IEP INFORMATION SHEET

Student Name:______ Student grade: ______Building: ______

Initial IEP (check 39 a, b, and c)  Annual IEP Name of Contact Provider - LISD staff or SE Teacher:______

Revised March 2013

IEP Date:______

IEP: Yes (if eligible, will continue to have IEPs)

 No (Not eligible)

IEP Status: (if yes above): SE

Primary Disability (select only one)

05 Cognitive Impairment

06 Emotional Impairment

07 Hearing Impairment

08 Visual Impairment

09 Physical Impairment

10 Speech & Language impairment

11 Early Childhood Dev Delay

13 Specific Leaning Disability

14 Severe Multiple Impairment

15 Autism Spectrum Disorder

16 Traumatic Brain Injury

17 Deaf-Blindness

20 Other

 22 Legally Blind

 24 Deaf

Secondary Disability: ______

(Use codes above if needed)

Current GE FTE: ______

Current SE FTE Section 52: ______

Placed by Other District IEP

Out of district student/nonresident of operating district

This does not include student who moved into the district or school of choice

Information for INITIAL IEP only

Parental Consent Eval (39a) (Only for initials)

11 IEP completed within 30 school days

12 IEP completed within extended timeline

13 IEP Not Timely: Parent did not make child available

14 IEP Not Timely: Timeline began in previous district

15 IEP Not Timely: Personnel not available for evaluation

16 IEP Not Timely: Personnel not available for IEP

17 IEP Not Timely: External reports not available

 18 IEP Not Completed: Student died

 19 IEP Not Completed: Parent withdrew consent

 20 IEP Not Completed: Parent did not make child available

 21 IEP Not Completed: Student moved

Result of Initial IEP: (39b)

1 Evaluated and found eligible

2 Evaluated and found not eligible

4 Initial IEP was not held for reason in 39a

Days Beyond Eval of IEP(39c): ______

Date of Parental Consent: ______

Date district received consent NOT when parent signed!!

MET Date: ______

SE Exit Date: ______

Primary Ed Setting - Placement is outside the general education building

02 Public or PrivateSpec.EdSchoolBuilding at Public Expense

03 Public or Private Residential Facility at Public Expense

05 Correctional Facility

06 Homebound/Hospital

07 Parentally Placed in Private School or HomeSchool at Private/Parent Expense

Primary Ed Setting - Placement within the general education building

11 Inside the gen. Ed classroom 80% or more of the school day

12 Inside the gen. Ed classroom between 40% and 79% of the school day

13 Inside the gen. Ed classroom less than 40% of the school day

 46 EC program at least 10 hr/wk majority of SE hrs in EC program

 47 EC Program at least 10 hr/wk majority of SE hrs in other location

Program Code Start Date End Date

 None

 110 Programs for Mild Cognitive Impairment

 140 Programs for Emotional Impairment

 194 Elementary or Secondary Level Resource Program

 120 Programs for Moderate Cognitive Impairment

 130 Programs for Severe Cognitive Impairment

 150 Programs for Learning Disabled

 160 Programs for Hearing Impairment

 170 Programs for Visual Impairment

 180 Programs for Physical or Other Health Impairment

 190 Programs for Severe Multiple Impairment

 191 Early Childhood SE (Classroom) Program

 192 Programs for Severe Language Impairment

 193 Programs for Autism Spectrum Disorder

 270 Early Childhood SE Services

Support ServicesStart Date End Date

 290 Speech & Language Impaired

 310 School Social Worker

 360 Occupational Therapy

 370 Physical Therapy

 200 TC Autistic Impaired

 210 TC Mentally Impaired

 220 TC Emotionally Impaired

 230 TC Learning Disabled

 240 TC Hearing Impaired

 250 TC Visually Impaired

 260 T.C. Physically & OHI

280 Homebound/Hospitalized

 291 Adaptive Physical Education

 320 School Psychologist

 383 Music Therapy

 390 Art Therapy

 400 Audiological Services

 406 Interpreter for the Deaf

 410 Recreation Services

 440 Special Transportation

 450 School Health Services

 460 Rehabilitation Counseling

 470 Orientation & Mobility

 480 Work Site Based Learning

 490 Comm. Training/Voc Ed (Gen Ed)

 491 Spec. Needs (Adapted Voc. Ed)

 492 Individual Voc. Education

 493 Community Training/Voc. Ed/Spec. Ed

SE Exit Reason:

 30 IEP team determined student no longer in need of SE

 31 Parent revoked consent for SE

Revised March 2013

Total Hrs/Min per Week / GE Hrs/Min Only / Co-Taught Hrs/Min / SE Hrs/Min Only
A / B / B/A= = Current Gen Ed FTE (Gen. Ed Teacher Time)
A / C / D / (C+D)/A= = Current SE FTE (SE Teacher Time)
A / B / C / (B+C)/A= = Primary Ed Setting
(Location of Student - Gen Ed)

Revised March 2013