DESERT/MOUNTAIN SPECIAL EDUCATION LOCAL PLAN AREA (CODE 3601)
DESERT/MOUNTAIN CHARTER SPECIAL EDUCATION LOCAL PLAN AREA (CODE 3651)
17800 HIGHWAY 18 • APPLE VALLEY, CA 92307 • (760) 552-6700
Individualized Family Service Plan
Individualized Education Program
Individualized Services Plan
Not Eligible
Eligible No Plan Parentally Placed in Private School
Eligible No Plan Other Reasons
DATE:
PURPOSE OF MEETING
Eligibility / Initial Placement
Transfer Placement
SELPA Code
Annual
Triennial
D/M 119
Regional
Completed
Other:
STUDENT INFORMATION:
Last:
First:
Middle Initial:
DOB:
Age:
Student No:
Gender:
M
F
Grade:
Ethnicity: Select one only
YES, Hispanic or Latino OR
NO, not Hispanic or Latino
Indicate one or more race(s) below:
(1)
(2)
(3)
Medi-Cal Eligible:
Yes
No
Medi-Cal No.:
SSID No.:
Parent/Guardian/Surrogate:
Home Phone:
Address:
Work Phone:
Mailing Address:
Emg. Phone:
Student’s Address (if different):
Residency Code:
District of Residence:
School of Residence:
District of Service:
Attending School:
School Type Code:
Weekly % of Time the Student is in the General Education Setting:
Infant Setting (Ages 0-2):
Preschool Setting (Ages 3-5):
School Age Setting (Ages 6-22):
DISABILITY:
Check all that apply below and indicate the Primary and
Secondary Disability Codes in the space provided.
Intellectual Disability (210)
Hard of Hearing (220)
Visual Impairment (250)
Emotional Disturbance (260)
Est. Med. Disability (281)
Spec.Learning Disability (290)
Autism (320)
Traumatic Brain Injury (330)
PRIMARY DISABILITY:
SECONDARY DISABILITY:
Deafness (230)
Orthopedic Impairment (270)
Deaf / Blindness (300)
Speech / Lang. Imp. (240)
Other Health Imp. (280)
Multiple Disabilities (310)
TIMELINE INFORMATION (DATES)
Please mark the appropriate box and complete all information as they relate to the child.
CHECK HERE IF INFANT (AGE 0-2)
Provider:
EXTENT OF PARTICIPATION IN NEXT STATEWIDE ASSESSMENT PROGRAM - *COMPLETE AND ATTACH FORM D/M 68L - TESTING ACCOMMODATIONS
CAHSEE:
CELDT:
10 - CAHSEE/CST-SCIENCE WITHOUT TESTING ACCOMMODATIONS
11 - CAHSEE/CST-SCIENCE WITH TESTING ACCOMMODATIONS *
12 - CAHSEE WITH TESTING MODIFICATIONS *
20 - CMA-SCIENCE WITHOUT TESTING ACCOMMODATIONS
ELA - READING:
CHECK HERE IF CHILD IS AGE 3-22
Referred by for Initial Assessment:
Date District Received Signed AP:
Initial Referral Date:
Initial IEP Meeting Date:
Pre-referral Intervention w/in last 2 Years:
Yes
No
If assessment not completed prior to student’s 3rd birthday, specify Code No.:
If assessment not completed within 60-day timeline, specify Code No.:
Low Incidence Disability:
Yes
No
Disability Code:
220
230
250
270
300
Original S.E. Entry Date:
Exit S.E. Date:
Exit S.E. Code:
Current Annual Date:
Next Plan Review Date:
Current Triennial Date:
Next Triennial Date:
Early Start Transition Plan Meeting Date:
Home Language Code:
English Language Learner:
Yes
No
Migrant:
Yes
No
Extended School Year:
Yes
No
No. of Days:
Agency Services:
CCS
Rehab
DMCC
Reg. Ctr.
