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Transfer In-state Documentation Form

By Donna Bell,2014-02-08 06:24
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Transfer In-state Documentation Formin,form,state,State,Form

    MO STATE SAMPLE

     <District Name>

    IDEA IN-STATE Transfer Student

    DOCUMENTATION FORM

REFER TO THE SPECIAL EDUCATION PROGRAM REVIEW: COMPLIANCE STANDARDS AND INDICATORS

    MANUAL, TRANSFER PROCEDURES SECTION, FOR A COMPLETE EXPLANATION OF REQUIRED DOCUMENTATION.

Student Name Date of Birth Grade

    Date of Enrollment (m/d/y) Date of student’s first day of school attendance (m/d/y):

Previous School

    Name of School District Building

    Address

    City State Zip

    Phone Fax

    Records Request: State and federal regulations require that when a student with a disability transfers from one school in the state to another school district in Missouri, the new school in which the child enrolls shall

    take reasonable steps to promptly obtain the child’s records, including the IEP and supporting documents and any other records relating to the provision of special education or related services to the child, from the

    previous school. The previous school in which the child was enrolled is required to take reasonable steps to promptly respond to such request from the new school.

The Missouri Safe Schools Act requires receiving school districts to request records within two (2) business

    days of enrollment. Sending Missouri districts are required to send records within five (5) business days of receiving a request for records.

    Requested (m/d/y) Received (m/d/y) Evaluation Report

    Requested (m/d/y) Received (m/d/y) IEP

    Other: Requested (m/d/y) Received (m/d/y)

     No evaluation report and no IEP received, go to Section 2.

     Evaluation report received, but no IEP, go to Section 3.

     IEP received, but no evaluation report, go to Section 4.

     Both evaluation report and IEP received, go to Section 5.

Revised July 24, 2013 Page 1

     Did review of information on enrollment form indicate that the child was receiving or had previously received Special Education

     Services? Yes No

     From interviews, is there any reason to suspect that the child is a child with a disability under IDEA?

     Yes No

Attach the Interview Documentation Form(s):

     Parent/Guardian/ Student Interview (age 18+)

     Officials of Sending LEA

    DECISION:

     NO reason to suspect the child has a disability. STOPPlace child in regular education.

     YES, there is reason to suspect the child has a disability under IDEA the LEA must provide comparable services based on

     interviews until eligibility determination can be made. Proceed below.

    Name/role of individual(s) making decision: Date of Decisions (m/d/y)_____/______/_______ Name Role

    Name Role

    Name Role

    SUBSECTION 2a:

     If a current evaluation report is received within 30 days of enrollment:

     Complete Section 3

     If a current evaluation report is NOT received within 30 days of enrollment:

     Documentation is present that revaluation procedures were initiated on (m/d/y) _____/_____/_____

    Was the child determined eligible? Date of eligibility determination: (m/d/y)______/______/______

     Yes

    ; IEP team convened within 30 days of eligibility determination to develop an IEP. Date of IEP meeting:

    (m/d/y) _______/_______/_______

     No

    ; Parent provided with prior written Notice of Action for Ineligibility/Change of Placement and child exited

    from services.

    EVALUATION REPORT

    The public agency reviewed the Evaluation Report to determine whether to accept or reject it.

     Date evaluation report reviewed and decision made regarding eligibility (m/d/y) _____/_____/_____

DECISION:

     Accepted

     Acceptance indicates that the evaluation report is compliant and includes all information necessary to

     determine eligibility in the State of Missouri. Proceed to Section 3a below.

     Rejected

     Reevaluation must be initiated to determine eligibility. Proceed to Section 3b below:

Name/role of individual(s) making decision:

    Name Role

    Name Role

    Name Role

    Revised July 24, 2013 Page 2

SUBSECTION 3a:

     Conduct interviews to determine services (attach Interview Form)

     Parent/Guardian / Student Interview (age 18+)

     Officials of Sending School

     Conduct an IEP meeting to develop an annual IEP for the student

     IEP developed on _____/_____/_____

     Was there a delay conducting the IEP meeting or determining acceptance of the evaluation report?

    o If Yes Public agency, in consultation with the parent, provided FAPE to the child, including services

    comparable to those described in the previous IEP, until such time as the public agency could adopt the

    previous IEP or convene an IEP team meeting to develop a new IEP that is consistent with Federal and State

    law and regulations.

    SUBSECTION 3b:

     Conduct interviews to determine services (attach Interview Form)

     Parent/Guardian Interview

     Student Interview (age 18+)

     Officials of Sending School

     Provide comparable services until eligibility can be determined.

