CECAS INPUT FORM Purpose: (Check All That Apply)

CECAS INPUT FORM Purpose: (Check all that apply)

Directions: Complete this form ANY time information Enroll

changes (See Purpose). Send copy to Transfer From:______Date______

Becky Garrison at Central Office. Initial Placement

 Reevaluation Placement

If New Placement: Need SIMS#______ IEP – Annual Review

Enrollment Date at Your School ______/______/______ Exit

**PLEASE COMPLETE IF NEW or CHANGE OF ADDRESS** Add Related Service______

Address: (Student)______ Delete Related Service ______

Telephone: ______ Change Setting

Parents:(Name)______ Change Label (MAKE SURE ALL COPIES ARE LEGIBLE)  Other______

Child Demographics

(Please complete entire Child Demographics section)

Last Name:______First Name:______Middle Name:______

Date of Birth: ______Gender (circle one): M F Primary Exceptionality______

If LD – areas: ______

School: ______Grade: ______

Ethnicity (circle one)African-American HispanicWhite Multi-CulturalOther:______

Special Education

Referral Date: (DEC 1) if Initial Placement ______

Date of new DEC 5: ______

Purpose: (circle one) Initial Placement Reevaluation Other/Reason______

Current IEP:

Purpose (circle one): Initial Reevaluation Annual Review Addendum Other: ______

Date of IEP Meeting: ______

Date of IEP: From ______To ______

Setting (circle one):REG RES SEP HOM PSS PKRG PKRE PKRS PKSP PKSC PKSS PKPLPKHM Other:______

Service delivery (fill in all that pertain to student):

ServiceTime Per Session Frequency Setting(circle) Notes (optional)

Consultation_____ minhrat ____ times per ____ in pulloutwith regular ______ Direct EC _____ minhr at ____ times per ____ in pulloutwith regular ______

Direct EC _____ minhrat ____ times per ____ in pulloutwith regular ______ Direct EC _____ minhr at ____ times per ____ in pulloutwith regular ______

Direct EC _____ minhrat ____ times per ____ in pulloutwith regular ______

Other: ______minhrat ____ times per ____ in pulloutwith regular ______

Related Services:

OT _____ minhrat ____ times per ____ in pulloutwith regular ______

PT _____ minhrat ____ times per ____ in pulloutwith regular ______

Speech/Lang _____ minhrat ____ times per ____ in pulloutwith regular ______

Speech/Lang _____ minhrat ____ times per ____ in pulloutwith regular ______

TranRestraints: (circle one) Yes / No Specify: ______

Other:______minhrat ____ times per ____ in pulloutwith regular ______

For Exit Only: Date of Exit:______

Reason: Exit EC (DE) Grad/Certificate Grad/Diploma Dropout Moved MaxAge Died

Completed by: ______Date:______

CO Database entry by:______Date:______

CECAS entry by (CO): ______Date:______

8/01/07

White Copy – CO Green Copy – EC Folder Yellow Copy - SIMS