Change in Placement Request
Student: ____________________________ DOB: ________ Eligibility:_____________
Most Recent IEP Date: ______________ Most Recent MET Date: ____________
Grade: ____ District: _______________
Building: ______________________________
Teacher: _________________________ Phone: ___________Email Address: _______________________ Date: ______________
Special Ed. Administrator Signature: ___________________________________
Date: _________
Type of Classroom Change to Consider:
 ASD Classroom Offsite
 ASD Classroom Onsite
 ECSE Classroom at WEdge
 ECSE Classroom in local
 MoCI Classroom at WEdge
 SCI Classroom at WEdge
 Resource Room in local
 Other:
 Improved Social Skills
 Decline in Social Skills
 Improved Medical Status
 Declining Health
Reason for Request (Check any that apply):
 Academic Progress
 Lack of Academic Progress
 Improved Behavior
 Decline in Behavior
Student Profile
1. Strengths
2. Needs
3. Sensory Sensitivities
Sensitivities:
Sensory Tools:
4. Reinforcers (include specific
phrases used, if applicable)
5. Triggers (including specific
phrases, if applicable)
6. Safety/Supervision Needs
7. Communication Method
8. Medical/Health Concerns
9. Current Medications
10. Behavior of Concern
11. Current Student Eligibility
Category (e.g. ASD, MoCI)
Family Information
WoodsEdge Learning Center Change in Placement Request
Page 1
Mother’s Name/Address
Father’s Name/Address
Student Address/Phone
Parent Communication
Preferred Method:
Frequency:
Types of Information Parents Prefer:
Current Placement Information
General Education
Special Education Class
Paraprofessional Support
Special Ed. Services (OT, PT, Speech etc.)
Other Classes and Activities (e.g.
music therapy, adapted PE,
swimming, community based
instruction, school job)
Subjects:
Subjects:
Subjects:
Type:
Type:
Type:
Type:
Time:
Time:
Time:
Frequency:
Frequency:
Frequency:
Frequency:
Type:
Type:
Type:
Type:
Frequency:
Frequency:
Frequency:
Frequency:
Curriculum
Subject
Program/Instructional Method/Level of Progress
Grade Level or Functioning
Level
Reading
Math
Science
Social Studies
Writing
Life Skills/Functional
Social Skills
Modifications/Accommodations
WoodsEdge Learning Center Change in Placement Request
*Effectiveness Scale
1 = Absolutely necessary—do not remove
Page 2
2 = Necessary
3 = In place, not needed every day, but shouldn’t be removed
4 = In place, effectiveness undetermined
Modification
Describe how it is used/when
*Effectiveness
Accommodation
Describe
*Effectiveness
Prompting Level Needed for Common Activities
Activity
1 step directions
Navigating the
school building
Sitting during
instruction
Taking care of
personal needs
Navigating the
classroom
Bus to
classroom
Completing a
task
Prompting Type Needed (circle one for each activity)
State Frequency Range
(e.g. 3-5 prompts)
Verbal
Verbal
Visual
Visual
Partial Physical
Partial Physical
Full Physical
Full Physical
Verbal
Visual
Partial Physical
Full Physical
Verbal
Visual
Partial Physical
Full Physical
Verbal
Visual
Partial Physical
Full Physical
Verbal
Visual
Partial Physical
Full Physical
Verbal
Visual
Partial Physical
Full Physical
WoodsEdge Learning Center Change in Placement Request
Page 3
*Effectiveness Scale
1 = Absolutely necessary—do not remove
2 = Necessary
3 = In place, not needed every day, but shouldn’t be removed
4 = In place, effectiveness undetermined
Supports
Support
Visual/Communication
Describe how it is used/when
*Effectiveness
 Interactive Visual Schedule
 Work System
 First/Then visual
 PECS (include current phase)
 Augmentative Comm. Device
 Other
Sensory
 Sensory Tools
 Scheduled Breaks (school job
or other activity)
 Alert/Self-regulation Group
 Sensory Diet
 Other
Social
 Social Skills Stories
 Social Stories (Carol Gray)
 Social Skills Group
 Peer pairing/modeling
 Para Facilitator
 Other
Behavior
 Visual Rules
 Environmental Structure
 Token Economy
 Behavior Support Plan
 Other
