DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
SCHOOL YEAR 2011-2012
OFFICE OF EARLY LEARNING AND SCHOOL READINESS
September 2011
Districts and ESCs both report for preschool special education state unit funding. Districts, ESCs, and county boards of
DD should establish mechanisms for sharing data to ensure consistency and accuracy. These forms are provided as a
communication tool for the preschool special education supervisor and the EMIS Coordinator to share critical
information. These forms do not represent all the information that needs to be reported in EMIS.
Included are forms for:
 Data Accuracy Checks for EMIS
 Business Rules for the Early Childhood Outcomes Summary Ratings
 Basic data for an eligible preschool child with a disability
 A Special Education Record for a preschool child with a disability
 A Special Education Record for child transferring into the district
 A Special Education Record for child being reevaluated for kindergarten transition
 Basic data for a child found to be ineligible during the evaluation process
 Basic data for a child transitioning from Help Me Grow who is not suspected of having a disability
 Basic data for a nondisabled peer enrolled in a preschool special education classroom
 Record keeping for assessments, such as Get It, Got It, Go! and Ages and Stages Questionnaire: Social-Emotional
for progress monitoring
 Record keeping for summarizing progress monitoring with the Early Childhood Outcomes Summary Form
 Documentation of transition activities for children from Help Me Grow
These forms may be used to document activities and information reported in the October K or the Yearend reporting
periods for EMIS.
October EMIS Reporting
 Eligible preschool children in the October (K) (that closed in January) data represent children enrolled as of
December 1.
 State preschool special education unit funding is based upon the data in October K Reporting period.
 The data from October K Reporting Period will also be used for the federal child count as of December 1.
Yearend EMIS Reporting
 EMIS information is also used in monitoring for compliance with federal and state regulations and a corrective
action plan may be required. Accuracy of data is a federal performance measure.
 EMIS now records changes over time so it is critical that EMIS be updated on a regular basis. October data
does not automatically transfer to the yearend reporting period. Districts must ensure that the yearend data
encompasses information for the entire year as this data is used for compliance determinations.
 These forms are not required unless ODE requires this documentation for corrective action.
Districts of residence report the special education record.
Districts of instruction (i.e. an ESC) report the assessment records.
Data is from June 1 through May 30.
Local decisions may be made as to the format and use of the forms unless required for corrective action. The general
data collection form for special education may also be used, as it includes preschool information as well.
Please refer to the EMIS Manual for additional information on data reporting. These forms are not intended to replace the
guidance provided in the manual.
PRESCHOOL SPECIAL EDUCATION EMIS
DATA ACCURACY CHECKPOINTS
This highlights the most common errors and does not represent all possible errors.
Data Points
Child Count
IEPs are current as of December 1
Any child with an SLD disability code is appropriately identified.
All preschool children with an IEP are reported, regardless of the type of services delivered.
If applicable, the district has obtained current and accurate data from the ESC or DD.
Unit Funding
IEPs are current as of December 1
Children are reported as 50% or 100% (half day or full day)
Children are “attached” to teachers.
Teachers with half day classes have a record for each class.
Teachers with more than one role have a record indicating centerbased and itinerant.
Related service staff members have a 99412 code to indicate preschool services.
All staff providing preschool special education services are listed on the report.
Transition from C to B
Children who only had a PSTC and are not suspected of having a disability are reported in the
aggregate and do not have a special education record.
Children who do not have an IEP by the 3rd birthday have a noncompliance code for the IETR or the
IIEP, or were ineligible for services.
When events cross school years and the child’s PSTC was in the spring and the child is three after the
end of the school year, all events are reported in the year in which the child received services.
The PSTC and referral date are equal.
For children who have a PSTC more than 90 days before the 3 rd birthday, a PR01 may have been
completed to conduct the evaluation at a later date but still have an IEP implemented by the 3 rd
birthday. This will be an error in EMIS for 2011-12 but records are available to document these
actions,
All children from HMG are represented with a special education record or in the aggregate. There are
no records (such as those out of compliance) that are not reported.
Children transitioning from HMG have the SSID as indicated on the quarterly report unless the district
assigned the number prior to the report; in cases where the district already assigned an SSID, the
district SSID is used. This discrepancy is reported to ODE as required.
Children referred from HMG 45 days or less before the 3 rd birthday meet the 120 day timeline for an
IEP.
There is a date or a code for every event on the special education record for PSTC, Referral, Consent,
ETR, IEP up to the point that the process was completed. (i.e. if at the ETR, the child is found
ineligible, the data ends with the ETR and there is no IIEP information).
LRE
The codes listed represent a child’s status as of 12/1
Separate school is used only for DD programs in which a child is in a setting in which there are no
nondisabled peers.
Children in a DD setting have the class composition considered to see if it is an EC (50/50) setting.
Assessment Records
Each child has a record for GGG.
Each child has a record for ASQSE.
Each child has a record for ECOSF.
Outcomes
Each child has a rating for each of the three outcomes.
The progress question is answered “yes” or” no” for each child who has an ECOSF for the second
time; this question is not answered for any first time summary report.
The first time the summary report is completed, the progress question is null.
The exit data is after the entry date.
There are no impossible rating combinations (see Business Rules)
Accurate
Needs
Reviewed
or Revised
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
BUSINESS RULES FOR EARLY CHILDHOOD OUTCOMES SUMMARY FORM REPORTING
Entry
Exit
Progress
OSEP
Category
Entry
Exit
Progress
OSEP
Category
Entry
Exit
Progress
OSEP
Category
Entry
Exit
Progress
OSEP
Category
1
1
y
b
3
1
y
b
5
1
y
b
7
1
y
b
1
2
y
c
3
2
y
b
5
2
y
b
7
2
y
b
1
3
y
c
3
3
y
b
5
3
y
b
7
3
y
b
1
4
y
c
3
4
y
c
5
4
y
b
7
4
y
b
1
5
y
c
3
5
y
c
5
5
y
b
7
5
y
b
1
6
y
d
3
6
y
d
5
6
y
d
7
6
y
e
1
7
y
d
3
7
y
d
5
7
y
d
7
7
y
e
1
1
n
a
3
1
n
a
5
1
n
a
7
1
n
a
1
2
n
Impossible
3
2
n
a
5
2
n
a
7
2
n
a
1
3
n
Impossible
3
3
n
Impossible
5
3
n
a
7
3
n
a
1
4
n
Impossible
3
4
n
Impossible
5
4
n
a
7
4
n
a
1
5
n
Impossible
3
5
n
Impossible
5
5
n
Impossible
7
5
n
a
1
6
n
Impossible
3
6
n
Impossible
5
6
n
Impossible
7
6
n
Impossible
1
7
n
Impossible
3
7
n
Impossible
5
7
n
Impossible
7
7
n
Impossible
2
1
y
B
4
1
y
b
6
1
y
b
2
2
y
B
4
2
y
b
6
2
y
b
2
3
y
C
4
3
y
b
6
3
y
b
2
4
y
C
4
4
y
b
6
4
y
b
2
5
y
C
4
5
y
c
6
5
y
b
2
6
y
D
4
6
y
d
6
6
y
e
2
7
y
D
4
7
y
d
6
7
y
e
2
1
n
A
4
1
n
a
6
1
n
a
2
2
n
Impossible
4
2
n
a
6
2
n
a
2
3
n
Impossible
4
3
n
a
6
3
n
a
2
4
n
Impossible
4
4
n
Impossible
6
4
n
a
2
5
n
Impossible
4
5
n
Impossible
6
5
n
a
2
6
n
Impossible
4
6
n
Impossible
6
6
n
Impossible
2
7
n
Impossible
4
7
n
Impossible
6
7
n
Impossible
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
(UNITS & FEDERAL REPORTING- OCTOBER K;; STATE REPORTING- YEAREND N)
Eligible preschool children in the October (K) data represent children enrolled as of December 1. State unit funding is based upon the data in October K Reporting period. EMIS
information is also used in monitoring for compliance with federal and state regulations and a corrective action plan may be required. Accuracy of data is a federal performance
measure. It is important to update district information at Yearend.
PRESCHOOL CHILD WITH A DISABILITY (PAGE 1)
DEMOGRAPHIC RECORD (GI)
Child’s First
Name
(GI330)
Child’s Last
Name
(GI350)
Child’s Middle
Name
(GI 340)
Gender
Male
Racial/Ethnic
Group (GI090)
H
W
B
Female
Hispanic/Latino
White (non-Hispanic)
Black or African America(non-Hispanic)
Date of Birth*
(GI070)
Native language
(GI270) [p 26 EMIS
Manual]
A
Asian
I
American Indian or Alaskan Native
P
Native Hawaiian or Pacific Islander
M
Multiracial
Legal District of
Residence/IRN
(FS150)
Sent to IRN
Autism Scholarship
(FS160)
(AU)
Attending an
MR/DD
Attending an ESC
MR/DD IRN
ESC IRN
Building of
Attendance/IRN
Teacher
*AGE Note: children are eligible for preschool special education services if they are: Age 4 or 5 as of the district’s cutoff entry date of
August 1st or September 30th OR Age 3 by December 1st.**If enrolled as of December 1, child is included in the October (K) reporting period
STUDENT STANDING (FS)
ELEMENT
ADMISSION DATE (FS070)
START DATE (FS060)
ADMISSION REASON
(FS080)
ATTENDANCE DAYS
(FS320)*
PERCENT OF TIME
(FS120)*
*Child Percent of Time





