E-09 (Rev 04/17/15) Capital Region ESD 113 Sound to Harbor Head Start/ECEAP Special Needs Concern (For Enrollment Only) The purpose of this form is to alert your Area Coordinator and Teachers of children coming into the program with a current IEP or of any child who is a concern for a suspected delay. Name of Child: HS/E Start Date: Parent/Guardian’s Name: Child’s DOB: Center: School District: Individual Education Program (IEP) A-77s signed by parent/guardian Parent/guardian brought in current IEP Staff requested IEP on this date: Out-of-state IEP Parent/guardian brought in current IEP Staff referred parent/guardian to local school district on this date: Staff requested IEP on this date: This child has need for a Special Placement Plan? Yes No Possible Interagency Referral Parent/guardian concern Staff concern Area of concern Communication Social, Behavior Motor Cognitive Comments: Routing: Email to your Area Coordinator and put a hard copy on green paper in the child/family file. Forms\Education\E-09 Special Needs Concern