Pleasants County Schools Wveis Data Collection Form

PLEASANTS COUNTY SCHOOLS WVEIS DATA COLLECTION FORM

**Must Accompany Initials/Reevaluations/Eligibility/IEP Meeting Paperwork

Student Name______WVEIS #______

Birthdate ______Current Grade ______School ______

Purpose of Mtg.(attach all req. paperwork)Circle/date all that apply: Initial/Elig.______Reeval/Elig. ______IEP______

Complete this Section for all Reevaluations and Eligibility

Reeval. Det. Plan Mtg. Date ______Consent for Testing Rec. (if applicable) ______Response ____ C=Consent N=No Response R=Refused Z=No Testing Required Date Elig. Det. ______EligibilityStatus ____ 1=Eligible 2=Not Eligible Reeval. Due Date ______E/R Code _____ AU, BD, CD, DB, DF, EG, GF, HI, LD, MD, MM, MP, MS, OH, PH, PS, TB, VI (See Directions Sheet for desc. and other codes)

COMPLETE THE FOLLOWING SECTIONS FOR ALL IEPS

CASE MANAGER

LIST ONE SPECIAL EDUCATION SERVICE (FROM SERVICES SECTION: PART B) OR RELATED SERVICE (PART C) PER LINE

E/R / U/D
Service / MPW
Indirect/Consult / MPW
Reg Ed Inclusion / MPW
Pullout/Sep Class / MPW
Total / TEACHER
Last Name
(4 letters)
First initial / SUBJECT AREA / STS / INITIAL DATE
(Des. In E/R) / EXIT DATE
(Mo/Da/Yr)
TOTAL / ------ / ------ / ------ / ------ / ------ / ------

LRE IS BASED ON MPW OF PULL-OUT INSTRUCTION TOTAL; SERVICES RECEIVED WITHIN A SPECIAL EDUCATION SETTING PER State Board Policy 2510

NOTICE OF MTG. (Date Sent): / METHOD (Circle One):
1=Regular Mail 2=Phone Request
3=Hand Delivered 4=Certified Mail / RESPONSE (Circle One):
W=Will Attend
N=Will Not Attend / LRE (From IEP Placement Page):
0 1 2 3 4 5 6 7 8 9
W X Y Z M N P R S
EXTENDED SCHOOL YEAR Yes No / DIPLOMA TYPE Regular Modified / SPECIALIZED TRANS. Yes No
TESTING / YES/NO / CODE(S)/DESCRIPTION
Standard Conditions / Yes No / None Needed
Standard Conditions with Accommodation(s) / Yes No
Alternate Assessment/Standard Conditions / Yes No / None Needed
Alternate Assessment with Accommodations / Yes No

*MEDICAID*

Medicaid Number (if known):Diagnosis Code: