IEP INFORMATION SHEET
Student Name: __________________________________________ Student grade:
 Initial IEP (check 39 a, b, and c)
 Annual IEP
IEP Date: __________________________________________
 Yes (if eligible, will continue to have IEPs)
 No (Not eligible)
IEP:
IEP Status: (if yes above): SE
Primary Disability (select only one)
 05 Cognitive Impairment
 06 Emotional Impairment
 07 Hearing Impairment
 08 Visual Impairment
 09 Physical Impairment
 10 Speech & Language impairment
 11 Early Childhood Dev Delay
 13 Specific Leaning Disability
 14 Severe Multiple Impairment
 15 Autism Spectrum Disorder
 16 Traumatic Brain Injury
 17 Deaf-Blindness
 20 Other
 22 Legally Blind
 24 Deaf
__________________________________
Current SE FTE Section 52: __________________________
Placed by Other District IEP
 Out of district student/nonresident of operating district
This does not include student who moved into the district
or school of choice
Information for INITIAL IEP only
Parental Consent Eval (39a) (Only for initials)
 11 IEP completed within 30 school days
 12 IEP completed within extended timeline
 13 IEP Not Timely: Parent did not make child available
 14 IEP Not Timely: Timeline began in previous district
 15 IEP Not Timely: Personnel not available for evaluation
 16 IEP Not Timely: Personnel not available for IEP
 17 IEP Not Timely: External reports not available
 18 IEP Not Completed: Student died
 19 IEP Not Completed: Parent withdrew consent
 20 IEP Not Completed: Parent did not make child available
 21 IEP Not Completed: Student moved
Result of Initial IEP: (39b)
 1 Evaluated and found eligible
 2 Evaluated and found not eligible
 4 Initial IEP was not held for reason in 39a
Days Beyond Eval of IEP(39c): __________________
Date of Parental Consent: _____________________
Date district received consent NOT when parent signed!!
MET Date: ________________________________________
SE Exit Date: ______________________________________
Total Hrs/Min per Week
A
GE Hrs/Min Only
Primary Ed Setting - Placement is outside the general education building
 02 Public or Private Spec. Ed School Building at Public Expense
 03 Public or Private Residential Facility at Public Expense
 05 Correctional Facility
 06 Homebound/Hospital
 07 Parentally Placed in Private School or Home School at Private/Parent Expense
Co-Taught Hrs/Min
Program Code

None
 110 Programs for Mild Cognitive Impairment
 140 Programs for Emotional Impairment
 194 Elementary or Secondary Level Resource Program
 120 Programs for Moderate Cognitive Impairment
 130 Programs for Severe Cognitive Impairment
 150 Programs for Learning Disabled
 160 Programs for Hearing Impairment
 170 Programs for Visual Impairment
 180 Programs for Physical or Other Health Impairment
 190 Programs for Severe Multiple Impairment
 191 Early Childhood SE (Classroom) Program
 192 Programs for Severe Language Impairment
 193 Programs for Autism Spectrum Disorder
 270 Early Childhood SE Services
Start Date End Date
Support Services
 290 Speech & Language Impaired
 310 School Social Worker
 360 Occupational Therapy
 370 Physical Therapy
 200 TC Autistic Impaired
 210 TC Mentally Impaired
 220 TC Emotionally Impaired
 230 TC Learning Disabled
 240 TC Hearing Impaired
 250 TC Visually Impaired
 260 T.C. Physically & OHI
 280 Homebound/Hospitalized
 291 Adaptive Physical Education
 320 School Psychologist
 383 Music Therapy
 390 Art Therapy
 400 Audiological Services
 406 Interpreter for the Deaf
 410 Recreation Services
 440 Special Transportation
 450 School Health Services
 460 Rehabilitation Counseling
 470 Orientation & Mobility
 480 Work Site Based Learning
 490 Comm. Training/Voc Ed (Gen Ed)
 491 Spec. Needs (Adapted Voc. Ed)
 492 Individual Voc. Education
 493 Community Training/Voc. Ed/Spec. Ed
Start Date End Date
SE Exit Reason:
 30 IEP team determined student no longer in need of SE
 31 Parent revoked consent for SE
SE Hrs/Min Only
B
A
A
Name of Contact Provider - LISD staff or SE Teacher: ______________________
Primary Ed Setting - Placement within the general education building
 11 Inside the gen. Ed classroom 80% or more of the school day
 12 Inside the gen. Ed classroom between 40% and 79% of the school day
 13 Inside the gen. Ed classroom less than 40% of the school day
 46 EC program at least 10 hr/wk majority of SE hrs in EC program
 47 EC Program at least 10 hr/wk majority of SE hrs in other location
Secondary Disability: _______________________________
(Use codes above if needed)
Current GE FTE:
C
B
_________________ Building: _______________________________
C
D
B/A=
= Current Gen Ed FTE (Gen. Ed Teacher Time)
(C+D)/A=
= Current SE FTE (SE Teacher Time)
(B+C)/A=
= Primary Ed Setting
(Location of Student - Gen Ed)
Revised March 2013
Revised March 2013