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.). PRIMARY EXCEPTIONALITY DOMAIN RATING/DATE: _____ / / FEFP: CONSULTATION / COLLABORATION SERVICES GIFTED CONSULTATION: ____.

2 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 . 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.

3 / /. / / / / : / / : / / : 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". 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).

4 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. 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 _____.

5 PRIMARY EXC. ASSESSMENT: DATE ____/ ____ / ____ OLPS/RLDA SCORE _____ LEP (Y/N) _____ ESOL LEVEL _____. 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.

6 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).