100%
100%
50%
50%
50%
DESCRIPTION
Does not change unless child
w/draws and re-enters
This date can change during
year if services change. This
date is the first contact and can
precede admission date. The
date of the PSTC may also be
this date.
Other codes in the EMIS Manual,
Chapter 2


4 Days/Week
5 Days/Week
Children receiving Itinerant
teacher services only are
reported at 50%
Related Services only
# Days in Operation
4 days/week (5 hrs or more/day)
5 full days/ week (5 hrs or
more/day)
4 half days/week
5 half days/week
Itinerant service –at least 1
hr/week
CODES
YYY/MM/DD:
YYY/MM/DD:

4-enrolling or the first time in
public school
 6-transferred from another
public school
4 Days/Week 100% of time = 144
days
5 Days/Week 100% of time = 180
days
1-19 hours
50%
0% time reported
Sum of Attendance + Absence
Days
4.0
5.0
2.0
2.5
At least 1.0
Updated on ___________ to
YYYY/MM/DD:
Updated on ___________ to
YYYY/MM/DD:

7- not newly enrolled in this
district
 2-transfer from out of
state/country
4 Days/Week 50% of time = 72
days
5 Days/Week 50% of time = 90
days
20+ hours
100%
Year End Sum of Attendance +
Absence Days
144
180
72
90
36
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
PRESCHOOL CHILD WITH A DISABILITY (PAGE 2)
STUDENT STANDING (FS)
ELEMENT
HOW RECEIVED (FS180)
WITHDRAWAL REASON
(FS100)
DESCRIPTION
How child arrived at district.
All codes listed in EMIS Manual,
Chapter 2.
Other codes in the EMIS Manual,
Chapter 2
CODES
 E- ECE ( formerly public
preschool grant)
 G- Federal Head Start
 36- withdrew from preschool

N-Other funding (catchall
category- most pscwd will be
coded N)
STUDENT ATTRIBUTE (FD OR FN) - FD REQUIRES A DATE; FN DOES NOT (FIST DAY FD ITEMS ARE VALID.)
OUTCOME CODES
ELEMENT
DESCRIPTION
DISABILITY CONDITION CODE

ET01-Multiple Disabilities (other than Deaf-Blind)
 ** No disability(FD130)

ET02-Deaf-Blindness






Typically Developing Peer
Note: The same codes are
reported as outcomes of the
evaluation team (ET) on the
special ed record. They are
reported there with a beginning
“ET.”
Date effective:
Updated:






GRADE LEVEL (FD080)
A child in kindergarten is a
school-age child and this
form is not used.
ATTENDANCE PATTERN
(FD100)
HOMELESS STATUS (FD150)
Children age 5 may be
served as a preschooler
or school-age child. No
kindergarten grade level
for preschool children
with disabilities.


NA
AS Alternative
Schedule
Child lacks a fixed regular
& adequate night-time
residence
LEP (LIMITED ENGLISH
PROFICIENCY) STATUS
(FD170)
MIGRANT (FD180)
GRADE LEVEL NEXT YEAR
(FN 080)
POVERTY LEVEL (FD120)
The disadvantagement level,
also reported on the student
demographic record, is
determined locally, by the
school district and is also
reported in EMIS.
ET03 -Deafness (Hearing Impairment)
ET04-Visual Impairments
ET05 -Speech and Language Impairments
ET06 -Orthopedic Impairments
ET08 -Emotional Disturbance (SBH)
ET09 -Cognitive Disabilities (Formerly Mental
Retardation or Developmentally Handicapped)
ET10 -Specific Learning Disabilities
ET12 -Autism
ET13 -Traumatic Brain Injury (TBI)
ET14 -Other Health Impaired (Major)
ET15 -Other Health Impaired (Minor)
ET16-Developmental Delay
IN- Infant/Toddler (0-2)
PS- Preschool (3-5)