Personal Care
 Toileting
 Feeding
 Positioning
 Other
Describe level of independence or support needed
WoodsEdge Learning Center Change in Placement Request
Page 4
Bathroom Independence
 Toilet trained
 Wears pull ups
 Wears diapers, needing an adult to change diaper
For each bathroom step, please circle the level of support most typically needed for this student:
Initiates
Door
Closed
I
G/V
PP
FP
R
I
G/V
PP
FP
R
Pants
Down
I
G/V
PP
FP
R
Sit /
Stand
I
G/V
PP
FP
R
Urinate
/
BM
I
G/V
PP
FP
R
Wipes
I
G/V
PP
FP
R
Pull-up:
Off
Pull-up:
On
I
G/V
PP
FP
R
I
G/V
PP
FP
R
Pants
Off
I
G/V
PP
FP
R
Pants
On
I
G/V
PP
FP
R
Pants
Up
I
G/V
PP
FP
R
Flush
I
G/V
PP
FP
R
Come
out
I
G/V
PP
FP
R
**Shaded areas are for pull-up wearers only
I – Independent
G/V – Gestural/Verbal Prompt
PP – Partial Physical Prompt
FP – Full Physical Prompt
R- Resistance / Refusal
Transportation
Does the student need special transportation? _______
Seating Placement Needs: _____________________________________ Special Equipment: _____________________
Medical Needs: _____________________________________________________________________________________
Other Needs: ______________________________________________________________________________________
How will we know the student is ready to return to a less restrictive placement (local)?
Please list up to 3 measurable goals, including criteria and how long it should be maintained before we consider the goal met and
call a team meeting to discuss possible change in placement. WoodsEdge staff will focus on improving these areas in order to
help the student be able to return to a less restrictive setting.
Goal
1.
2.
3.
WoodsEdge Learning Center Change in Placement Request
Criteria
How Long?
Page 5
Transition Information
(Students 16 and older)
Description of Work Experience
*Level of Support: 1 = Independent 2 = Passive Supervision Needed 3 = Frequent direction 4 = Full support for all work
Location
Job Duties
*Level of
Support
Preferred?
*Effectiveness Scale
1 = Absolutely necessary—do not remove
2 = Necessary
3 = In place, not needed every day, but shouldn’t be removed
4 = In place, effectiveness undetermined
Supports
Support
How Long?
Describe how it was used
WoodsEdge Learning Center Change in Placement Request
*Effectiveness
Page 6
Documents Included
All Referrals





Behavior Referrals (additional information needed)
Last 2 IEP’s (unless in TIENET)
Current MET (unless in TIENET)
Academic Assessments/Progress Graphs Attached
Current Report Card
Other: ___________________________________
 Transition Plan (16+)
 ESTR Assessment (16+)
 Work Experience Assessments (16+)









Last 2 FUBA’s
Last 2 BIP’s
Graphed data showing intervention change lines
Target behavior clearly defined
Copy of check sheet/token economy/behavior supports used
Signature of staff member submitting request: ___________________________ Date: ________
Title:____________________________
WoodsEdge Office Use Only:
Date Received: _________________
Local Special Education Administrator Contacted: ________________________
Administrator Contact Completed By: __________________________________
Date: _______________
 Approved to Proceed to Team Meeting
Questions for the Team:
Paperwork sent to:__________________________________________________________________________________
Change in Placement Team Decision:
Placement (per IEP): ________________________________________
Start Date: ______________________
Action Plan for Smooth Change in Placement (Completed by sending teacher with team)
Who
Does What
WoodsEdge Learning Center Change in Placement Request
By When
Page 7
Follow Up (To be completed after follow up observation/phone call)
Sending Teacher Follow Up Date: _____________________
 Observation
 Phone Call
Comments:
Sending Teacher Signature: ______________________________
WoodsEdge Learning Center Change in Placement Request
Date turned in to administrator: __________
Page 8