West Clermont Data Collection Form for Students with Suspected/Identified Disabilities
Use for Events From June 1, 2014 Through May 31, 2015
Name: _________________________ Student ID#: _____________________
Resident District: ________________ District of Attendance: ___________
Grade Level: ____________________ Race: ________________________
Event Date
from PRA. Date Type Codes: Activity
XX form
DOB: ________________________
Building of Attendance: __________
Disability Category: _____________
Outcome (circle)
Date: ________________________
Autism Scholarship? ____________
Teacher: _____________________
Begin
Date
End
Date
Compliance
1. PSTC (Preschool Transition -transition from
Help Me Grow)
Date______
N/A
N/A
2. RFRL (Referral for Evaluation - after the
child is suspected of having a disability)
Date______
N/A
N/A
Date______
CNGT
(consent
granted)
3. CNST (Parent Consent for Evaluation -on or
after referral date)
# days between CNST & IETR: __________
4. IETR (Initial Evaluation Team Report Completion due 60 days from consent)
5. IIEP (Initial IEP - 30 days from ETR
Completion; by third birthday if PSTC)
****FILL OUT STEPS 2,3, and 4 ABOVE!!!!!!!
Date______
Date______
GNGI
(Initial
Eval)
CNNR
CNDP
(consent
(consent
not
moved to due
returned)
process)
ETDP (ETR resulted in due process)
CNRF
(consent
refused)
ETNE (not eligible)
Disability Category (circle):
ET01(MD)
ET02(Deaf/Blindness) ET03(HI) ET04(VI)
ET05(speech) ET06(Orth) ET08(ED) ET09(ID) ET10(SLD)
ET12(AU)
ET13(TBI) ET15(OHI) ET16(DD) preschool
IEPR (parent refusal / FAPE)
IEDP (resulted in due process)
LRE CODES (circle)
IE13-spec ed outside reg. class less that 21% of day
IE14-spec ed outside reg. class 21% to 60 % of day
IE15-spec ed outside reg. class more than 60% of day
IE16-public separate school greater than 50%
IE17-private separate school greater than 50%
IE18-public residential facility
IE19-private residential facility
IE20-homebound/hospital
IE39-nonpublic, placed by parent, service plan
PRESCHOOL CODES (circle)
IE51-WC program w/regular early childhood program +10 hours
IE53-WC itinerant w/regular early childhood program -10 hours
IE55-WC program w/regular early childhood program +10 hours
IE56- WC program w/regular early childhood program -10 hours
IE62-special education program – separate school
IE64-special education program – residential facility
IE70-home
N/A
Code:_____
Date
_____
Date
____
Code:_____
FY09
Codes for Compliance Column
**Not out of compliance 04Schedule conflicts with family 05Parental choice 06Parent refused consent 07Child’s health 08Student incarcerated
West Clermont Data Collection Form for Students with Suspected/Identified Disabilities
Use for Events From June 1, 2014 Through May 31, 2015
ETDP(resulted in due process)
8. RETR (Reevaluation Team Report - 3 years
from prior ETR)
***Fill out at every IEP meeting
9. RIEP Periodic Review
(1 year from previous IEP)
of IEP
8. TETR (Transfer Student ETR Adoption)
Date______
Date______
Date______
C. Secondary Planning Element (Transition Plan
reported for students who turn 14 prior to end of this
IEP)
D. Related Services (2150XX)
ETEX(exiting special education)
Disability Category (circle):
ET01(MD)
ET02(Deaf/Blindness) ET03(HI) ET04(VI)
ET05(speech) ET06(Orth) ET08(ED) ET09(ID) ET10(SLD)
ET12(AU)
ET13(TBI) ET15(OHI) ET16(DD) preschool
IEPR (parent refused / FAPE)
IEDP (resulted in due process)
LRE CODES (circle)
IE13-spec ed outside reg. class less that 21% of day
IE14-spec ed outside reg. class 21% to 60 % of day
IE15-spec ed outside reg. class more than 60% of day
IE16-public separate school greater than 50%
IE17-private separate school greater than 50%
IE18-public residential facility
IE19-private residential facility
IE20-homebound/hospital
IE21-correctional facility
IE39-nonpublic, placed by parent, service plan
PRESCHOOL CODES (circle)
IE51-WC program w/regular early childhood program +10 hours
IE53-WC itinerant w/regular early childhood program -10 hours
IE55-WC program w/regular early childhood program +10 hours
IE56-WC program w/regular early childhood program -10 hours
IE62-special education program – separate school
IE64-special education program – residential facility
IE70-home
Disability Category (circle):
ET01(MD)
ET02(Deaf/Blindness) ET03(HI) ET04(VI)
ET05(speech) ET06(Orth) ET08(ED) ET09(CD) ET10(SLD)
ET12(AU)
ET13(TBI) ET15(OHI) ET16(DD) preschool
Code:_____
Date
_____
Date
____
Date
_____
Date
____
Code:_____
Circle One:
TFYG – Transition Statement and/or Plan in Place. Student plans to meet
graduation requirements entering ninth grade
TPCE – Transition Plan in Place. Met Grad requirements and will continue as
Grade 23
**** Not Applicable
Service:
Start
End Date
FY09
Codes for Compliance Column
**Not out of compliance 04Schedule conflicts with family 05Parental choice 06Parent refused consent 07Child’s health 08Student incarcerated
West Clermont Data Collection Form for Students with Suspected/Identified Disabilities
Use for Events From June 1, 2014 Through May 31, 2015
(Record only those related services described on
IEP)
215002
Aide Services
215003
Attendant Services
215004
Audiology
215006
Interpreter Services
215007
Medical Services
215008
Occupational Therapy Services
215009
Orientation and Mobility Services
215010
Physical Therapy Services
215011
Reader Services
215012
School Psychological Services
215013
Speech and Language Services
215015
Rehabilitation Counseling
215017
Parent Counseling and Training
215018
Counseling Services
215020
Recreational Services
215021
Special Transportation
215022
Social Work Services
215023
Other (Work Study, Adapted PE, Adapted Equipment)
215026
School Health Services
215027
School Nurse Services
E. Preschool Itinerant Services (a teacher)
220100 Provider:
F. Testing
TEST TYPE required by IEP:
Accommodations required:
OGT Required for Graduation?
Requirements
ALT - Alternate Assessment
** not applicable
NO
Yes
No
NA
Met Participation Requirements? Yes No
STR – NO accommodations
Y1 – yes, 504 plan
STA – with accommodations
Y2 – yes, IEP
date:_____________
Y3 – yes, LEP
IEP Meeting Date:______________
IEP Effective Dates From _________________ To ___________________
District Representative: _____________________________________
Date:_________________
FY09
Codes for Compliance Column
**Not out of compliance 04Schedule conflicts with family 05Parental choice 06Parent refused consent 07Child’s health 08Student incarcerated