FE- full day/every day
FO- full day/every other day
*
A
B
C
No
Yes
NA
Shelter
Unsheltered
Doubled-Up
No
Yes
** NA
IN- Infant/Toddler (0-2)
Parents are asked to
identify which category is
applicable based upon
federal poverty level
chart. The chart is
determined by the Federal
Poverty Guidelines not
free and reduced lunch.
Parent may choose not to
provide this information.
 A 1-100%
 B 101-125%
 C 126-150%
 D 151-175%
 E 176-185%
 F 186-200%
 G 201+%
HE-half day/every day
HO- half day/every other day
I
Motel/Hotel
LEP- Enrolled in US Schools
for first time
LEP-Trial Mainstream
PS- Preschool (3-5)
KG- Kindergarten
 N Not a preschooler
 P Parent income information
not requested or provided
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
PRESCHOOL CHILD WITH A DISABILITY (PAGE 3)
ELEMENT
STUDENT COURSE
RECORD (GN)
ONLY 2 ARE ALLOWED.
Itinerant teachers do
not have a course
record; they are
reported with a course
record 196095 and an
assignment area of
999412 Program code
220100 for child is
required.
DESCRIPTION
A child is not to receive both
preschool itinerant services and
centerbased preschool special
education. By the 2010-2011
school year, both codes will not
count toward dual unit funding
(October reporting); a child will be
counted only at 50% FTE and
funded accordingly.
The child is reported with a student
course record and a student
program record (requiring the
teachers state ID as well).
Children should not be coded with a
196095 and a program code of
220100 or the least restrictive
environment will be questioned.
CODES
Children receiving center-based
preschool special education
services are scheduled with a
local classroom code of a special
education teacher, a course
subject code of 196095, and
student population element of D8
or DP, Teachers have an
assignment area of 999412. This
applies to nondisabled peers as
well, regardless of the funding
source for the children; ECE
children enrolled as nondisabled
peers in a preschool special
education class have the same
codes.
COURSE
 196095- preschool special
education
OR
Itinerant Services
 Program Code 2201000
Student Population
 D8 or
 DP (class where all are
HH or VH)
Effective Date:
Change Date:
 A PRESCHOOL CHILD WITH A DISABILITY ENROLLED IN AN ECE ENTITLEMENT GRANT PROGRAM (TEACHER IS NOT A
SPECIAL EDUCATOR)
o How received code = E
o Course Code = 180108
o Itinerant code 220100 and/or related services codes
 AN ECE ENTITLEMENT GRANT NONDISABLED PEER ENROLLED IN A PRESCHOOL SPECIAL EDUCATION CLASSROOM
(TAUGHT BY SPECIAL EDUCATION PERSONNEL)
o How received code = E
o Course Code = 196095
 A NONDISABLED PRESCHOOL CHILD ENROLLED IN A PRESCHOOL SPECIAL EDUCATION CLASSROOM (TAUGHT BY SPECIAL
EDUCATION PERSONNEL)- ENROLLMENT SUPPORTED BY LOCAL FUNDS, TUITION, ANY OTHER FUNDING
o How received code = N (If the child is funded through federal Head Start, the code is G)
o Course Code = 196095
Building of Attendance/IRN
Local Class Code
Teacher
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
PRESCHOOL CHILD WITH A DISABILITY (PAGE 4)
PROGRAM RECORD (GQ)
EARLY CHILDHOOD SERVICE DELIVERY OPTIONS/LEAST RESTRICTIVE ENVIRONMENT(NEW DEFINITIONS for 2010-2011)
All Preschoolers with a disability must have only ONE of the following outcome codes on the special education record. This code does not apply
for nondisabled peer in the classroom. If a child spends ANY time in a regular early childhood program (district or community) where at least half
the enrollment consists of children without disabilities, the child must be entered with IE51, IE53 IE55, or IE56.
 IE60
Special Education Program –
 IE 51 Regular Education Early Childhood
 IE 53
Regular Education Early
Separate Class -A special
Program 10 or more hours per
Childhood Program Less than 10
week and receiving the majority
hours per week and receiving the
education program in which a
(more than 50%) of their special
majority (more than 50%) of their
child with a disability is in a class
education and related services in
special education and related
with less than 50% non-disabled
the general early childhood setting
services in the general early
students. Do not report if student
childhood setting
is also enrolled in a Regular Early
Childhood Program
 IE62
Special Education Program –
 IE 55 Regular Education Early Childhood
 IE 56
Regular Education Early
Separate School-A special
Program 10 or more hours per
Childhood Program Less than 10
week and receiving the majority
hours per week and receiving the
education program in which a
(more than 50%) of their special
majority (more than 50%) of their
child with a disability receives all
education and related services in
special education and related
of his/her special education and
some other location other than the
services in some other location
related services in an educational
general early childhood setting
other than the general early
program in public or private day
childhood setting
schools designed specifically for
children with disabilities. Do not
report if student is also enrolled in
a Regular Early Childhood
Program
 IE64
Special Education Program –
 IE70 Pre-School-Home  IE72
Service Provider Location
Residential Facility -A special
A program in which the child
A program in which a child with a
education program in which a
with a disability receives all of
disability receives all of his/her
child with a disability receives all
their special education and
special education and related
of his/her special education and
related services in the principle
services from a service provider
related services in a publicly or
residence of the child’s family or
and did not attend an early
privately operated residential
caregivers and who did not
childhood program or special
school or in a residential medical
attend an early childhood
education program provided in a
facility on an impatient basis.
program or a special education
separate class, separate school
Do not report if student is also
program provided in special
or residential facility. For
enrolled in a Regular Early
class, separate school, or
example, speech instruction is
Childhood Program
residential facility. Included are
provided in private clinicians’
children who receive special
offices, clinicians’ offices located
education BOTH at home AND
in school buildings, hospital
in a service provider location.
facilities on an outpatient basis,
libraries and other public
locations.
A CHILD SHOULD NOT BE REPORTED WITH BOTH CENTERBASED AND ITINERANT TEACHER SERVICES. LRE MUST BE DETERMINED.
PRESCHOOL ITINERANT SERVICES
 220100
Student receiving Preschool special education services from an itinerant teacher; this is not used for related services. (GQ070)
This should only be used for ECE Settings, Home or Service Provider Location. It can be used as a second form of service if child receiving
preschool special education in centerbased classroom but if it is LRE should be questioned. Dual enrollment is not a transition practice to
transition from one setting to another. If the child needs transition assistance from one setting to another, a transition plan should be
developed so the child only needs to deal with ONE type of setting.
RELATED SERVICES- Code APE and related services listed on the IEP. APE and related services funding is based upon the
number of children with these codes. Not for nondisabled peers.
 215001 Adaptive Physical Education
 215012
 215002 Aide Services
 215013
 215003 Attendant Services
 215004 Audiological Services
 215006 Interpreter Services
 215017
 215007 Medical Services
 215018
 215008 Occupational Therapy Services
 215009 Orientation and Mobility Services
 215020
 215010 Physical Therapy Services
 215021
 215011 Reader Services
 215022
 215023
 215026
 215027
School Psychological Services
Speech and Language Services
Parent Counseling and Training Services
Counseling Services
Recreational Services
Special Transportation
Social Work Services
Other:
School Health Services
School Nurse Services
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
SPECIAL EDUCATION DATE CODES - INITIAL ENROLLMENT OR TRANSITION FROM HELP ME GROW
Reporting Period
October (K)
Yearend (N)
From
6/1 of previous school year
6/1 of previous school year
To
December 1st of the current school year
5/31 of current school year
PSTC – Preschool Transition Conference Date The date of the transition conference that the School District is required to attend.
Invitation from Help Me Grow about a child transitioning from Part C to Part B Services. This element is required only for transitioning
preschool students, NOT to be used for reporting the completion of transition services for school-age children.
Year ________ Month______
Day______
ONLY record if the district was involved in the conference. If child came from another district, do NOT enter. ONLY use for children age 3.
1.
2. RFRL – Referral for Evaluation Date The date the PR04-Referral for Evaluation from is received by the District. This date should be
reported for all students referred for evaluation since the last reporting cycle..Year ________
Month______
Day______ Per
OSEP clarifications, December 2009, the PSTC is the referral date.
3. CNST – Parent/Guardian Consent for Evaluation Date The date the parent/guardian grants/refuses consent for evaluation, from
PR05-Parent Consent for Evaluation Part 1 (Grant Consent) or Part 2 (Refuse Consent). This element should be reported with an
Outcome ID to indicate status (e.g. Consent Granted, Consent Refused, etc.). Year ________
Month______
Day______
Outcome ID:
 CNGT – Consent Granted  CNRF – Consent Refused  CNNR - Consent Not Returned  CNDP - Consent moved to due process
4. IETR – Evaluation Team Report Completion Date-Initial The date the PR06-Evaluation Team Report is completed (from Part B,
PR06). This element should be reported with an Outcome ID to indicate status (e.g. Student was determined to be eligible for services;
Student was determined to NOT be eligible for services, etc.). If the Evaluation Team Report completion date does not meet compliance
standards, then a Non-compliance ID is required.
Year ________ Month______
Day______
Outcome ID:
 ETNE – Not eligible for Services  ETDP – ETR Resulted in Due Process  Exiting Special Education
 ET01-Multiple Disabilities (other than Deaf-Blind)
 ET09 -Cognitive Disabilities (Formerly Mental Retardation or
 ET02-Deaf-Blindness
Developmentally Handicapped)
 ET03 -Deafness (Hearing Impairment)
 ET10 -Specific Learning Disabilities
 ET04-Visual Impairments
 ET12 -Autism
 ET05 -Speech and Language Impairments
 ET13 -Traumatic Brain Injury (TBI)
 ET06 -Orthopedic Impairments
 ET14 -Other Health Impaired (Major)
 ET08 -Emotional Disturbance (SBH)
 ET15 -Other Health Impaired (Minor)
 ET16-Developmental Delay
Reason why event has not met federally mandated time lines (60 days from parent consent):
 ** Not Applicable
 06-Parent/Guardian Refused Consent
 01-No identified Reason
 07-Child’s Health
 02-Staff Not Available – Summer Months
 08-Student Incarceration
 03-Staff Not Available – School Year
 09-District in compliance with due process timelines, but
 04-Scheduling Conflicts with Family
incorrect/missing data reported in prior reporting period.
 05-Parental Choice
5. IIEP – Individualized Education Program (IEP) Completion Date-Initial The meeting date when the Individualized Education Program
was completed. From page 1, PR07-Individualized Education Program meeting date. If the Individualized Education Program completion
date does not meet compliance standards, then a Non-compliance ID is required. Year ________ Month______
Day______
Outcome ID:
IEP Complete – Not Served
IEP Complete Parental refusal
IEP Resulted in Due Process



