2111 Pontiac Lake Road
Waterford, MI 48328-2736
Telephone: 248.209.2049
Facsimile: 248.209.2474
http://www.oakland.k12.mi.us
Special Education
District Service Request
School Year: 2014 / 2015
Student Information
First Name:
Student UIC #:
District:
Last Name:
Date of Birth:
Date of IEP / IFSP:
Attending Building:
Contact Information
Contact Person:
Phone Number:
Title / Job Role:
Email:
Direct Services – Direct support for the implementation of IEP goals and objectives for low incidence disabilities
Service Type
Frequency
Duration
(Ex. 1-2x/month)
(Ex. 30-60 minutes)
Supplementary Aids / Services – Consultation services and materials to support the implementation of IEP for low incidence disabilities
Service Type
Frequency
Duration
(Ex. 1-2x/month)
(Ex. 30-60 minutes)
Context
OR
Evaluation – Participate with local district teams in evaluation activities
HI
TBI
VI
Psychiatric (Fee for Service)
Consent Date:
/
/
AT Consideration – Resulting in information for the local district team to consider
Alternative/Augmentative Communication
Hearing
Vision
Written Output (Due to Physical Limitations)
Central Coordination – Coordination of problem solving for students with complex needs and/or facilitation of accessing student placement
Problem Solving:
Individual Student
Program Level
Placement:
Integrated Program for All
Separate Program for All
Oakland Schools/Havenwyck Program
_____________________________________________________
_________________________________________________________________
District Special Education Director
Oakland Schools Supervisor
Date
Date
Fax with copies of required documentation (see checklist for required document) to: DSR Coordinator (248.209.2474)
Oakland Schools Feedback to Local Districts (Not Applicable to Central Coordination)
Status
Accepted
Accepted
Accepted
Accepted
Accepted
Service Type
Service Provider(s) Name
Comments
Rejected
Rejected
Rejected
Rejected
Rejected
Oakland Schools  Department of Special Education
08.19.14