Pennsylvania Department of Education
Bureau of Special Education
Intensive Interagency
"ACTIVE" MEMBERS: "All Pennsylvania children with disabilities whose school districts have determined that they
cannot currently be appropriately educated in a public educational setting and who waited or have been waiting for more
than 30 days for the provision of an appropriate educational placement."
"AT RISK" MEMBERS: "At-risk", this definition includes all children who are in substantial jeopardy of becoming
active class members, students who are without appropriate educational programs for 30 days or more; therefore, this
definition includes, but is not limited to, all children for whom it is anticipated that their IEPs cannot be implemented
within 10 days after completing the IEP and all children for whom an IEP can no longer be successfully implemented. In
addition, students who are "at-risk" of becoming active class members include those without IEPs where it is likely that
an IEP meeting will not be convened in a timely manner because of anticipated problems in locating and securing an
appropriate placement. The "at-risk" category also includes students with IEPs on home instruction for reasons other
than temporary physical illness or mobility or other physical problems that prohibit the student's departure from the
home.
"OUT OF DISTRICT" MEMBERS: This category of children includes students who were once Active class members
and who currently have an educational placement but, by way of agreement of the local interagency team, are in a more
restrictive setting than the child's needs warrant. In example, a child who is placed residentially in an approved private
school due primarily to a lack of access to a community based residential program would fit into this category.
"PAST" MEMBERS: Students who "met the class definition at some point on or after March 14, 1991, but were
subsequently provided with an appropriate program and placement."
COMPENSATORY EDUCATION: Services designed to compensate the student for any delay and/or loss of instruction
experienced while awaiting appropriate services. These services must be designed by the IEP team, and may take the
form of services beyond normal school days or hours, extra in-school services, extended eligibility for services (e.g.,
beyond age 21), non-instructional services, or any other intervention that the IEP team determines to be reasonable
compensation for the delay that the student experienced. If the student was on homebound or instruction conducted in
the home during the period of delay, the student must be offered services at least comparable in nature and duration to the
services that were recommended for the child but not provided. Families may waive their right to compensatory services
if they choose. All class members who experienced placement delays, including past class members (see above), are
eligible for compensatory education.
INITIAL REPORT -- Page 1 of 4
(09/12/2011)
Pennsylvania Department of Education
Bureau of Special Education
Intensive Interagency INITIAL Report
(Report each class member immediately to Sharon Becker (sbecker@pattan.net) at PaTTAN Harrisburg – 6340 Flank Drive,
Harrisburg, PA 17112; Phone: 800-360-7282 ; Fax: 717-541-4968)
1.
2.
3.
4.
District's name
AAO (Phila Only)
Superintendent's name
Class member's name
Birth date
Sex: M / F Social Security Number______________ County of residence
Today's date
Parent:
Legal Guardian:
Foster Parent:
(If other than parent)
(Where applicable)
Name
Address
Telephone number
5.
District Contact
Telephone number
6.
Please indicate the most accurate status as either "Active", "At Risk" or "Out of District", and
all other applicable descriptors for the class member being reported:
___Active; not in appropriate placement
___At risk of being without an appropriate placement
___Out of District
Other descriptors:
___*On Homebound Instruction or Instruction Conducted in the Home
___May be eligible for compensatory education as a result of having been on an inappropriate placement
some time in the past.
7.
Date of most recent
ER______________
IEP______________
NOREP______________
*Indicate all applicable systems to this class members case: ‫ڤ‬BSE ‫ڤ‬C&Y ‫ڤ‬DOH ‫ڤ‬JPO ‫ڤ‬MR
)yficeps esaelp( rehtO‫ ڤ‬RVO‫ ڤ‬SASHMO‫ڤ‬
*Indicate all applicable At Risk Trigger Points ‫ڤ‬1 ‫ڤ‬2 ‫ڤ‬3 ‫ڤ‬4 ‫ڤ‬5 ‫ڤ‬6 ‫ڤ‬7
Date team determined placement inappropriate
Receiving Medical Assistance: Y / N
*Recipient CIS Number
Current placement
Placement being sought
*Type of Service
Type of Support
Reason for placement being sought
INITIAL REPORT -- Page 2 of 4
Location
(09/12/2011)
* See attached CODES TO BE USED
[Item 8, for "Active" or "Out of District" class members only]
8.
(a) Date student became an Active class member
(b) Additional comments concerning "Out of District" class members only. (If student is "Active",
record N/A)
[Item 9, for "At Risk" class members only]
9.
(a) Description of "at risk" factors
(b)
10.
Date when appropriate placement was acquired
Provide a brief current status report for this class member
Report submitted by
Position
* See attached CODES TO BE USED
INITIAL REPORT -- Page 3 of 4
(09/12/2011)
CODES TO BE USED
Type of Service
Type of Support
I
S
FT
AS
ES
HI
LS
LSS
MD
PS
SLS
VI
RE
Itinerant
Supplemental
Full Time
Autistic Support
Emotional Support
Deaf or Hearing Impaired Support
Learning Support
Life Skills Support
Multiple Disability Support
Physical Support
Speech and Language Support
Blind or Visually Impaired Support
Regular Education
Location
Systems
R
PSFD
APSD
PSFR
APSR
HOS
CF
OSF
HOME
BSE
Bureau of Special Education
C&Y Office Of Children & Youth
PA Department of Health
JCJC Juvenile Court Judges Commission
JP
Juvenile Probation
ODP
Office of Developmental Prog
OMHSAS Office of Mental Health and
Substance Abuse Services
OVR
Office Of Vocational Rehabilitation
Regular school with non disabled peers
Public Separate Facility (Non Residential), e.g., Special Education Center
Private Separate Facility (Non Residential), e.g., Day student in an APS DOH
Public Residential Facility, e.g., State operated residential facility
Private Residential Facility, e.g., Residential student in an APS
Hospital, e.g., Long-term admissions
Correctional Facility, e.g., Students receiving services while incarcerated
Out of State Facility
Instruction Conducted in the Home, e.g., IEP Team Placements
AT RISK TRIGGER POINTS
1 - A student with an IEP has been placed on home instruction for reasons other than temporary physical illness, mobility, or other
physical problems.
2 - A student with an IEP who is placed in a foster home, group home, institution, or host home for 30 days or longer
3 - A student with an IEP who has repeated serious disciplinary infractions which is likely to interrupt or interfere with the
successful implementation of his or her IEP.
4 - A student who’s IEP has stopped being successfully implemented for reasons including, but not limited to, significant behavior
problems.
5 - The need for an out of district placement, but such placement has not yet been achieved
6 - The need for community based services for a student has been identified and recommended for the successful implementation
of the student's IEP, but the services have not yet been provided.
7 - The family or student has declined to participate fully in the current IEP, and as a result the school cannot provide a Free
Appropriate Public Education (FAPE).
HOMEBOUND INSTRUCTION – Education provided in the home as a result of a medical crises which makes it impractical for the
student to attend school for a specific period of time; not to be used as a substitute for a special education placement when an
appropriate placement cannot be found.
INSTRUCTION CONDUCTED IN THE HOME – Special education and related services provided in the home instead of the school, as
specified by the IEP team as the appropriate placement for this student at this time; not to be used as a substitute for an appropriate
placement when one cannot be found.
CIS NUMBER – Client Information System Number. 10 digit unique number identifying the MA recipient. Can be found on ACCESS Card.
RMT – Regional Management Team.
SDI – Specially Designed Instruction.
INITIAL REPORT -- Page 4 of 4
(09/12/2011)