Circle one)
CONSENT INFORMATION
Evaluation Permission:
Placement Consent Given:
STATE REPORTING
60 Day Exception:
NO YES
NO YES
____________
(Circle one)
Primary
N
P T
Other
N
P T
Other
N
P T
Other
N
P T
Other
N
P T
(age 3-5)
A B J K L M S
(AGE6-21)
(student profile/ESE Details/Programs/ESY)
__9D m___
Referral
Date
Dismissed
EXTENDED SCHOOL YEAR SERVICES
__9E m____
ESE COST FACTOR (always ADD Never Edit)
Effective Date
S
D__
Comments:
Placement
Status
__99
P
Private School Name:
ESY Services: (Circle one)
NO YES
All information for new exceptionalities is required
Eval
Completion/
Orig Eval
ESY Services:
__9G m____
Eligibility
Date:
__9I m_____
Gifted Elig
Mins
A, B, or Z
To/
From
Placed
(use for ref/orig/elig/placed)
Check all that apply & indicate Mins
__9F m____
Amended IEP (Data Specialist Types comment in)
C D F H P Z
EXCEPTIONALITIES/PROGRAMS (student profile/ESE Details/Exceptionalities & Programs)
__9ST
O
End IEP/EP/SP:
IDEA Ed Environment:
New
H
(student profile/ESE Details/State reporting)
IEP/EP/SP Manager:
Exceptionality
G
(same as Referral Date)
Service Plan:
Start IEP/EP/SP:
D
DISTRICT RECEIVED DATE:
Dismissal Reason:
IEP/EP/SP INFORMATION (student profile/ESE Details/IEP information)
B
YES
Permission Date:
Placement Consent Date:
(Use ONLY if dismissed from ALL ESE programs)
Dismissed Date:
NO
A
________________
__91 m____
__92 m____
__93 m____
(Student Profile/ESE/ESE Details/ESE Cost Factor/ADD)
(IEP Start Date)
Curriculum
Learning
Social Emotional
Independent
Functioning
Health Care
Communication
____________
__________
__________
__________
__________
__________
Special
Consider
+
Total
Ratings
=
_______
Cost Factor
_______
SPECIAL CONSIDERATIONS
ELIGIBLE FOR HOSPITAL/HOMEBOUND RECEIVING INDIVIDUAL INSTRUCTION…….……...…………………………….…..
13 Points
PRE-K SERVED IN HOME OR HOSPTIAL ON A ONE-TO-ONE BASIS ………………………………………………………….….…
13 Points
PRE-K STUDENT EARNING LESS THAN 0.5 FTE DURING AN FTE SURVEY PERIOD ….…………………………………………
3 Points
EXACTLY 17 (5 IN 3 DOMAINS and 1 IN REMAINING DOMAINS) OR EXACTLY 21 (5 IN 4 DOMAINS and 1 IN REMAINING DOMAIN)….
1 Point
ESE Minutes / SPECIAL EDUCATION PLACEMENT
SEP: (Circle one)
A
B
C
DO NOT COMPLETE THIS SECTION FOR GIFTED ONLY STUDENTS
Mins in School Week:
SPECIAL PROGRAMS Category (Student Profile/Special Programs/Local Programs)
Alternate Assessment (Alt Assess)
FIG - FCAT Ignore from Pregrid (Local Programs)
BIP – Behavior Intervention Plan (Local Programs)
FBA - Functional Behavior Assessment (Local Programs)
Test Accommodations(*Fed/ST Ind) Select one if applicable
FCAT/EOC Waiver
Content Area:
GRADUATE OPTION(Student Profile/General/Profile/Graduate Opt)
SD ES
3 Points
STUDENT IDENTIFIED AS VISUALLY OR DUAL-SENSORY IMPAIRED ……………………………………………………………
E2
Mins w/Non-Disabled:
Prior Program End date
C L
P
Q
R
U
New Start Date
Z
Meeting Date (if granted):
SPECIAL TRANSPORTATION (circle all that apply) (Student Profile/Busing/Transport)
ADD
B C
D
E
F
G
M
O
S
T
V
W
X
REMOVE B
C
D
E
End Date:
(no longer needs Special Transportation)
F
Date:
School Data Specialist:
Date:
Yellow: ESE Specialist or Guidance Counselor
G
M
O
S
T
V
W
X
__________________________
LEA:
White: School Data Specialist
(Student Profile/ESE/ESE Details/ESE Minutes/Edit)