     Initiate reevaluation for the student. Documentation is present that reevaluation was initiated on

     _____/_____/_____

    Was the child determined eligible? Date of eligibility determination: (m/d/y)______/______/______

     Yes

    ; IEP team convened within 30 days of eligibility determination to develop an IEP. Date of IEP meeting:

    (m/d/y) _______/_______/_______

     No

    ; Parent provided with prior written Notice of Action for Ineligibility/Change of Placement and child exited

    from services.

    IEP

    The public agency reviewed the IEP to determine whether to accept or reject it.

Date IEP reviewed and decision made to accept or reject: (m/d/y) _____/_____/_____

DECISION:

     Accepted the transferred IEP IEP Implemented on _____/_____/_____. Proceed to Section 4a.

     Acceptance indicates the IEP is compliant with Missouri Regulations and can be implemented as written

     without any revisions.

     Rejected the transferred IEP. Proceed to Section 4b.

     Name/Role of Individual(s) Making Decisions

    Name Role

    Name Role

    Name Role

    SUBSECTION 4a:

    Was there a delay in determining acceptance of the IEP?

     No, the IEP is implemented as written.

     Yes, the Public Agency, in consultation with the parent, provided FAPE to the child, including services comparable to

    those described in the previous IEP, until such time as the public agency could adopt the previous IEP or convene an IEP

    team meeting to develop a new IEP that is consistent with Federal and State law and regulations. Date of IEP meeting to

    review/revise the IEP (m/d/y) _____/_____/_____.

Revised July 24, 2013 Page 3

SUBSECTION 4a (continued):

    Was Evaluation Report received within 30 days of enrollment?

     Yes, Date Evaluation Report Received (m/d/y) _____/_____/_____

     Date Evaluation Report Reviewed (m/d/y) _____/_____/_____

    DECISION:

     Accepted

     Acceptance indicates that the evaluation report is compliant and includes all information necessary

     to determine eligibility in the State of Missouri.

     Rejected, reevaluation must be initiated to determine eligibility*.

     No, reevaluation must be initiated to determine eligibility*.

    * Reevaluation initiated to determine eligibility due to rejection of the Evaluation Report OR not receiving an Evaluation

    Report:

     Initiate reevaluation for the student. Documentation is present that reevaluation was initiated on

    _____/_____/_____

    Was the child determined eligible? Date of eligibility determination: (m/d/y)______/______/______

     Yes

    o IEP team convened within 30 days of eligibility determination to review/revise the

    IEP, if needed.

    o Date of IEP meeting: (m/d/y) _______/_______/_______

     No

    o Parent provided with prior written Notice of Action for Ineligibility/Change of

    Placement and child exited from services. SECTION 4b:

     The Public Agency, in consultation with the parent, provided FAPE to the child, including services comparable to those described in the previous IEP, until such time as the public agency could adopt the previous IEP or convene an IEP team meeting to develop a new IEP that is consistent with Federal and State law and regulations.

    Date of IEP meeting to review/revise the IEP (m/d/y) _____/_____/_____

    Was Evaluation Report received within 30 days of enrollment?

     Yes, Date Evaluation Report Received (m/d/y) _____/_____/_____

     Date Evaluation Report Reviewed (m/d/y) _____/_____/_____

    DECISION:

     Accepted*

     *Acceptance indicates that the evaluation report is compliant and includes all information necessary

     to determine eligibility in the State of Missouri.

     Rejected, reevaluation must be initiated to determine eligibility*

     No, reevaluation must be initiated to determine eligibility*

     *Reevaluation initiated to determine eligibility due to rejection of the Evaluation Report OR not receiving an Evaluation

    Report:

     Initiate reevaluation for the student. Documentation is present that reevaluation was initiated on

    _____/_____/_____

     Was the child determined eligible as a result of the reevaluation?

     Date of eligibility determination: (m/d/y)______/______/______

     Yes

    ; IEP team convened within 30 days of eligibility determination to review/revise the IEP, if

    needed.

    ; Date of IEP meeting: (m/d/y) _______/_______/_______

     No

    ; Parent provided with prior written Notice of Action for Ineligibility/Change of Placement and

    child exited from services.

Revised July 24, 2013 Page 4

EVALUATION REPORT

     The public agency reviewed the Evaluation Report to determine whether to accept or reject it.

Date evaluation report reviewed and decision made regarding eligibility (m/d/y) _____/_____/_____

DECISION:

     Accepted the transferred Evaluation Report. Acceptance indicates that the evaluation report is compliant and includes

    all information necessary to determine eligibility in the State of Missouri. Proceed to review of the transfer IEP below.