IENS
IEPR
IEDP

IE51
Regular Early Childhood Program 10 or more
hours/week with special ed/related services in this setting
IE53
Regular Early Childhood Program less than 10
hours/week with special ed/related services in this setting
IE55
Regular Early Childhood Program 10 or more
hours/week with special ed/related services provided in some other
location








IE 56
Regular Early Childhood Program less than 10
hours/week with special ed/related services provided in some other
location
IE60
Special Education Program – Separate Class
IE62
Special Education Program – Separate School
IE64
Special Education Program – Residential Facility
IE70
Pre-School-Home
IE72
Service Provider Location
Reason why event has not met federally mandated time lines (90 days from parent consent):






** Not Applicable
01-No identified Reason
02-Staff Not Available – Summer Months
03-Staff Not Available – School Year
04-Scheduling Conflicts with Family
05-Parental Choice




06-Parent/Guardian Refused Consent
07-Child’s Health
08-Student Incarceration
09-District in compliance with due process timelines, but
incorrect/missing data reported in prior reporting period.
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
SPECIAL EDUCATION DATE CODES - RE-EVALUATION OR TRANSITION TO KINDERGARTEN
Reporting Period
October (K)
Yearend (N)
From
6/1 of previous school year
6/1 of previous school year
To
December 1st of the current school year
5/31 of current school year
6. RETR - Evaluation Team Report Completion Date-Reevaluation
The date the PR06-Evaluation Team Report is completed (from Part B, PR06). This element should be reported with an Outcome ID to
indicate status (e.g. Student was determined to be eligible for services; Student was determined to NOT be eligible for services, etc.). If the
Evaluation Team Report completion date does not meet compliance standards, then a Non-compliance ID is required.
Year ________ Month______
Day______
Outcome ID:
 ETDP – ETR Resulted in Due Process
 ETEX – Exiting Special education
Outcome ID:
 ETNE – Not eligible for Services  ETDP – ETR Resulted in Due Process  Exiting Special Education
 ET01-Multiple Disabilities (other than Deaf-Blind)
 ET09 -Cognitive Disabilities (Formerly Mental Retardation or
 ET02-Deaf-Blindness
Developmentally Handicapped)
 ET03 -Deafness (Hearing Impairment)
 ET10 -Specific Learning Disabilities
 ET04-Visual Impairments
 ET12 -Autism
 ET05 -Speech and Language Impairments
 ET13 -Traumatic Brain Injury (TBI)
 ET06 -Orthopedic Impairments
 ET14 -Other Health Impaired (Major)
 ET08 -Emotional Disturbance (SBH)
 ET15 -Other Health Impaired (Minor)
 ET16-Developmental Delay
Reason why event has not met federally mandated time lines:
 ** Not Applicable
 01-No identified Reason
 02-Staff Not Available – Summer Months
 03-Staff Not Available – School Year
 04-Scheduling Conflicts with Family
 05-Parental Choice




06-Parent/Guardian Refused Consent
07-Child’s Health
08-Student Incarceration
09-District in compliance with due process timelines, but
incorrect/missing data reported in prior reporting period.
7. RIEP – Individualized Education Program (IEP) Completion Date-Reevaluation
The meeting date when the Individualized Education Program was completed. From page 1, PR07-Individualized Education Program
meeting date. If the Individualized Education Program completion date does not meet compliance standards, then a Non-compliance ID is
required.
Year ________ Month______
Day______
If the IEP addressed the last part of the preschool year and the beginning of the kindergarten year, do not report as two separate IEPs. Report the preschool
information for the yearend and in October, report the override element to give the kindergarten LRE code.
Outcome ID:












IENS
IEPR
IEDP
IE51
IE53
IE55
IE 56
IE60
IE62
IE64
IE70
IE72
IEP Complete – Not Served
IEP Complete Parental refusal
IEP Resulted in Due Process
Regular Early Childhood Program 10 or more hours/week with special ed/related services in this setting
Regular Early Childhood Program less than 10 hours/week with special ed/related services in this setting
Regular Early Childhood Program 10 or more hours/week with special ed/related services provided in some other location
Regular Early Childhood Program less than 10 hours/week with special ed/related services provided in some other location
Special Education Program – Separate Class
Special Education Program – Separate School
Special Education Program – Residential Facility
Home
Service Provider Location
Reason why event has not met federally mandated time lines:
 ** Not Applicable
 01-No identified Reason
 02-Staff Not Available – Summer Months
 03-Staff Not Available – School Year
 04-Scheduling Conflicts with Family
 05-Parental Choice




