Kentucky Department of Education
Division of Learning Services
REQUEST TO EXCEED CASELOAD, CLASS SIZE AND/OR
GRADE RANGE REQUIREMENTS
2017-2018
(707 KAR 1:350)
Date of Request:
Type of Request (Check all that apply):
Caseload Class Size Grade Range
Special Education Cooperative / Select from drop listCentral Kentucky Educational CooperativeGreen River Regional Educational ConferenceJefferson County Exceptional Child Education ServiKentucky Educational Development CorporationKentucky Valley Educational CooperativeNorthern Kentucky Cooperative for Educational ServOhio Valley Educational CooperativeSoutheast/South-Central Educational CooperativeWest Kentucky Educational CooperativeDistrict: / District Number:
Director of Special Education: / Phone Number:
School:
Principal:
Teacher: / Total Caseload:
Classroom Type: / Select from drop listRegular Education Class (Co-Teaching)Resource RoomSeparate/Special ClassSeparate School
School Level: / Select from drop listElementaryMiddle SchoolHigh School
Grade Range of School: / to
Special Education Code: / Select from drop list6010 - VI Special Class6012 - VI Resource/Itinerant6020 - HI Special Class6022 - HI Resource/Itinerant6030 - MMD Special Class6032 - MMD Resource/Itinerant6040 - EBD Special Class6042 - EBD Resource/Itinerant6060 - SLD Special Class6062 - SLD Resource/Itinerant6070 - OI/OHI Special Class6072 - OI/OHI Resource/Itinerant6102 - Speech Patholist Only6103 - Speech Path with 1 SLPA6104 - Speech Path with 2 SLPAs6120 - FMD Special Class6122 - FMD Resource/Itinerant6133 - MD with FMD Special Class6134 - MD with FMD Resource Plan6135 - MD with MMD Special Class6136 - MD with MMD Resource Plan6263 - Co-Teaching Model
1. Has a Waiver Request been approved for this teacher in the last two school years?
Yes No
If Yes, explain:
2. Briefly explain the unusual circumstances and specific reasons that warrant this request.
3. Is there a full-time instructional aide assigned to this teacher for each class period?
Yes No
If no, is there an aide assigned to the special education teacher when an overage occurs?
Yes No
4. Is this teacher assigned to teach any general education classes (not including collaboration) during the instructional day?
Yes No
5. Is this class/unit located at a school campus that is age and grade level appropriate for the students being served? (e.g., High school age or grade level students are not being served at a unit located on a middle or primary school campus.)
Yes No
DESCRIBE TEACHERS DAILY SCHEDULE
INCLUDE CASELOAD, CLASS SCHEDULE AND GRADE RANGE PER PERIOD
Attach the plan for reducing the caseload and/or grade range for this class prior to the beginning of next school year.
If granted, this waiver will not impede any exceptional child from achieving his or her Individual Education Program in the least restrictive environment (KRS 157.360(4)).
Superintendent Signature
FOR OFFICE USE ONLY
REQUEST NO.: DATE:
APPROVED: DATE:
(Reviewer’s Initials)
NOT APPROVED: DATE:
(Reviewer’s Initials)
CORRECTIVE ACTION PLAN APPROVED:
(Reviewer’s Initials) Date
2 | Page Caseload, Class Size and/or Grade Range Waiver
2017-2018