     Rejected the transferred Evaluation Report. A reevaluation must be initiated to determine eligibility. Provide

    comparable services. Reevaluation initiated on (m/d/y)_______/_______/_______

     Was the child determined eligible? Eligibility determined on (m/d/y)___/____/_____

     Yes

     IEP team convened within 30 days of eligibility determination to develop an IEP

     No

     Parent provided with prior written Notice of Action for Ineligibility/Change of Placement and child

    exited from services

     Name/Role of Individual(s) Making Decision:

    Name Role

    Name Role

    Name Role

    IEP

    The public agency reviewed the IEP to determine whether to accept or reject it.

Date IEP reviewed and decision made to accept or reject: (m/d/y) _____/_____/_____

    DECISION:

     Accepted. Acceptance indicates the IEP is compliant according to Missouri Regulations and can be implemented as

     written without any revisions the transferred IEP. IEP Implemented on _____/_____/_____.

     Rejected the transferred IEP. The Public Agency, in consultation with the parent, provided FAPE to the child,

     including services comparable to those described in the previous IEP, until such time as the public agency could adopt

     the previous IEP or convene an IEP team meeting to develop a new IEP that is consistent with Federal and State law

     and regulations. Date of IEP meeting to review/revise the IEP (m/d/y) _____/_____/_____.

Name/Role of Individual(s) Making Decision

    Name Role

    Name Role

    Name Role

    Revised July 24, 2013 Page 5

    ATTACHMENT

    INTERVIEW INFORMATION

    DOCUMENTATION FORM

    Student Name: Date of Enrollment (m/d/y): Name of Sending District: Name of School Building:

    Date of Interview: Method: Phone (_____)-___________________

     In person Other:______________

Name of parent/guardian/student (18+) interviewed :

Name/Role of LEA personnel conducting interview:

    IEP Information Evaluation Information: Does the student have current IEP? Has the student been found eligible for special education? No STOP. No STOP. Yes, complete information below Yes, complete information below Date (m/d/y) of current IEP: _____/_____/_____ Date (m/d/y) of current evaluation: _____/_____/_____ Brief summary of Present Level of Performance: Category of eligibility: Autism Deaf/Blindness Summary of Goals on the IEP: Emotionally Disturbance Hearing Impaired/Deafness Intellectual Disability Special Education/Related Services: Multiple Disabilities Description Amount Frequency Location Orthopedic Impairment Other Health Impaired

     Specific Learning Disability (check category)

     Oral Expression Written Expression

     Reading Fluency Reading Comprehension

     Basic Reading Skills Math Problem Solving

     Math Calculations Listening Comprehension Summary of Accommodations/Modifications:

     Speech Impaired

     Articulation:_____________________

     Fluency Placement:

     Voice

     Language Impaired Special Considerations:

     Expressive Student has BIP?

     Receptive Yes describe:________________________________

     Pragmatics No

     Traumatic Head Injury (TBI)

     Visual Impairment/Blindness Transportation is a related service?:

     Young Child with a Developmental Delay Yes describe:________________________________

     No

    Brief summary of Evaluation Report / additional areas of

    concern: Student take MAP-A? Yes No

     Other relevant information:

    Revised July 24, 2013 Page 6

    Date of Interview: Method: Phone (_____)-___________________

     In person Other:______________

Name(s) /Role(s) of Sending LEA personnel interviewed :

Name/Role of Receiving LEA personnel conducting interview:

    IEP Information Evaluation Information: Does the student have current IEP? Has the student been found eligible for special education? No STOP. No STOP. Yes, complete information below Yes, complete information below Date (m/d/y) of current IEP: _____/_____/_____ Date (m/d/y) of current evaluation: _____/_____/_____ Brief summary of Present Level of Performance: Category of eligibility: Autism Deaf/Blindnesss Summary of Goals on the IEP: Emotionally Disturbance Hearing Impaired/Deafness Intellectual Disability Special Education/Related Services: Multiple Disabilities Description Amount Frequency Location Orthopedic Impairment Other Health Impaired

     Specific Learning Disability (check category)

     Oral Expression Written Expression

     Reading Fluency Reading Comprehension

     Basic Reading Skills Math Problem Solving

     Math Calculations Listening Comprehension Summary of Accommodations/Modifications:

     Speech Impaired

     Articulation:_____________________

     Fluency Placement:

     Voice

     Language Impaired Special Considerations:

     Expressive Student has BIP?

     Receptive Yes describe:________________________________

     Pragmatics No

     Traumatic Head Injury (TBI)

     Visual Impairment/Blindness Transportation is a related service?:

     Young Child with a Developmental Delay Yes describe:________________________________

     No

    Brief summary of Evaluation Report / additional areas of

    concern: Student take MAP-A? Yes No

     Other relevant information:

    Revised July 24, 2013 Page 7

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