06-Parent/Guardian Refused Consent
07-Child’s Health
08-Student Incarceration
09-District in compliance with due process timelines, but
incorrect/missing data reported in prior reporting period.
8. CIEP – IEP Consent with drawn by Parent
The date the Parent/Guardian withdraws consent for a previously written IEP that is still in effect.
Year ________ Month______
Day______
Outcome ID:
 ETDP – ETR Resulted in Due Process
 ETEX – Exiting Special education
Document1
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
SPECIAL EDUCATION DATE CODES - INITIAL ENROLLMENT FOR A TRANSFER INTO THE DISTRICT
Reporting Period
October (K)
Yearend (N)
From
6/1 of previous school year
6/1 of previous school year
To
December 1st of the current school year
5/31 of current school year
Note: Report outcome date- no new 3 year timeline begins. Re-eval based on date of original IEP.
PSTC – Preschool Transition Conference Date The date of the transition conference that the School District is required to attend.
Invitation from Help Me Grow about a child transitioning from Part C to Part B Services. This element is required only for transitioning
preschool students, NOT to be used for reporting the completion of transition services for school-age children.
Year ________
Month______
Day______
ONLY record if the district was involved in the conference. If child came from another district, do NOT enter. ONLY use for children age 3.
1.
2. RFRL – Referral for Evaluation Date The date the PR04-Referral for Evaluation from is received by the District. This date should be
reported for all students referred for evaluation since the last reporting cycle.Year ________
Month______
Day______ Per
OSEP clarifications, December 2009, the PSTC is the referral date.
3. CNST – Parent/Guardian Consent for Evaluation Date The date the parent/guardian grants/refuses consent for evaluation, from
PR05-Parent Consent for Evaluation Part 1 (Grant Consent) or Part 2 (Refuse Consent). This element should be reported with an
Outcome ID to indicate status (e.g. Consent Granted, Consent Refused, etc.). Year ________
Month______
Day______
Outcome ID:
 CNGT – Consent Granted  CNRF – Consent Refused  CNNR - Consent Not Returned  CNDP - Consent moved to due process
4. TETR – Evaluation Team Report Completion Date-Initial The date the PR06-Evaluation Team Report is completed (from Part B,
PR06). This element should be reported with an Outcome ID to indicate status (e.g. Student was determined to be eligible for services;
Student was determined to NOT be eligible for services, etc.). If the Evaluation Team Report completion date does not meet compliance
standards, then a Non-compliance ID is required.
Year ________ Month______
Day______
Outcome ID:
 ETNE – Not eligible for Services  ETDP – ETR Resulted in Due Process  Exiting Special Education
 ET01-Multiple Disabilities (other than Deaf-Blind)
 ET09 -Cognitive Disabilities (Formerly Mental Retardation or
 ET02-Deaf-Blindness
Developmentally Handicapped)
 ET03 -Deafness (Hearing Impairment)
 ET10 -Specific Learning Disabilities
 ET04-Visual Impairments
 ET12 -Autism
 ET05 -Speech and Language Impairments
 ET13 -Traumatic Brain Injury (TBI)
 ET06 -Orthopedic Impairments
 ET14 -Other Health Impaired (Major)
 ET08 -Emotional Disturbance (SBH)
 ET15 -Other Health Impaired (Minor)
 ET16-Developmental Delay
Reason why event has not met federally mandated time lines (60 days from parent consent):










** Not Applicable
01-No identified Reason
02-Staff Not Available – Summer Months
03-Staff Not Available – School Year
04-Scheduling Conflicts with Family
05-Parental Choice
06-Parent/Guardian Refused Consent
07-Child’s Health
08-Student Incarceration
09-District in compliance with due process timelines, but
incorrect/missing data reported in prior reporting period.
5. TIEP – Individualized Education Program (IEP) Completion Date-Initial The meeting date when the Individualized Education
Program was completed. From page 1, PR07-Individualized Education Program meeting date. If the Individualized Education Program
completion date does not meet compliance standards, then a Non-compliance ID is required.
Year ________ Month______
Day______
Outcome ID:




IE51
Regular Early Childhood Program 10 or more
hours/week with special ed/related services in this setting
IE53
Regular Early Childhood Program less than 10
hours/week with special ed/related services in this setting
IE55
Regular Early Childhood Program 10 or more
hours/week with special ed/related services provided in some
other location





IE 56
Regular Early Childhood Program less than 10 hours/week
with special ed/related services provided in some other location
IE60
Special Education Program – Separate Class
IE62
Special Education Program – Separate School
IE64
Special Education Program – Residential Facility
IE70
Home
IE72
Service Provider Location
Reason why event has not met federally mandated time lines (90 days from parent consent):





** Not Applicable
01-No identified Reason
02-Staff Not Available – Summer Months
03-Staff Not Available – School Year
04-Scheduling Conflicts with Family
Document1




05-Parental Choice
06-Parent/Guardian Refused Consent
07-Child’s Health
08-Student Incarceration
Child
School Year
2009-2010
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION

09-District in compliance with due process timelines, but
incorrect/missing data reported in prior reporting period.
PRESCHOOL CHILD WITH A DISABILITY
AUTISM SCHOLARSHIP PROGRAM
Child is reported with a disability code of 12 during October (K), December (M) and Yearend (N) reporting periods.
DEMOGRAPHIC RECORD (GI)
Child’s First
Name
(GI330)
Child’s Last
Name
(GI350)
Child’s Middle
Name
(GI 340)
Gender
Male
Racial/Ethnic
Group (GI090)
W
B
H
Female
White (non-Hispanic)
Black or African America(non-Hispanic)
Hispanic/Latino
Date of Birth*
(GI070)
Native language
(GI270) [p 26 EMIS
Manual]
A
Asian
I
American Indian or Alaskan Native
P
Native Hawaiian or Pacific Islander
M
Multiracial
Legal District of
Residence/IRN
Autism Scholarship
(FS150)
(AU)
*AGE Note: children are eligible for preschool special education services if they are: Age 4 or 5 as of the district’s cutoff entry date of
August 1st or September 30th OR Age 3 by December 1st.**If enrolled as of December 1, child is included in the October (K) reporting period
Data Element
Legal District of
Residence Element
Effective Date Elements
Report for Autism Scholarship Participants
Resident District IRN
If first attend ASP program in current school year, close out any open record for the
student and open a new record with an Effective Start Date of the first day the student is
in the ASP program.
How Received Element
How Received IRN
Sent Reason
Sent To IRN Element
IRN, if known, of entity providing services to student; otherwise 999999
Student Percent of Time
Element
Sent To Percent of Time Indicate the percent of time the student would be receiving instruction if he/she were
attending the resident district.
District Relationship
Element
Attendance Days
October (K) Count Week The number of days the student was enrolled in the district and
Elements
attending the Autism Scholarship Program (new open record) and/or your district during
October Count Week (record closed when student starts ASP).
Disability Condition
Element
Program Code Element
Code
School Year Only report the days that the student actually attended in your district, if any,
on the closed record. If the student attended the Autism Scholarship Program for the
entire year, the district is not required to report any attendance at yearend.
Usually 12 –but exceptions exist
Least Restrictive Environment (report one code for preschool students)-outcome of the
IEP code: IE 51, 53, 55,56, 60, 62, 64, 70, 72
Do not report any Related Service Codes
*
******
AU
000
3
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
NONDISABLED PEER ENROLLED IN PRESCHOOL SPECIAL EDUCATION UNITS (PAGE 1)
DEMOGRAPHIC RECORD (GI)
Child’s First Name
(GI330)
Child’s Last Name
(GI350)
Child’s Middle Name
(GI 340)
Date of Birth*
(GI070)
Native language
(GI270) [refer to EMIS Manual]
District of Residence/IRN
(GI100)
Male
Female
Legal District of Residence/IRN
(FS150)
Building of Attendance/IRN
Teacher
Attending an MR/DD
Attending an ESC
MR/DD IRN
ESC IRN
*AGE Note: children are eligible for preschool special education services if they are:
Age 4 or 5 as of the district’s cutoff entry date of August 1 st or September 30th OR Age 3 by December 1st
**If enrolled as of December 1, child is included in the October (K) reporting period
ELEMENT
DESCRIPTION CODES
W
White (non-Hispanic)
RACIAL/ETHNIC GROUP
A
Asian
B
Black or African America
(GI090)
I
American Indian or Alaskan Native
(non-Hispanic)
P
Native Hawaiian or Pacific Islander
H
Hispanic/Latino
M
Multiracial
STUDENT STANDING (FS)
ELEMENT
DESCRIPTION
ADMISSION DATE (FS070)
START DATE (FS060)
ADMISSION REASON
(FS080)
ATTENDANCE DAYS
(FS320)*
PERCENT OF TIME
(FS120)*
*Child Percent of Time





