SPECIAL ED DATA FORM – Revised Oct 1, 2015 Teacher ____________________________________ Today’s date ____________________ ENTRY DATE _____________ EXIT DATE ___________ Exit code _______ Change (check here_____ Reason for change____________ EXIT STATUS (Circle) DI = deceased; DO = dropped out; GC= graduated w/certificate; GD= Graduated with regular diploma; MA=reached maximum age; MK= Moved, known continuing; RC= Returned to regular class PP= Parentally placed in private school. Student ID # __________________________________ Social Security # __________________________________ Last name ____________________________________ First name _______________________________________ Sex ( M or F ) Birthdate ________________ Race ________ ELL (English Lang Learner) Y or N (Ethnic codes –Code all that applies: H=Hispanic; N=Am Indian; A=Asian; B=Black or African Am; P=Native Hawaiian/Pac Islander; W=White Building Elem/Jr. High/Sr. High ____________ Grade _______ Transfer ( Y or N ) Alternate Portfolio code ________ ALM (alt. lit/math..grades: 3,4,6,8 & 11 ) ALMS (Alt. Lit/Math/Sci (Grades: 5 & 7) NA Not applicable DLM Delaying Alt. Lit/Math to Grade 11 (Grade: 9 only) SLDM Taking Alt. Sci.; delaying Alt. Lit/Math to Grade 11 (Grade: 10 only) Medicaid eligible ( Y or N ) Medicaid # _______________________________ SECONDARY Transition Date ___________________________ (DONE @ ANNUAL REV. AT END OF 8TH GRADE/OR WHEN STUDENT IS 15 YEARS OLD Referral Date ________________________ Person/Agency Referring ________________________________ Eligibility Det. Date _________________ (Original date decided to place) date that changes) Last Comp Eval Date ____________________ (Last eval was done/when re-eval is done this is the only Annual Review date _________________ Temporary Student ( Y or N ) Extended year ( Y or N ) _____________________________________________________________________________________________________________________ _______________________ EDUCATIONAL PLACEMENT ______________ EDUCATIONAL PLACEMENT LAST YEAR _________________ SPECIAL ED PLACEMENT DATE __________________ (ORIGINAL date student was determined eligible for services and placed. (Educational Placement codes) DB=Day School-Public;HH=Hospital/Homebound; RB=Residentialpublic;RI=Residential-Private; CF=Correctional Facility;RR=Resource Room 421-1260 MW;RG=Regular classroom 420 and less MW;SC=Self Contained 1261 and more MW;CF=Correctional Facility; PP=Parentally Placed in Private school PRIMARY DISABILITY _________________________ SECONDARY DISABILITY ____________________ (Primary Disability Codes: AU=Autism; DB=Deaf-Blindness; ED=Emotional Disturbance; HI= Hearing Impaired; MD=Multiple Disabilities; MR=Intellectual Disability; OHI=Other Health Impairment; OI=Orthopedic Impairments; SI=Speech/Language Impairments; SLD=Specific Learning Disorder; TBI=Traumatic Brain Injury; VI=Visual Impairments) SPEECH……. Date speech entered ________________ Date terminated _______________ TIME SERVED unit (MW for Resource)__________ (MW for speech)_____________ Total minutes served _____________