Other:
Severe Disability
Non-severe Disability
Solely Low Incidence Disability (0-2 Years Only)
GRADUATION INFORMATION
Participate in High School Curriculum to Graduate with a Diploma:
Yes
No
High School Program Leading to a Certificate of Completion
Yes
No
SPECIAL TRANSPORTATION INFORMATION
Check if student requires special transportation arrangements to participate in special education services.
Eligible (indicate type and provider)
Eligible – Parent Declined
Not Eligible
Type:
ELA - WRITING:
21 - CMA-SCIENCE WITH TESTING ACCOMMODATIONS *
30 - PARTICIPATE IN CAPA
40 - CAASPP WITH UNIVERSAL TOOLS, DESIGNATED SUPPORTS, ACCOMMODATIONS *
50 - CAASPP WITHOUT DESIGNATED SUPPORTS, ACCOMMODATIONS
DRDP TYPE:
ELA - LISTENING:
MATHEMATICS:
60 - CELDT WITH TESTING ACCOMMODATIONS
70 - CELDT WITHOUT TESTING ACCOMMODATIONS
80 - NOT TO PARTICIPATE (STUDENT PASSED BOTH SUBTESTS OF CAHSEE)
90 - NOT TO PARTICIPATE (STUDENT OUTSIDE TESTING GROUP OR ON AN ISP)
SPECIFY RATIONALE FOR ADMINISTRATION OF ALTERNATE ASSESSMENT:
SPECIAL EDUCATION AND RELATED SERVICES
SERVICE (CODE NO.)
CLASS
NO.
PROVIDER
LOCATION OF SERVICE (CODE NO.)
PROJECTED
START DATE
FREQUENCY
(CODE NO.)
DURATION (MINUTES PER
FREQUENCY)
Primary
2
3
4
5
6
7
NOTE: Programs and services will be provided according to where the student is in attendance and consistent with the district of service calendar and scheduled services, excluding holidays, vacations, and non-instructional days unless otherwise specified.
COMMENTS:
D/M 68A Rev. 08/14
Page 1 of ____
Ages 0-2 Only
100 Home
200 Community
Based Setting
900 Other Setting
FEDERAL PROGRAM LOCATION OF SERVICES
Ages 3-5 Only
Ages 6-22 Only
400 Regular Early Childhood
Program or Kindergarten
400 Regular Classroom
(50-69% nondisabled children)
Public Day School
410 Regular Early Childhood
450 Separate School
Program or Kindergarten
460 Residential Facility
(70%+ nondisabled children)
470 Homebound/Hospital
440 Separate Class
480 Correctional Facility
450 Separate School
490 Parentally Placed in
460 Residential Facility
Private School
470 Home
475 Service Provider Location
SPECIAL EDUCATION AND RELATED SERVICES (3-22 YEARS)
330 Specialized Academic Instruction
715 Interpreter Services
340 Intensive Individual Services
720 Audiological Services
350 Individual & Small Group Instr. (ages 3-5)
725 Specialized Vision Services
only) Individual & Small Group Instr. (ages 6+)
355
730 Orientation & Mobility
415 Language & Speech
735 Braille Transcription
417 SELPA/DMCC Speech
740 Specialized Orthopedic Services
425 Adapted Physical Education
745 Reader Services
435 Health & Nursing – Specialized Physical
750 Note Taking Services
Health Care Services
755 Transcription Services
436 Health & Nursing – Other Services
760 Recreation Services includes
445 Assistive Technology Services
Therapeutic Recreation
450 Occupational Therapy
820 College Awareness
460 Physical Therapy
840 Career Awareness
510 Individual Counseling
850 Work Experience Education
515 Counseling & Guidance
855 Job Coaching (includes job
520 Parent Counseling
shadow and service learning)
525 Social Work Services (DMCC)
860 Mentoring
530 Psychological Services
865 Agency Linkages (referral and
535 Behavior Intervention Services
placement)
540 Day Treatment Services
870 Travel Training (includes
545 Residential Treatment Services
Mobility training)
550 Residential Monitoring (DMCC)
890 Other Transition Services
610 Specialized Services for Low
900 Other Special Education/Related
Incidence Disabilities
Services
710 Specialized Deaf and Hard of
901 Transportation
Hearing
INFANT RELATED SERVICES (AGES 0-2 YEARS)
210 Family Training, Counseling, and
250 Special Instruction
Home Visits
260 Special Education Aide in
220 Medical Services (evaluation only)
Regular Dev. Class Child Care
