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