XED0069 REV 1/2014
Directions for completing Data-Input Form – Exceptional Student Education
1. School- Enter Student’s current school number or name.
2. Work in Progress – Check box ONLY if the evaluation/reevaluation is not yet completed.
3. Student Placement Status – Circle the appropriate code related to the student’s placement. (see chart below)
I – Evaluated and Eligible
T – Transferred and Placed
R – Referred and Pending evaluation
P – Determined Eligible and Placed
N – Determined eligible and not placed
Z – Student dismissed from all ESE Programs
4. Type of Evaluation – indicate the type of evaluation: 4a. Initial Evaluation, 4b. Reevaluation, 4c. Transfer – Out of State transfer student
5. Referral Date – Date parent signed consent for the evaluation.
6. Evaluation Start –Date the last test is given.
7. Reevaluation - Enter the date that revaluation is due (no more than 3 years from evaluation start date.)
8. Eligibility Determination - The date the initial eligibility or ineligibility determination for ESE was made by the staffing committee.
9. Evaluation Completed - The date all applicable initial evaluation procedures are completed for the purpose of determining a student’s initial eligibility
for exceptional student education.
10. Referral Reason – Circle the appropriate code which gives the reason for which the initial student referral for exceptional education was made.
A - Academic
B - Behavior
D – Disabilities
G - Gifted
P - Pre-K
H - Health
O - Other
S - Speech
11. 60 Day Exception – (initial SLD only) Indicate whether an exception to the 60-day timeline for initial evaluation has been agreed on by the
parent and the LEA.
Exceptionality Key
12. Evaluation Permission –Indicate if the parent gave permission for Evaluation. Yes or No.
13. Permission Date – Indicate the date the parent gave permission for Evaluation.
1 - Speech Related Service
14. District Received Date – (Same as Referral Date) Date the parents signed consent.
2 - Language Related Service
15. Placement Consent Given – Indicate if the parent came permission for Placement. Yes or No.
3 - Orientation & Mobility
C - Orthopedically Impaired
16. Placement Consent Date – Indicate the date the parent gave permission for Placement.
D - Occupational Therapy
17. Dismissed Date –The date the student was found no longer eligible for ESE services.
E - Physical Therapy
18. Service Plan –Indicate if the student has a Service Plan.
F - Speech Impaired
18a Private School Name – Name of the Private School the student is attending.
G - Language Impaired
19. Start IEP - The date of the most recent IEP, EP or Services Plan.
H - Deaf/Hard of Hearing
20. End IEP - The date of the most recent IEP, EP, or Service Plan Expires.
I - Visually Impaired
21. IEP Manager – Indicate the IEP manager or person responsible for the IEP/ case due.
J - Emotional/Behavioral Disability
21a. Check box if IEP is amended. Comment: Amended IEP – Data Specialist will type comment into comment box.
K -Specific Learning Disabled
22. IDEA ED Environment Code – Indicate the educational environment in which a student with disabilities is served.
L - Gifted
Age 3-5 Years
M - Hospital/Homebound
J – Service Provider -student attends a public school
L –Special Ed Program - A student who attends an ESE
O - Dual-Sensory Impaired
site for only speech/language therapy or some
classroom for the majority of their day
P - Autism Spectrum Disorder
other related service such as OT, PT.
Q - Severely Emotionally Disturbed
K- Early Childhood - student who attends a public
M–Early Childhood/majority of services outside of Early
S - Traumatic Brain Injured
school site for VPK or KG or a Head Start or a
Childhood - student who is in a general education
ST - Special Transportation
T - Developmentally Delayed
privately owned PK who receives “push-in” ESE
classroom for the majority of the day but receives
V - Other Health Impaired
services for the majority of their ESE services.