230 Nutrition Services
Center or Facility Child Care Home
240 Service Coordination
270 Respite Care Services
REASON FOR EXITING SPECIAL EDUCATION
70 Returned to General Education or No Longer Eligible for Special Education or
Successful Completion of IEP/IFSP/ISP
71 Graduated from High School with Diploma
72 Graduated from High School with Certificate of Completion or Other than Diploma
73 Reached Maximum Age
74 Dropped Out, includes Attempts to Contact Unsuccessful or Not Known to be
Continuing
76 Moved, and Known to be Continuing, includes Transfer to Another Program
77 Deceased
78 Parent Withdrawal/Self Withdrawal if over 18 (includes parent revocation of consent)
81 Received High School Completion/Achievement Certification through General
Educational Development (GED) or Requirements of E.C. 56390
82 Graduated from High School with a Diploma using Exemption authorized by E.C. 60852.3(c)
83 Graduated from High School with a Diploma using Waiver authorized by E.C. 60851(c)
D/M 68A Rev. 08/14
LOCATION OF SERVICES
540 Separate School or Special Education
Center or Facility
550 Public Residential Facility
560 Other Public School or Facility
570 Charter School (operated by an LEA/District)
580 Charter School (operated as an LEA/District)
610 Continuation School
620 Alternative Work Education Center/Work
Study Facility
630 Juvenile Court School
640 Community School
650 Correctional Institution or Facility
210 Home Instruction Based on IEP
Team Determination (not medical)
220 Hospital
310 Head Start Program
320 Child Development or Child Care Facility
330 Public Preschool
340 Private Preschool
350 Extended Day Care
360 Residential Facility
510 Regular Classroom/Public Day School
520 Separate Classroom in Public
Integrated Facility
530 State Special School
District of Services
County Office of Education
SELPA
Another District, County or SELPA
WorkAbility
Transition Partnership Program
Regional Center
Alcohol and Drug Prevention Program
240
250
300
310
320
330
340
400
00
10
11
15
19
24
30
31
No School (0-5 Only)
Public Day School
Public Residential School
Special Educ. Center or Facility
Other Public School or Facility (such as
a store-front transition program)
Continuation School
Alternative Work Education Center/Work
Study Program
Independent Study
Juvenile Court School
Community School
SCHOOL TYPE (WHERE ENROLLED)
32 Correctional Institution or Incarcerated Facility
40 Home Instruction Based on IEP Team
Team Determination
45 Hospital Facility
50 Community College
51 Adult Education Program
55 Charter School (operated by an LEA/District/
COE)
56 Charter School (operated as an LEA/District)
61 Head Start Program
62 Child Development or Child Care Facility
63 State Preschool
00
01
02
03
04
05
06
07
08
09
English
Spanish
Vietnamese
Cantonese
Korean
Filipino (Tagalog)
Portuguese
Mandarin (Putonghua)
Japanese
Khmer Cambodian
10
11
12
13
14
15
16
17
18
19
Lao
Arabic
Armenian
Burmese
Croatian
Dutch
Farsi
French
German
Greek
20
21
22
23
24
25
26
27
28
29
840
850
860
890
900
PROVIDER
Child Development Funded Program
Head Start
Department of Mental Health
California Children’s Services
Department of Social Services
Department of Rehabilitation
Employment Development Department
Nonpublic Agency under Contract w/SELPA or District
100
110
120
130
200
210
220
230
20
22
710
720
810
820
830
Chamorro
Hebrew
Hindi
Hmong
Hungarian
Ilocano
Indonesian
Italian
Punjabi
Russian
LANGUAGE CODES
30 Samoan
31 Serbian
32 Thai
33 Turkish
34 Tongan
35 Urdu
36 Cebuano (Visayan)
37 Sign Language
38 Ukrainian
39 Chaozhou (Chaochow)
Community College
Adult Education Facility
Nonpublic Day School
Nonpublic Residential School in CA
Nonpublic Residential School
outside CA
Private Day School (not certified
by Special Educ. Div.)
