Cecil County Public Schools

Cecil County Public Schools

CECIL COUNTY PUBLIC SCHOOLS

201 Booth Street

Elkton, Maryland 21921

REQUEST FOR PROGRAMMING ASSISTANCE MEETING (PAM)

DATE SUBMITTED:Click here to enter a date.

Student Name: / Student Address:
Parent Name: / Referring School:
Grade / D.O.B. / Gender / Race / GPA / Disability / ESOL / FBA / BIP
Primary Concerns Required Documents
Behavior / MTSS Intervention Data / Current FBA/PTR**
Reading / PWN from most recent IEP meeting / Current BIP/SSP**
Mathematics / Current Classroom Observation / Discipline Record*
Written Language / MTSS Team Minutes (DAT,PST, and/or SST) / Academic Transcripts/Grades*
Related Services
(OT, PT, Speech) / SARF/BMP/504 / State Assessment Results*
Current Psychological Assessment** / Attendance*
Current Educational Assessment** / Current Related Services Assessments**

*Do not send copies of the indicated items; however, be prepared to summarize.

** Please ensure that these documents are electronically uploaded in the MDIOEP program.

1. Describe concerns regarding the student and Analyze/Summarize Behavioral and/or Academic data:

2. MTSS Intervention History: (Please ensure data collection is attached)

Date / Tiered Intervention / Duration/Frequency / Results

3. Agency/Building Involvement:

A.  Program Facilitator describe level of involvement:

B.  School Counselor describe level of involvement:

C.  School Psychologist describe level of involvement:

D.  Pupil Personnel Worker describe level of involvement:

E.  Principal/Assistant Principal describe level of involvement:

______

Agency Involvement: / / Case Manager / Phone Number
Department of Social Services
Department of Health & Mental
Hygiene
Department of Juvenile Services
Mental Health/Counseling
CAP/Partnership Seat-Current

Signature, Principal/Assistant Principal

Date submitted______

For Office Use Only:

Disposition (to be completed by the Director for Special Education/Director for Student Services):

Programming Assistance meeting will be scheduled.

Programming Assistance meeting will not be scheduled at this time.

Additional information is needed to process this request (see notes).

Notes: ______

Signature__________Date______

Director for Special Education/Director for Student Services

Rev. 8/4/2016