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Hernando County Schools Exceptional Student Education Data Entry Form
Student last name:
Student first name:
Birthdate:
Grade:
Student ID:
CASE
MGR
School:
COMPLETED BY
LEA:
NEW STUDENT and/or NEW EVALUATION:
Placement status:
Evaluation type:
Evaluation Start:
Evaluation Completed:
INITIAL CONSENT INFORMATION:
60 Day Exception/Extension:
Permission date:
Placement consent date:
IEP/EP START DATE:
EXCEPTIONALITY CODE
IEP/EP END DATE:
"X" IF
PRIMARY
CONSENT/
REFERRAL
DATE
ORIGINAL
EVALUATION
DATE
IEP/EP TYPE:
ELIGIBILITY
DATE
AGE 3-5 ENVIRONMENTAL
CODE
ASSESSMENT DATA ELEMENT
FOR GRADES 3-12 ONLY
TTSW
TNDP
COMPLETION DATE
PLACEMENT
DATE
DISMISSAL
DATE
INELIGIBILITY
DATE
DIPLOMA
OPTION
DISMISSAL REASON:
FEFP/COST FACTOR NUMBER
ESY
GIFTED ELIGIBILITY
3YR REEVAL DUE DATE:
TEST ACCOMMODATION
MEDICAID CONSENT
DISTRIBUTION:
11-2-20
1. COPY TO CINDY MORTON @ ESE
2. COPY PLACED IN STUDENT'S ESE FILE
3. COPY OF PRE-K TO LINDA KASZUBA AND NICOLE BENOIST