100%
100%
50%
50%
50%
HOW RECEIVED
(FS180)
WITHDRAWAL REASON
(FS100)
Document1
Does not change unless child
w/draws and re-enters
This date can change during
year if services change. This
date is the first contact and can
precede admission date. The
date of the PSTC may also be
this date.
Other codes in the EMIS
Manual, Chapter 2``
 4 Days/Week
 5 Days/Week
Children receiving Itinerant
teacher services only or related
services only are reported at
50%
# Days in Operation
CODES
YYY/MM/DD:
YYY/MM/DD:

4-enrolling or the first time in
public school
 6-transferred from another
public school
4 Days/Week 100% of time = 144
days
5 Days/Week 100% of time = 180
days

7- not newly enrolled in this
district
 2-tranfer from out of
state/country
4 Days/Week 50% of time = 72
days
5 Days/Week 50% of time = 90
days
1-19 hours
50%
Sum of Attendance + Absence
Days
4.0
5.0
2.0
2.5
At least 1.0
4 days/week (5 hrs or more/day)
5 full days/ week (5 hrs or
more/day)
4 half days/week
5 half days/week
Itinerant service –at least 1
hr/week
How child arrived at district.
All codes listed on page 52-53 of
the EMIS Manual, Chapter 2.
Other codes on page 40-41 of
EMIS Manual, Chapter 2
Updated on ___________ to
YYYY/MM/DD:
Updated on ___________ to
YYYY/MM/DD:



E- ECE (formerly public
preschool grant)
G- Federal Head Start
36- withdrew from preschool
20+ hours
100%
Year End Sum of Attendance +
Absence Days
144
180
72
90
36

N-Other funding
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
NONDISABLED PEER ENROLLED IN PRESCHOOL SPECIAL EDUCATION UNITS (PAGE 2)
STUDENT ATTRIBUTE (FD OR FN) - FD REQUIRES A DATE; FN DOES NOT
CODES
ELEMENT
DESCRIPTION
DISABILITY CONDITION

 ** No disability-Typically Developing Peer
CODE
(FD130)
Children age 5 may be served as a
GRADE LEVEL
preschool or school-age child. No
(FD080)
Infant/Toddler (0-2)
Preschool (3-5)
kindergarten grade level for
preschool children with disabilities.
ATTENDANCE PATTERN
(FD100)


HOMELESS STATUS
(FD150)
Child lacks a fixed regular &
adequate night-time residence
NA
AS – Alternative Schedule
LEP (LIMITED ENGLISH
PROFICIENCY) STATUS
(FD170)
MIGRANT (FD180)
GRADE LEVEL NEXT
YEAR (FN 080)
POVERTY LEVEL
(FS120)
The disadvantagement
level, also reported on
the student
demographic record, is
determined locally, by
the school district and is
also reported in EMIS.
ELEMENT
STUDENT COURSE
RECORD (GN)
IN


FE- full day/every day
FO- full day/every other
day
*
NA
A
Shelter
B
Unsheltered
No
Yes
No
Yes
** NA
IN- Infant/Toddler (0-2)
Parents are asked to identify which
category is applicable based upon
federal poverty level chart. The chart
is determined by the Federal Poverty
Guidelines not free and reduced
lunch. Parent may choose not to
provide this information. No
documentation is required to support
the parental report.
DESCRIPTION
Children receiving center-based
preschool special education services
are scheduled with a local classroom
code of a special education teacher,
a course subject code of 196095, and
a student population of D08, Teacher
s have an assignment area of
999412.
 A 1-100%
 B 101-125%
 C 126-150%
 D 151-175%
 E 176-185%
 F 186-200%
 G 201+%
CODES
Typically developing peers in a
preschool special education
classroom taught by a preschool
special education teacher are
scheduled in the same local
classroom code and a course
code of 196095
PS


HE-half day/every day
HO- half day/every other day
C
I
Doubled-Up
Motel/Hotel
LEP- Enrolled in US Schools for
first time
LEP-Trial Mainstream
PS- Preschool (3-5)
KG- Kindergarten
 P Parent refusal
Use only if not supported with
state funds OR a preschool child
with a disability in an ECE or PSE
CB class. (If child is reported with
ECE funding, poverty level must
be reported)

196095- preschool special
education
 D8 Subject population
Student population
 D8 OR
 DP
AND if funded with ECE-grant
funds:
 How received code of E
If not funded with ECE-grant
funds:
 How received code of N
A child dually enrolled in two preschool programs is required to be scheduled into both preschool courses and should have 2 student
course records reported.
Building of Attendance/IRN
Teacher
Local Class Code
Teacher Fund Source
Document1
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
Beginning in 2006-2007, all preschool children with disabilities have GGG & ASQSE scores reported regardless of the type of services provided. All
nondisabled peers enrolled in a state funded unit classroom have GGG scores reported, except for those in DD or ESC programs.
Child’s Name
Student ID#
IEP Begin Date
IEP End Date
ASSESSMENT RECORD
PRESCHOOL ASSESSMENT: GET IT, GOT IT, GO! (GGG)


October K Reporting Period
TEST DATE Year ________ Month______ Day______
Yearend Reporting Period
Duration of IEP (# of months): ___________________
 STR Standard
TYPE OF ASSESSMENT (GB215)
SCORE NOT REPORTED (GB235)



