STUDENT SERVICES/ESE SERVICES DATA INPUT SHEET …

1 Clear Form DOC. TYPE 6487. DATE. (MM/DD/YY) _____. PRINT STUDENT 'S NAME (LAST) (FIRST) ( ) STUDENT . ID. NO. _____ _____ _____. STUDENT SERVICES /ESE SERVICES data INPUT SHEET . (This SHEET is optional. Do not place in the cumulative folder.). PF 16 Screen PF 4 Screen SERVICE DATE OUTCOME SERVICE PROVIDER ---- CURRENT COURSE INFORMATION ---- SCHL CRSE NUM EMP NUM CDE HRS/WEEK WEEK LOC NAME. INTERVENTION DEVELOPMENT: z SST CONFERENCE / /. PSYCHOLOGICAL: z CONSENT FOR EVAL / / z CASE OPENED / /. z CURRENT EVALUATION / /. REPORT SUBMITTED / / z SPEECH/LANGUAGE: z CONSENT FOR EVAL / /. CURRENT EVALUATION / / z MEDICAL (VI AND PI REEVAL DATE): z CONSENT FOR EVAL / /. z CURRENT EVALUATION / /. z PF 8 Screen MEDICAID PARENTAL CONSENT: PF 17 Screen - Dismiss from 504 (N screen) prior to data INPUT for students with disabilities eligibility (if applicable.)

2 PRIMARY EXCEPTIONALITY DOMAIN RATING/DATE: _____ / / FEFP: CONSULTATION / COLLABORATION SERVICES GIFTED CONSULTATION: ____. IEP: CONFERENCE: / / DURATION: / / IQ SCALE. PRIVATE SCHL/DISTRICT PROVIDED: IDEA ED ENV: GIFTED ELIGIBILITY: ---------------------------------------- ---------------------------------------- ------------------------------ CONSENT. ---PLACEMENT--- FOR CURRENT EVAL ELIG EVAL PLACEMENT. EXCP STATUS REASON EVAL DETERM TYPE DATE DISMISSAL. / / / / / / / / / /. / / / / / / / / / /. / / / / / / / / / /. / / / / / / / / / /. PF 18 Screen ALTERNATE ASSESSMENT: / / YES, NO, PARTIAL. TEST ACCOMMODATIONS: TIME, TOTAL SCHOOL WEEK (IN MINUTES): TIME WITH NON-DISABLED PEERS (IN MINUTES): N Screen STUDENT Case Management System SECTION 504 PLAN FAB/BIP Screen ACCOMMODATION SERVICES .

3 STUDENT SERVICES FORM INFORMATION. ESE ELIGIBLE (Y/N): CONSENT FOR EVAL DATE: / / EVAL DATE: / /. EVALUATION TYPE: EMPLOYEE NO: NAME: ELIG SPEC PARA NRS RSP INSTR CONT. DETERM OT PT TRANS PROF THERAPY MODIF ELIG. STUDENT ID: NAME: SERVICE. / /. SCM# OR SPAR# DATE TIME CODES. / /. / / / / : / / : / / : R Screen EXTENDED SCHOOL YEAR SERVICES . ESY ESY DELIVERY - - - - - - - - - DURATION - - - - - - - - - - - - - - - - - - FREQUENCY - - - - - - - - - SCHL SERV MODEL START END DAYS/ MINUTES/ TIMES/. CODE (MM/DD/YY) (MM/DD/YY) WEEK SESSION MONTH. / / / / / /. / / / / / /. / / / / / /. / / / / / /. Transportation Information and Codes on page 2 Page 1 of 2 FM-6487 Rev. (06-10). TRANSPORTATION INFORMATION. Q Screen PF 22 Screen (This screen can only be accessed if "X".)