Private Residential School (not
certified by Special Educ. Div.)
Parochial School
Service Provider Location
Any Other Location/Setting
410 Nonpublic School under Contract
w/SELPA or District
500 Other Public Program
550 DMCC
600 Other Private Program
64
65
70
71
72
75
76
79
80
Private School
Extended Day Care
Nonpublic Day School
Nonpublic Residential School in CA
Nonpublic Residential School
outside CA
Private Day School (not certified by
Special Educ. Div.)
Private Residential School (not
certified by Special Educ. Div.)
Nonpublic Agency
Parochial School
40
41
42
43
44
45
46
47
48
49
Pashto
50 Khrmu
Polish
51 Kurdish
Assyrian
52 Serbo-Croatian
Gujarati
53 Toishanese
Mien
54 Chaldean
Romanian
56 Albanian
Taiwanese
57 Tigrinya
Lahu
60 Somali
Marshallese
61 Bengali
Mixteco
99 Other Language
RACE
STUDENT’S GRADE LEVEL
205 Asian Indian
208 Hmong
303 Samoan
100 Amer Ind or Alaska
01 First Grade
07 Seventh Grade
13 12+ Grade/
207 Cambodian
202 Japanese
304 Tahitian
Native
02 Second Grade
08 Eighth Grade
Transition
201 Chinese
203 Korean
204 Vietnamese
600 Black or African
03 Third Grade
09 Ninth Grade
15 Ungraded
400 Filipino
206 Loatian
700 White
American
04 Fourth Grade
10 Tenth Grade
16 Infant
302 Guamanian
299 Other Asian
900 Intentionally left blank
05 Fifth Grade
11 Eleventh Grade
17 Preschool
301 Hawaiian
399 Other Pacific Islander
06 Sixth Grade
12 Twelfth Grade
18 Kindergarten
REFERRED BY
FREQUENCY
PRIMARY TRANSITION
STUDENT’S RESIDENTIAL STATUS
10 Parent
10 Daily
100 None
502 Functional
10 Parent or Legal Guardian
20 Teacher
20 Weekly
200 Training
Vocational
20 Licensed Children’s
50 Residential Facility
30 Student Study Team
30 Monthly
300 Education
Evaluation
Institution (LCI)
60 Incarcerated Institution
40 Other School Dist Prsnl
40 Yearly
400 Employment
30 Foster Family Home (FFH)
71 State Hospital
90 Other
90 Any Other Frequency
500 Comm. Exp
40 Hospital (except state
72 Development Center
as Needed
501 Ind. Living
hospital)
90 Other
REASON FOR EVALUATION DELAY (ASSESSMENT PRIOR TO 3RDBIRTHDAY)
REASON FOR DELAY OF 60 DAY TIMELINE FOR ASSESSMENT
10 Parent refusal to consent
91 IEP was late, completed after
10 Parent chose not to make student available
90 Other reason must be provided to CDE
20 Parent did not make student available
3rd bday / previously in Part C
20 Official school break of more than 5dys
91 IEP was late, more than 60 days after
30 Official school break of more than 5dys
92 New Referral after 3rd birthday /
30 Transferred
parental consent was received
90 Other Reason (Must be provided to CDE)
Student not previously in Part C
Page 2 of ____
DESERT/MOUNTAIN SELPA SCHOOL SITES
ADELANTO SD
School
Adelanto Elem
Bradach Elem
Columbia MS
Eagle Ranch
George Magnet MS
Gus Franklin Elem
Mesa Linda MS
Morgan Kincaid Prep
Theodore Vick Elem
Victoria Magathan
West Creek Elem
Westside Park
El Mirage
APPLE VALLEY USD
School
Apple Valley Private School
Apple Valley Sr.
