Change of Placement Plan
Part I: Referral for Change of Educational Environment
Directions:
This document should be started at the student’s current school and completed by the IEP team at the conclusion of this process. The current school team must complete this form if the student remains in the current educational environment at the conclusion of the process.
The IEP team including parents, school administration, general education and ESE teachers, and student support personnel must consider why the general education setting with additional services and supports or current education environment is not appropriate to meet the academic and/or emotional/behavioral needs of the student.
This plan is typically appropriate for the following educational environments:
Self Contained Academic (SCA)
Emotional/Behavioral Disorders (EBD)
Regular Standards Autism Spectrum Disorder (RS-ASD)
Special Standards Autism Spectrum Disorder (SS-ASD)
Intellectual Disabilities (InD)
Therapeutic Emotional/Behavioral Disorders (TEBD) (Secondary Only)
Specialized Inclusion Setting with Specific Supports (ASD-SIS or EBD-SIS)
Independent Special Standards Behavior (ISSB) (Secondary Only)
Student Name:
Student Number:
Current School:
Home School:
Parent Name(s):
Parent Name(s):
Date:
Birth Date:
ESE Teacher:
General Ed Teacher:
Parent Phone/Email:
Parent Phone/Email:
Contact for current setting:
Contact for receiving school:
What instructional environment is the team considering?
__SCA __ EBD __ RS-ASD __ SS-ASD __InD __ ASD-SIS ___EBD-SIS
(Secondary Only: __ISSB __TEBD)
Parent Contact
A meeting that includes parent must be convened to review data and discuss concerns with current services and setting prior to contacting the recommended site administration. Please remember, at this point the in process, the proposed environment and/or program is only one of the options the team may be considering.
Date Parent Contact/Meeting:
Results of Contact/Meeting:
General Information
Date student staffed into ESE:
Areas of eligibility:
Other support services/interventions (e.g., ESL, 504)
Has the considered educational environment staff observed the student and/or participated in an In-
School Staffing prior to the recommendation for the change in educational environment? Yes No
If yes, were recommendations from SC staff considered or implemented? Please attach appropriate conference notes, data, or observation report.
BC 6/21/12

Diagnostic Teaching (DT)
Did the team recommend diagnostic teaching? Yes No
If yes, list dates of DT and attach the completed DT planning sheet.
Was a re-evaluation (809) form signed? Yes No
Health Care and Supervision
Does the student require any medical services?
If yes, describe the services and level of support provided by school personnel.
Who provided the identified support?
Does the student currently have additional adult support? If yes, please explain level of support.
Transportation
Will transportation be altered? Yes No
If yes, will the student require a change in bus? Yes No
Will the student be a car rider? Yes No
Are any special instructions or supports required for arrival and dismissal? Yes No
Assistive Technology and Individualized Materials
Does the student utilize assistive technology (e.g., communication materials, Co-writer)?
If yes, will assistive technology accompany student? Explain.
Are additional materials or supports needed to support the student or SC staff? Yes No
If yes, what material or supports are needed and who will provide them?
Documents and Data
Current IEP, progress reports, accommodation data and data of goals should be attached.
Include and attach the following documents if applicable
Pasco Star demographics page
FAIR scores for current and past year
Check if Included
FCAT and/or SAT scores (If applicable)
Data from current reading program (weekly and unit assessments)
Data from current intervention reading programs (Tier II and III)
Running records history
Data from current math curriculum (pre & post tests)
Core K12 math scores
Writing samples and score
Functional Behavior Assessment/ Behavior Intervention Plan
OT/PT Plan of Care
Speech/Language scores and Plan of Care
Pre-Kindergarten Galileo report
Pre-Kindergarten BDI report
CORE Team Report
Assistive Technology Report
S-BIT Board
Recent formal evaluations (e.g., social history, psychological reports, language evaluations)
Other data sources: (Add in lines below)

Briefly describe current educational environment and services: ( An S-BIT board may be included.
Please add any information not covered in S-BIT document)
Describe Subject Area
Reading curriculum and instructional level:
Tier I:
Weekly Minutes of Direct ESE
Services
Tier II:
Tier III:
Language Arts/Writing:
Math curriculum and instruction level:
Tier I:
Tier II:
Tier III:
Social Studies/Science curriculum and instructional level:
Special Areas:
Other:
Positive Behavior Supports:
Tier I:
Tier II:
Tier III:
Use the following guiding questions to convey the team’s rational in recommending a change of placement. Teams do not need to repeat information included in any attached data or information.
Why has the student been recommended for a change in placement?
What alternative option(s) has been considered or attempted?
What additional supports is the team recommending be added to the IEP and educational program?
Based on the documentation/discussion, the IEP Team is considering placement at _________________.
7.
8.
5.
6.
9.
10.
Name Title Signature
1.
Administrator
2.
3.
4.

Change of Placement Plan
Part II: Recommendations
This document must be completed by the IEP team at the conclusion of the team’s consideration for a change of environment.
Student Name:
Student Number:
Date:
Birth Date:
Current School:
Recommended School:
Team Members:
Teacher:
Recommended ESE Teacher:
Indicate which results/option the team has selected by completing the questions and corresponding area:
_____Yes _____N/A
1) Determine that the recommended instructional environment is appropriate. a) Anticipated date/time/place for IEP review or revision b) Who will attend this meeting? c) Anticipated transportation available (if needed) d) New school enrollment date (if needed) e) Monitor new placement. Anticipated date to review new placement data. Who will attend this meeting?
_____Yes _____N/A
2) Both school teams (including parent) agrees that the student should remain in current instructional environment. a) Student stays in current setting with a review of services, interventions and progress monitoring data b) Anticipated date/time/place for IEP review or revision c) Who will attend this meeting?
_____Yes _____N/A
3) Receiving team does not agree with placement in a recommended instructional environment. a) Sending school requests a district case review b) Sending school administrator contacts district staff c) District case review with sending and SC representation d) IEP meeting to consider recommendation of case review
_____Yes _____N/A
4) Receiving team does not agree with placement in recommending instructional environment. If student remains in current setting: a) IEP team reconvenes to consider current educational setting and services or consider alternative educational setting.
_____Yes _____N/A
5) Parent disagrees with recommending instructional environment.
a) District case review and parent meeting
_____Yes _____N/A
6) Other options as determined by the IEP team. a) IEP team reviews data and recommendations. Develops appropriate action plan.

If a student changes to a different educational environment, the IEP team must monitor the appropriateness of the setting. Describe when the team will review the student’s progress and appropriateness in the new setting.
Anticipated date/time/place for review/IEP meeting:
Who will attend this meeting?
What data will the team review?
What are the recommendations of the IEP team?
What next steps are required?
Create appropriate action plan if needed