Self assess your completion of State Data:	Yes	No	N/A
1. Student - general placement information
Case manager – select your name if applicable
Home school – select the student’s home school (verify first)
Exited program/Exit reason – complete if applicable
2. Important Dates
This IEP (date of current IEP)
Next IEP (date should be 1 year from This IEP date)
Last Eligibility – date of most recent report or reevaluation consideration
Next Eligibility (date should be 3 years from Last Eligibility)
Initial placement (date from Permission to Place form)
Psychological evaluation date
Medical evaluation date (only if OHI)
Audiological evaluation date (only if Deaf/HH)
Parents informed of student progress - select the statement
3. Active Exceptionalities
Exceptionality – the student’s eligibility category
Classification – can only be 1 primary, all others are secondary
Delivery model – half day or less, more than half day, consultative, etc.
Provider - your teacher number (case mgr. or other provider)
Segments – check segment(s) during which student receives special ed services (only #1-4 available for block high schools)
Hours per week – the number or range of hours of special ed service received NOTE = OK to combine here hours from small group plus Inclusion segments under the Primary Exceptionality!
Entry – date this service begins, NOT initial placement into special ed.
Withdrawal – indicate for terminated service(s) if applicable
Status – Active unless you are withdrawing a student

Self assess your completion of State Data:	Yes	No	N/A
4. Program Summary
Subject /Service – select subject, service or domain
Level – select school level
Start date – select start date for this service only
End Date – select end date for this service only
Time – select the number of segments or minutes per…
Time period – select the time period – per day, per week…
Location – select general ed, inclusive, or small group
State Time Code – leave blank unless 1 of 1^st twelve services listed
Schedule type – for block high schools = “4X4”
5. Additional Services
Inclusion – use code 9 if this is a collaborative or team taught segment. Use code 4 if student has an IEP-assigned parapro this segment. Use codes 5-8 where applicable. NOTE = you CANNOT use code 4 AND check the same segment for special ed service on the Active Exceptionalities screen! NOTE = code 9 ONLY applies to certified special ed teachers, not parapros!
Itinerant – leave blank unless you are an itinerant teacher
Transportation – only code 1 segment (when the student leaves to go to CBI or CBVT on the count day)
Supplemental Speech – leave blank unless you are a speech pathologist
Self-contained – check if student is in small group more than half the day
Special bus – check if student is transported to or from school by special ed transportation
Interim – check if student is on interim status
6. View Program Summary
Click and print the Program Summary for school file
7. View Student Profile
Click and print the Student Profile for school file

Please complete all State Data changes for FTE by the due date in the cover memorandum.

Yes

No

N/A

Yes

No

N/A