AV Childcare
AV Christian
Desert Knolls
Granite Hills
Mariana
Marina Daycare
Mesquite
Phoenix Academy
Rancho Verde
Rio Vista
Sandia
SB Academy
St. Mary’s
St. Timothy’s
Sycamore Rocks
Vanguard Preparatory
Wanda’s Preschool
Willow Park (Cont.)
Yucca Loma
BAKER VALLEY USD
School
Baker Elem
Baker Jr.
Baker Sr.
BARSTOW USD
School
Barstow Baptist Acad.
Barstow Christian
Barstow Intermediate
Barstow Jr.
Barstow Sr.
Barstow Stem Acad.
Cameron Elem
Central HS
Challenges
Crestline
Henderson
D/M 68A Rev. 08/14
Site
174
117
433
409
425
898
370
604
441
VMA
WCE
694
MIR
Site
549
423
209
690
337
894
240
ANA
597
PHX
257
605
346
SBA
155
163
825
VAN
ASP
464
265
Site
273
193
076
Site
172
794
281
537
803
452
299
712
672
307
349
BARSTOW USD (CONT.)
Hinkley
Ingles
Lenwood
Montara
St. Joseph
Skyline
Thomson
356
357
372
380
STJ
414
422
BEAR VALLEY USD
School
Baldwin Lane
Baptist Preschool
Big Bear Elem
Big Bear MD
Big Bear Sr.
Chautauqua
Fallsvale
Living Waters Christian
Methodist Preschool
North Shore
Rose Hills Preschool
Site
866
IST
936
463
066
290
741
LIV
ODI
052
HIL
HELENDALE SD
School
Academy of Careers/Expl.
Carousel of Kid Preschool
Helendale
Riverview
Site
723
296
935
072
HESPERIA USD
School
Carmel
Canyon Ridge
Cedar MS
Cottonwood
Cypress Academy
Desert Trails (Alt Ed)
Eucalyptus
Hesperia Christian
Hesperia Com Day
Hesperia Jr.
Hesperia Sr.
Hollyvale
Joshua Circle
Juniper
Just 4 Kids Preschool
Kids World
Kingston
Krystal Elem
Lime Street
Maple
Mesa Academy
Mesa Grande
Mesquite Trails
Mission Crest Elem
Mojave High
New Life
Oak Hills HS
Site
120
444
108
498
805
811
968
534
944
547
407
112
943
950
J4K
WOR
937
KRY
454
M37
MAC
643
680
090
472
051
OAK
HESPERIA USD (CONT.)
Oxford Academy
Pathways Center
Ranchero MS
Shadow Ridge
Sultana
Summit Elem
T.C. Academy
Topaz
LUCERNE VALLEY USD
School
Lucerne Elem
Lucerne MS
Lucerne Sr.
Lucerne Com Day
Mountain View (Cont.)
Sky Mountain Charter
813
PTC
359
811
746
854
DMY
751
Site
976
330
563
795
696
SKM
NEEDLES USD
School
Chemehuevi
Essex
ETC
Kate Hohstadt Elem
Needles Christian
Needles MS
Needles Seventh-Day Adv
Needles Sr.
Parker Dam
Vista Colorado
Site
885
954
266
081
881
929
457
169
107
115
ORO GRANDE SD
School
Mojave River Academy
Oro Grande
Riverside Prep
Site
807
453
928
SILVER VALLEY USD
School
Calico High (Cont.)