*
A
B
Not Applicable
Medical Reasons
Parent Refusal



C
D
F
Student Refusal
Suspension/Expulsion
Other than listed

L
Disability of deafness or blindness

J
Student moved in/out of district before
assessment administered
TYPE OF ACCOMMODATION (GO230)
** Not Applicable No No, child did not take test with accommodations
Y2
SCORE (GS240)
** Not Applicable
UNS
PNO
Parents request results not be reported to state
Yes, child took test with IEP
accommodations
Unable to answer sample items
Picture Naming Score(GB240)
Rhyming Score (GB250)
Alliteration Score (GB260)
(000-096)
(000-048)
(000-040)
ASSESSMENT RECORD
PRESCHOOL ASSESSMENT: ASQ:SE


October K Reporting Period
TEST DATE Year ________ Month______ Day______
Yearend Reporting Period
Duration of IEP (# of months): ___________________
All preschool children with disabilities and Early Childhood Education funding complete this record. The questionnaire is to be
done by staff with the parent.
TEST DATE (GS210)
Year ________ Month______
Day______
TEST SCORE (GS240) ___________________________ (000-0495)
Not Applicable PNO Parents request results not be reported to state
**
TEST LEVEL (GS200)
30
03
30 month form (27-34 months- only from Help Me Grow exit
score) (Score 000-435)
3 year form (33-41 months) (Score 000-465)
04
4 year form (42-53 months)(Score 000-495)
05
5 year form (54-65 months)(Score 0-495)
TYPE OF ASSESSMENT (GS215) STR Standard
SCORE NOT REPORTED (GB235)

*


A
B
Document1
Not Applicable

C
Student Refusal

OL
Child older than maximum age of 65
months
Medical Reasons
Parent Refusal


D
F
Suspension/Expulsion
Other (Reason not
listed)

J
Student moved in/out of district before
assessment administered
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
Beginning in 2006-2007, all preschool children with disabilities have GGG & ASQSE scores reported regardless of the type of services provided. All
nondisabled peers enrolled in a state funded unit classroom have GGG scores reported, except for those in DD or ESC programs.
Child’s Name
Student ID#
IEP Begin Date
IEP End Date
ASSESSMENT RECORD
EARLY CHILDHOOD OUTCOMES SUMMARY FORM (ECOSF)


October K Reporting Period
Yearend Reporting Period
Duration of IEP (# of months): ___________________
ASSESSMENT ELEMENT (GM 200)
E- POSITIVE SOCIAL-EMOTIONAL
SKILLS
K- ACQUIRING & USING KNOWLEDGE &
SKILLS
T-TAKING APPROPRIATE ACTION TO
MEET NEED
TEST DATE (GM 210)
TEST DATE (GM 210)
TEST DATE (GM 210)
Year ______ Month_____ Day______
Year ______ Month_____ Day______
Year ______ Month_____ Day______
PROGRESS ELEMENT (GM 245)
Progress Element (GM 245)
Progress Element (GM 245)





* - NA-Not
applicable –
child not
assessed
F- First
assessment
(can be used
only once) so
progress not
noted

N- Child has not
shown any new
skills or
behaviors
Y- Child has
shown new
skills or
behaviors


* - NA-Not
applicable –
child not
assessed
F- First
assessment
(can be used
only once) so
progress not
noted

N- Child has not
shown any new
skills or
behaviors
Y- Child has
shown new
skills or
behaviors


* - NA-Not
applicable –
child not
assessed
F- First
assessment
(can be used
only once) so
progress not
noted

N- Child has not
shown any new
skills or
behaviors
Y- Child has
shown new
skills or
behaviors
SCORE NOT REPORTED (GM235)
SCORE NOT REPORTED (GM235)
SCORE NOT REPORTED (GM235)


















* Not Applicable
A Medical Reasons
B Parent Refusal
D Suspension/Expulsion
F Other (reason not listed)
J Student moved in or out of district
before summary completed
* Not Applicable
A Medical Reasons
B Parent Refusal
D Suspension/Expulsion
F Other (reason not listed)
J Student moved in or out of district
before summary completed
* Not Applicable
A Medical Reasons
B Parent Refusal
D Suspension/Expulsion
F Other (reason not listed)
J Student moved in or out of district
before summary completed
TEST TYPE (GM215) STR Standard
TEST TYPE (GM215) STR Standard
TEST TYPE (GM215) STR Standard
SCORE (GM240)
Circle One
1 2 3
SCORE (GM240)
Circle One
1 2 3
SCORE (GM240)
Circle One
1 2 3
4
5 6
7
4
5 6
7
4
5 6
7

