SPECIAL ED DATA FORM – Revised Oct 1, 2015
Teacher ____________________________________ Today’s date ____________________
ENTRY DATE _____________ EXIT DATE ___________ Exit code _______ Change (check here_____ Reason for
change____________
EXIT STATUS (Circle) DI = deceased; DO = dropped out; GC= graduated w/certificate; GD= Graduated with regular diploma; MA=reached
maximum age; MK= Moved, known continuing; RC= Returned to regular class PP= Parentally placed in private school.
Student ID # __________________________________ Social Security # __________________________________
Last name ____________________________________ First name _______________________________________
Sex ( M or F )
Birthdate ________________ Race ________ ELL (English Lang Learner) Y or N
(Ethnic codes –Code all that applies: H=Hispanic; N=Am Indian; A=Asian; B=Black or African Am; P=Native Hawaiian/Pac Islander; W=White
Building Elem/Jr. High/Sr. High ____________ Grade _______ Transfer ( Y or N )
Alternate Portfolio code ________ ALM (alt. lit/math..grades: 3,4,6,8 & 11 ) ALMS (Alt. Lit/Math/Sci (Grades: 5 & 7) NA Not applicable DLM
Delaying Alt. Lit/Math to Grade 11 (Grade: 9 only) SLDM Taking Alt. Sci.; delaying Alt. Lit/Math to Grade 11 (Grade: 10 only)
Medicaid eligible ( Y or N ) Medicaid # _______________________________
SECONDARY Transition Date ___________________________ (DONE @ ANNUAL REV. AT END OF 8TH GRADE/OR WHEN STUDENT IS 15
YEARS OLD
Referral Date ________________________ Person/Agency Referring ________________________________
Eligibility Det. Date _________________
(Original date decided to place)
date that changes)
Last Comp Eval Date ____________________
(Last eval was done/when re-eval is done this is the only
Annual Review date _________________
Temporary Student ( Y or N )
Extended year ( Y or N )
_____________________________________________________________________________________________________________________
_______________________
EDUCATIONAL PLACEMENT ______________ EDUCATIONAL PLACEMENT LAST YEAR _________________
SPECIAL ED PLACEMENT DATE __________________ (ORIGINAL date student was determined eligible for services and
placed.
(Educational Placement codes) DB=Day School-Public;HH=Hospital/Homebound; RB=Residentialpublic;RI=Residential-Private; CF=Correctional Facility;RR=Resource Room 421-1260 MW;RG=Regular
classroom 420 and less MW;SC=Self Contained 1261 and more MW;CF=Correctional Facility;
PP=Parentally Placed in Private school
PRIMARY DISABILITY _________________________ SECONDARY DISABILITY ____________________
(Primary Disability Codes: AU=Autism; DB=Deaf-Blindness; ED=Emotional Disturbance; HI= Hearing
Impaired; MD=Multiple Disabilities; MR=Intellectual Disability;
OHI=Other Health Impairment; OI=Orthopedic Impairments; SI=Speech/Language Impairments;
SLD=Specific Learning Disorder; TBI=Traumatic Brain Injury;
VI=Visual Impairments)
SPEECH……. Date speech entered ________________ Date terminated _______________
TIME SERVED unit (MW for Resource)__________ (MW for speech)_____________ Total minutes
served _____________