4 Is entered under Secondary Transportation Mode on the Q. STUDENT REQUIRES THE RELATED SERVICE OF SPECIALIZED TRANSPORTATION. SPECIAL TRANSPORTATION RELATED SERVICES . Screen data entry section.). PRIMARY TRANSPORTATION MODE. INDIVIDUALIZED STOP WITHOUT SUPERVISION ALTERNATE MODE OF TRANSPORTATION: CAR SEAT. INDIVIDUALIZED STOP WITH SUPERVISION. LIFT BUS WHEELCHAIR WITH SUPERVISION. LIFT BUS WHEELCHAIR WITHOUT SUPERVISION. SAFETY VEST (INDIVIDUALIZED STOP WITH SUPERVISION). SAFETY BELT/UNIQUE SEATING DEVICES(INDIVIDUALIZED STOP WITH SUPERVISION). ALTERNATE MODE OF TRANSPORTATION (SPECIFY). SECONDARY TRANSPORTATION MODE. AIDE REQUIRED SPECIFY: MEDICALLY FRAGILE STUDENT /MEDICAL CONSULTATIVE REVIEW REQUIRED. MEDICAL EQUIPMENT (SPECIFY). STUDENT TRANSPORTED OUT OF SCHOOL DISTRICT.

5 OCCUPATIONAL/PHYSICAL THERAPY. SHORTENED SCHOOL DAY OR ALTERNATE SCHOOL DAY TIME(S). VOCATIONAL/SHARE TIME PROGRAM. SCHOLARSHIP PROGRAM FOR students WITH DISABILITIES. AIR CONDITIONING/MEDICAL CONSULTATIVE REVIEW REQUIRED. Alternate Transportation Address Information PF 5 Screen PICKUP: HOUSE NO _____ DIR _____ STR _____ BLDG/LOT _____. APT _____ CITY _____ ZIP _____ - _____ CONTACT PHONE (_____) _____ - _____. HOUSE NO _____ DIR _____ STR _____ BLDG/LOT _____. DELIVERY: APT _____ CITY _____ ZIP _____ - _____ CONTACT PHONE (_____) _____ - _____. J Screen SURVEY: DATE ____ / ____ / ____ RESPONSES _____ PARENT/GUARDIAN LANG _____ STU LANG _____. PRIMARY EXC. ASSESSMENT: DATE ____/ ____ / ____ OLPS/RLDA SCORE _____ LEP (Y/N) _____ ESOL LEVEL _____.

6 METROPOLITAN: GRADE _____ RAW SCORE: RDG _____ LANG _____ PERCENTILE: RDG _____ LANG _____. ENTRY DATE _____ / _____ / _____ BASIS OF ENTRY _____ ESOL SEMESTER _____ LEP SERVICES _____. EXIT DATE _____ / _____ / _____ BASIS OF EXIT _____ OLPS/RLDA SCORE _____. METROPOLITAN: GRADE _____ RAW SCORE: RDG _____ LANG _____ PERCENTILE: RDG _____ LANG _____. RECLASSIFICATION DATE _____ / _____ / _____. SCHL CRSE EMP HRS/WK MIN/WK SCHL CRSE EMP HRS/WK MIN/WK. NUM NUM NUM NUM. CODES. Code/Exceptionalities P Autism Spectrum Disorder L Gifted E Physical Therapy H Deaf or Hard of Hearing M Hospital/Homebound K Specific Learning Disabled T Developmentally Delayed (age: 0-5) G Language Impaired F Speech Impaired O Dual-Sensory Impaired D Occupational Therapy S Traumatic Brain Injured J Emotional/Behavioral Disabilities C Orthopedically Impaired I Visually Impaired U Established Conditions (age: 0-2) V Other Health Impaired W Intellectual Disabilities CURRENT ESE COURSE NUMBERS.

7 Placement Status Codes Outcome Codes IQ Scale 7650130 PK Handicapped (3-5). I Evaluated and Ineligible G Gifted F Full Scale 7650030 B-2. N Eligible/Not Placed P Psychological Evaluation P Performance Scale 7755010 Kindergarten ESE. P Eligible/Placed D Developmental V Verbal Scale 7763050 Occupational Therapy S Speech 7763070 Physical Therapy Not Placed/Reason M Medical 7763030 Speech Impaired D Parent Denied Initial Placement R Reevaluation 7763040 Language Impaired L LRE 7763080 Itinerant Vision P Parental Request 7763020 Itinerant Hearing W Withdrawn from M-DCPS. R Revocation of Consent Page 2 of 2 FM-6487 Rev. (06-10).