Colin Powell
Ft. Irwin MS
Ironwood Christian
Lewis Elem
Newberry
Silver Valley Sr.
Silver Valley Com
Silver Valley Acad
Tiefort View Int
Yermo
Site
282
84A
681
922
331
406
274
SVC
199
096
455
SNOWLINE JUSD
School
Baldy Mesa
Chaparral (Cont.)
Desert View Ind
Eagle Summit CDS
Heritage
Site
710
365
589
720
924
SNOWLINE JUSD (CONT.)
Phelan
Pinon Hills
Pinon Mesa
Quail Valley
Serrano
Vista Verde Elem
Wrightwood
461
260
116
932
233
718
394
TRONA JUSD
School
Trona CDS
Trona Elem
Trona High
Trona MS
Site
258
199
487
196
VICTOR ELEMENTARY SD
School
A Child’s Place
Bonanza
Brentwood
Challenger
Del Rey
Discovery
Discovery World
Endeavor
Faith Baptist
Galileo Academy 101
Greentree East
Irwin Academy
La Petite
Lakeside Academy
Liberty
Liberty Christian
Lomitas
Mojave Vista
Mtn. View Montessori
Park View
Puesta Del Sol
Sixth Street Prep
United Methodist
Village
West Palms Conserv
Zion Preschool
VVUHSD
School
Adelanto HS
Cobalt MS
Hook Jr.
Goodwill HS
Lakeview Leadership Acad
Options (Charter)
Silverado
Susie Matthews
University Prep Acad
Victor Valley Sr.
VV Home Academy
Site
510
NZA
757
641
329
766
OVE
449
FB7
386
522
352
368
V74
860
839
219
587
350
360
227
927
DME
386
WEP
275
Site
419
698
554
GWH
562
670
787
931
064
012
039
D/M OPERATIONS
School
AVEEC
Community School
Family Infant
First (1st) Class
Juvenile Hall
Siegrist
Site
AV9
431
FIC
1CC
HDJ
348
ACADEMY FOR ACADEMIC
EXCELLENCE
837
NORTON SPACE AND
AERONAUTICS ACADEMY
NOR
EXCELSIOR CHARTER
SCHOOLS
761
HEALTH SCIENCES HIGH
MIDDLE COLLEGE
School
Health Sciences High
Health Sciences Middle
Site
462
HSM
SBC - HIGH TECH HIGH
CHARTER
School
HTH North County
HTH North County Elem
HTH North County Middle
HTH Chula Vista HS
HTH Chula Vista Elem
HTH Chula Vista MS
Site
HNC
NOE
NHM
HCV
CHE
CHN
HIGH TECH HIGH CHARTER
School
Explorer Elem
High Tech High
High Tech International
High Tech Middle
HTH Media Arts
HTM Media Arts
Site
683
HTH
HTI
HTM
HMA
573
D/M CHARTER SELPA
School
Desert Trails Prep Acad
Encore Jr./Sr.
LaVerne Elementary
Taylion High Desert Acad
Site
918
707
059
462
Page 3 of ____
DESERT/MOUNTAIN SPECIAL EDUCATION LOCAL PLAN AREA (CODE 3601)
DESERT/MOUNTAIN CHARTER SPECIAL EDUCATION LOCAL PLAN AREA (CODE 3651)
17800 HIGHWAY 18, APPLE VALLEY, CA 92307 * (760) 552-6700
Individualized Education Program Services
Addendum/Revision Individualized Education Program Services
IEP Dated: ____/____/____
Student Name:
DOB:
LAST
FIRST
District of Service:
Age:
Grade:
Student No.:
M.I.
Attending School:
SPECIAL EDUCATION AND RELATED SERVICES
Service (Code No.)
Class No.
Provider
Location of Service (Code No.)
Projected Start Date
Frequency (Code No.)
Duration (Minutes per
Frequency)
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
D/M 68A Rev. 08/14
Page 4 of ____