*
NA-Not applicable – child not
assessed

*
NA-Not applicable – child not
assessed

*
NA-Not applicable – child not
assessed

P
Parents requested results
not reported to state

P
Parents requested results
not reported to state

P
Parents requested results
not reported to state
Document1
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
TRANSITION FROM PART C-DOCUMENTATION OF DATES AND ACTIVITIES
District
Child
Child DOB
Initial Awareness of the Child and Family
Actual Date:
Can occur 12 months prior to the third birthday. The source may be the quarterly report from HMG to district.
Comment:
Preparation for Transition Conference
Actual Date:
Can occur nine months prior to the third birthday. HMG Service Coordinator works with the family to determine if the district will be included
in the Transition Conference. HMG gathers information for records review and with parent consent shares them with the district.
Comment:
Records Review
Actual Date:
Can begin nine months prior to the third birthday. District decides what additional data is needed to determine if a disability is suspected.
Comment:
Transition Conference (District is required to attend under PL 108-446 IDEA.)-PSTC
Actual Date:
No later than 90 days and no sooner than 9 months prior to third birthday. May be less than 90 days for children entering HMG 90 to 46
days prior to third birthday. If the child is not suspected of having a disability then the PR-01 form is provided to the family. (EMIS Entryaggregate of those not suspected of having a disability-see form for district information)
Comment: 90 days or more prior to third birthday? Yes  No 
PR-01 Form completed? Yes  No 
Referral for Evaluation Date (PR-04 Form)-RFRL (equals the PSTC date)
Actual Date:
If a disability is suspected, the PR-04 is signed. The date the district signs the PR-04 this is same date as the Transition Conference. The
district may choose to have parents sign the PR-05 form at the same time the PR-04 is signed, which may be at the Transition Conference.
If the PR-05 is not signed, then there should be a discussion of when it will be signed.
Comment: Disability suspected? Yes No
Parent/Guardian Consent For Evaluation Date (PR-05Form)-CNST
Actual Date:
90 days prior to third birthday or less for children entering HMG 90-45 days prior to the third birthday. The date the PR-05 is signed/or not
signed by parent. EMIS Outcomes:
Granted
Refused (Document parent refusal with PR-O1 or letter from parent)
Not returned
Moved to Due Process
Comment:
Evaluation Team Report to Determine Eligibility-IETR
Actual Date:
Completed no later than 60 days after parental consent or less for children entering HMG 90-45 days prior to the third birthday. EMIS
Outcomes: Eligible Disability Code: _____________ Due Process Not Eligible Evaluation delayed with parent consent until
child is at least 2 yr. 6 mos. (PR-01)
60 days prior to third birthday? Yes No If no, non-compliance ID required. If child not eligible: Document with PR-01.
Comment:
IEP Completed-IIEP
Actual Date:
No later than 30 days after eligibility is determined. On/before child’s third birthday? Yes No
If no, why not? Staff not available-summer  Staff not available-school year  Schedule conflicts with family
 Parent choice Refused consent  Child’s health
Provided within 30 days of third birthday Yes No
Number of days past third birthday__________
Comment:
Documentation will be required to verify compliance. This is a sample form to assist LEAs but is not required. The LEA may modify it to fit local needs and if
additional information is desired.
Document1
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
PRESCHOOL CHILD INELIGIBLE FOR SERVICES
SCENARIO I: PRESCHOOL CHILD REFERRED FOR PRESCHOOL SPECIAL EDUCATION, EVALUATED AND FOUND INELIGIBLE
Once a child is referred, demographic information must be entered and the “how received” code is V
.
Child’s First Name
(GI330)
Child’s Last Name
(GI350)
Child’s Middle Name
(GI 340)
Date of Birth*
(GI070)
Native language
Male
Female
(GI270) [p 26 EMIS Manual]
A
Asian
W
White (non-Hispanic)
I
American Indian or Alaskan Native
B
Black or African America(non-Hispanic)
Racial/Ethnic
P
Native Hawaiian or Pacific Islander
H
Hispanic/Latino
Group (GI090)
M
Multiracial
District of Residence/IRN
(GI100)
*AGE Note: children are eligible for preschool special education services if they are:
Age 4 or 5 as of the district’s cutoff entry date of August 1 st or September 30th OR Age 3 by December 1st
**If enrolled as of December 1, child is included in the October (K) reporting period
Enroll using date of ETR for effective start and effective end; Percent of Time is 0.
1. PSTC – Preschool Transition Conference Date The date of the transition conference that the School District is required to attend.
Invitation from Help Me Grow about a child transitioning from Part C to Part B Services. This element is required only for transitioning
preschool students, NOT to be used for reporting the completion of transition services for school-age children.
Y
ear ________
Month______
Day______
ONLY record if the district was involved in the conference. If child came from another district, do NOT enter. ONLY use for children age 3.
2. RFRL – Referral for Evaluation Date The date the PR04-Referral for Evaluation from is received by the District. This date should be
reported for all students referred for evaluation since the last reporting cycle. Year ________
Month______
Day______
3. CNST – Parent/Guardian Consent for Evaluation Date The date the parent/guardian grants/refuses consent for evaluation, from
PR05-Parent Consent for Evaluation Part 1 (Grant Consent) or Part 2 (Refuse Consent). This element should be reported with an
Outcome ID to indicate status (e.g. Consent Granted, Consent Refused, etc.). Year ________
Month______
Day______
Outcome ID:
 CNGT – Consent Granted  CNRF – Consent Refused  CNNR - Consent Not Returned  CNDP - Consent moved to due process
4. IETR – Evaluation Team Report Completion Date-Initial The date the PR06-Evaluation Team Report is completed (from Part B,
PR06). This element should be reported with an Outcome ID to indicate status (e.g. Student was determined to be eligible for services;
Student was determined to NOT be eligible for services, etc.). If the Evaluation Team Report completion date does not meet compliance
standards, then a Non-compliance ID is required.
Year ________ Month______
Day______
Outcome ID:
 ETNE – Not eligible for Services  ETDP – ETR Resulted in Due Process
 ETEX - Exiting Special Education
Reason why event has not met federally mandated time lines (60 days from parent consent):
 ** Not Applicable
 05-Parental Choice
 01-No identified Reason
 06-Parent/Guardian Refused Consent
 02-Staff Not Available – Summer Months
 07-Child’s Health
 03-Staff Not Available – School Year
 08-Student Incarceration
 04-Scheduling Conflicts with Family
 09-District in compliance with due process timelines, but
incorrect/missing data reported in prior reporting period.
5. CIEP – IEP Consent with drawn by Parent
The date the Parent/Guardian withdraws consent for a previously written IEP that is still in effect.
Year ________ Month______
Day______
Outcome ID:
 ETDP – ETR Resulted in Due Process
Document1
 ETEX – Exiting Special education
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
PRESCHOOL CHILDREN INELIGIBLE FOR SERVICES
 SCENARIO II: CHILDREN FROM HELP ME GROW/PART C/EARLY INTERVENTION WHO HAVE A PSTC BUT ARE
NOT SUSPECTED OF A DISABILITY. RECORD THE AGGREGATE OF ALL CHILDREN IN EMIS. DOCUMENT WITH A
PR01 FORM.
For children with only a PSTC and no referral/evaluation, there is no demographic record and no “how received” code.
Child’s First Name
(GI330)
Child’s Last Name
(GI350)
Male
Female
Racial/Ethnic
Group (GI090)
W
B
H
Child’s Middle Name
(GI 340)
Date of Birth*
(GI070)
Native language
(GI270) [p 26 EMIS Manual]
A
Asian
White (non-Hispanic)
I
American Indian or Alaskan Native
Black or African America(non-Hispanic)
P
Native Hawaiian or Pacific Islander
Hispanic/Latino
M
Multiracial
District of Residence/IRN
(GI100)
☼ Preschool Transition Conferences Held After 3rd Birthday No Disability Suspected Element
Record Field Number DR750
Count of preschool transition conferences
 Check if
(PSTC) for students potentially moving from Part C to Part B special
applicable
education services where a decision was made at the PSTC that no
disability was suspected and where the district will not pursue
additional evaluation of the child. The PSTC occurred after the child’s
3rd birthday.
Valid Options
000 – 999
Reporting Instructions. This element is reported by city, local, and exempted village school districts and represents
a final headcount as of the district’s yearend (July 1 to June 30).
☼ Preschool Transition Conferences Held By 3rd Birthday No Disability Suspected Element
Record Field Number DR740
Count of preschool transition conferences (PSTC) for students
 Check if
potentially moving from Part C to Part B special education services
applicable
where a decision was made at the PSTC that no disability was
suspected and where the district will not pursue additional evaluation of
the child. The PSTC occurred by the child’s 3rd birthday.
Valid Options
000 – 999
Reporting Instructions. This element is reported by city, local, and exempted village school districts and represents
a final headcount as of the district’s year end (July 1 to June 30).
Document1
Child
School Year
2011-2012
Copies: EMIS Coordinator, Student File
DATA COLLECTION FORM FOR PRESCHOOL SPECIAL EDUCATION
Preschool Transition Conference (PSTC)
Optional Form
Child’s Name
Child’s Date of Birth
District
Date of Transition Conference
Location of Transition
Conference
The result of the conference is:




Referral (Attach PR04)
Parent Consent (Attach PR05)
PR-01- No suspected disability (Attach PR01)
PR-01- Delay date for evaluation (Attach PR01)
Signatures documents (for audit purposes) that the district representative attended the
Preschool Transition Conference.
Print Name
District
Representative
HMG Service
Coordinator
Parent
Other Attendees:
Document1
Signature
Date