Oregon Department of EducationOffice of Student Services

Public Service Building

255 Capitol St. NE

Salem, OR 97310-0203

CORRECTION REQUEST (For Data Collection Form Submitted 2015-2016School Year)

Coordinated Early Intervening Services (CEIS)

2015-2016 Data Collection Form

District:______/ District ID:______
Authorized Person Completing Form: ______Phone:______
Section I - 2014-2015Information
  1. Did your agency use IDEA funds for Coordinated Early Intervening Services (CEIS) during the 2014-2015 school year?
/ Yes / No
  1. How many students received CEIS provided by your agency during the 2014-2015school year?

  1. How many students were found eligible for special education during the 2014-2015school year who:
  2. Received CEIS* during the 2014-2015 school year?
  1. Received CEIS* during the 2013-2014school year?
  1. Received CEIS* during the 2012-2013 school year?

a.
b.
c.
* If needed, please note explanatory comments on a separate sheet and attach it to this form (see Instructions for further information).
Section II - Planned Use of 2015-2016Funds
  1. Is your district planning on using 2015-2016IDEA funds for Coordinated Early Intervening Services (CEIS) in 2015-2016 or 2016-2017?
/ Yes No
  1. Enter2015-2016IDEA Part B Flow-Through Estimatefrom
/ $ ______X 0.15 =
Total amount of 2015-2016IDEA funds district can use for CEIS $ ______
  1. Enter total amount of 2015-2016 IDEA funds district has reserved for CEIS in 2015-2016$

  1. Enter total amount of 2015-2016 IDEA funds district has reserved for CEIS in 2016-17**$

Section III –CEIS Activities Planned in2015-2016
Please describe each CEIS activity that will be funded with the amount reserved for CEISin 2015-2016(please list any additional activities on a separate sheet and attach it to this form):
Type of Activity () / General Description of Activity
 Professional
Development
 Services/Supports
 Professional
Development
 Services/Supports

Signature of Special Ed Director ______Date ______

Please send the originalform by 04/01/17 to:Jennifer Bevers

Oregon Department of Education

255 Capitol Street NE

Salem OR 97310-0203

Form 581-1483-A (Rev 08/2016)