“pull-out” services for the majority of ESE services
W - Intellectual Disabilities
A - Home
S – Student attends a school serving only disabled students
W1 - IND - Independent
Age 6-21 Years
W2 -IND - Supported
C – Corrections Facility
H – Home/Hospital
W3 -IND - Participatory
D – Private Separate Facility
P - Private School
91 -ESY Speech Related Srv
92 - ESY Language Related Srv
F – Public Separate Facility
Z – None of the above
93 - ESY Orientation and Mobility
23. ESY Service- Circle the appropriate letter to indicate whether or not a student is eligible to receive extended school
99 - ESY Services
year (ESY) services in accordance with the student’s individual educational plan (IEP). (See below)
9D - ESY Occupational Therapy
N The IEP team determined that ESY services were not necessary.
9E - ESY Physical Therapy
Y The student is eligible to receive extended school year services in accordance with an IEP team decision.
9F - ESY Speech Therapy
24. Exceptionalities /New – Indicate any/all exceptionalities the student has recently been found eligible and placed.
9G - ESY Language Therapy
25. Exceptionalities /Primary - Primary indicates that exceptionality which most affects the student’s ability to learn
9I - ESY Visually Impaired
25a. Other Exceptionalities- Indicate each exceptionality or related service beyond the primary exceptionality in which 9ST - ESY Specialized Trans
the student is placed.
26. Placement Status-Code defining the placement status of the student in ESE.
E - Evaluated and pending eligibility determination N - Determined eligible and not placed
R - Referred and pending evaluation
I - Evaluated and ineligible
P - Determined eligible and placed
T - Transferred and placed (out of state)
27. Dismissed- Date the student is found no longer eligible for the program.
28. Referral Date-The Date the initial referral for the Program was made.
29. Evaluation Completion- Date the initial referral for the Program was completed.
30. Eligibility- The date initially found eligible for the program.
31. Placed- The initiation date for services for the program.
32. Gifted Eligibility- Identify the eligibility criteria under which a student was found eligible for the gifted program.
A – IQ 130 or Higher
B – Low SES or LEP & Alt Elig Criteria
Z –Found Elig for Gifted Prior to July 1, 2009
33. Mins to/from- Indicate the minutes of service per week for therapy, vision, or related services.
34. Extended School Year Services – Date –Enter Date ESY Eligibility was determined.
35. ESY Services – Check only services to be provided during ESY.
36. Effective Date – Date of the most recent Matrix of service.
37. Domains – Indicate the appropriate number for each Domain according to the Matrix of Service.
Curriculum Learning
Social Emotional
Independent Functioning
Health Care
Communication
38. Special Considerations-Indicate any appropriate Special Consideration according to the Matrix of Service.
39. Total rating- Total Rating from Matrix of Service.
40. Cost Factor- Cost Factor based on level of services provided.
41. SEP- Indicate Placement based on amount of time Student is with General education students.
A – 80% or more with Gen Ed B – 41% - 79.99% with Gen Ed
C – 0% - 40.9% with Gen Ed
42. Mins in School Week-Total minutes of school week.
43. Minutes with Non-Disabled – Total minutes ESE student is with General Education Students during the school week.
44. a. Prior Program End Date –Enter the date the old plan will end.
44b. Program Begin Date - End the date the current plan begins.
Alternate Assessment, FIG-FCAT Ignore from Pre-grid, BIP – Behavior Intervention Plan, FBA – Functional Behavior Assessment
45. Test Accommodations
C Contracted Braille
P Paper-Based Test
R Reading Passage Booklet
L Large Print
Q Unique Accommodations
U Uncontracted Braille
46. FCAT/EOC Waiver
47. Graduate Option – Select the appropriate code for diploma track at the age of 14 or Eighth Grade.
48. Special Transportation.
B – Seat Belt D – Shortened Day
F – Reimburse Parent
M – Medical Condition S – Aide or Monitor W – Wheel Chair
C - Car Seat E – Medical Equipment G – Residence not in Zone
O – Out of District
V – Easy on Vest
X - Oxygen
T – Specialized Need other than Established
49. Add – Circle all Special transportation codes that apply.
50. Remove – circle all Special Transportation codes that should be removed from the students Record.
51. End Date – Date that the student is no longer eligible for specialized transportation.
White: School Data Specialist
Yellow: ESE Specialist or Guidance Counselor
XED0069 REV 1/2014