PUPILS ENROLLED IN SPECIAL EDUCATION TRANSITION
SCHOOL
DISTRICT: YEAR: 2011-2012
Building/ COUNT September
Program: DAY February
I certify that this is a true and accurate list of Special Education Transition pupils.
Authorized Representative Signature Title Date
Complete for all Special Education Pupils enrolled in Community Based Instruction (CBI),
Vocational Evaluation or Work Activity Center Services. Training Agreement, Safety
Training and Time Verification must be included for each student. For any missing
INSTRUCTIONS: documentation an FTE deduction will happen.
Current Grade Level
Direction or Away
If Paid
from School
Meaningful
51% of Time Under
Assigned to
SE Teacher
Assigned to
Approved
Deviation
Supervision of
On IEP
First Name Last Name Instructor (List
Wage
Certificated
Teacher's
Teacher
Name)
(Y/N) (Y/N) (Y/N) (Y/N) (Y/N)
First Name
Last Name
Current Grade Level
Assigned to
(Y/N)
Instructor
Meaningful
Direction or Away
(Y/N)
from School
On IEP
(Y/N)
Assigned to
(Y/N)
SE Teacher
Approved
Wage
(Y/N)
Deviation
If Paid
(Y/N)
Teacher
Certificated
Supervision of
51% of Time Under
PUPILS ENROLLED IN SPECIAL EDUCATION TRANSITION
GRADES 9-12
District: School Year 2011-2012
School:
STUDENT INFORMATION
Last Name: First Name: Middle:
Grade: Counselor:
WORK ASSIGNMENT
Position / Assignment: Class Period:
Supervising Administrator / Teacher:
This assignment is: (check one)
for the marking period for the semester for the school year
Beginning Date: Ending Date:
Hours per week: Number of Credit Hours Granted:
Date (s) of safety instruction:
Concurrent, related academic course:
EDUCATION GOALS
List the education goals related to this placement that align with the student's career pathway contained in
the student's Educational Development Plan (EDP).*
*Attach copy of the EDP or initial here that the placement coordinator has reviewed the EDP listing the
student's career pathway and educational goals. _________ (initials of placement coordinator)
TRAINING PLAN (Specific Job Tasks To Be Learned At The Worksite) - See Attached Training Plan
IN ORDER FOR THIS TRAINING AGREEMENT TO BE VALID, A RELATED TRAINING PLAN FOR THE PUPIL BEING
PLACED MUST BE ATTACHED OUTLINING THE SPECIFIC SKILLS THAT THE STUDENT WILL BE LEARNING.
(For any unpaid work-based learning experience, specific, unduplicated skills that the pupil will be learning need to be listed for
each 45 hours of placement.)
STUDENT'S RESPONSIBILITIES
1. Complete work assignments in a timely manner
2. Complete activity log sheets on a regular basis
3. Complete work hours verification on a regular basis
4. Be in assigned location on days and times scheduled
5. Follow school's health and safety work rules
6. Abide by all policies and procedures of the program, school district, and the school building
7. Maintain good attendance in school
8. Maintain grades in all subject areas
9. Bring assignment/work problems to attention of your assigned teacher/supervisor
EVALUATION CRITERIA
As part of a Work-Based Education Program (Special Education Transition), this student will be evaluated
in the following areas:
Dependability/Responsibility - attendance, punctuality
Job knowledge - follows instruction, understand procedures
Teamwork - works well with others
Quality of Work - works neatly, accurately; finishes tasks
Personal Management Skills - self-directed, works to potential, positive work attitude
Communication - asks for help, uses appropriate voice tones, uses correct grammar
PROGRAM GUIDELINES
1. Program is an intergral component of the student's educational process and is for the benefit of the
2. Program operates during the school day
3. The district certificated teacher/coordinator makes at least one visit, every nine weeks, to the training
4. Student is regularly supervised by certified staff and provided instruction in areas of skill attainment and
work safety
5. High school completion credit is granted
6. Daily attendance is recorded by using a time sheet and having the supervisor sign the form
7. The program must not violate the Fair Labor Standards Act and the Youth Employment Standards Act
8. The program is designed primarily for benefit of student; assignments progressive in nature
10. It is the school's policy not to unlawfully discriminate on the basis of race, color, religion, national origin
or ancestry, age, gender, height, weight, marital status or disability.
Student's Signature Date
Parent's Signature (If student is not 18 years old) Date
Certificated Supervisor/Coordinator's Signature Date
Principal's Signature Date
IMPORTANT: ATTACH A COPY OF THE STUDENT'S SCHEDULE AND EDUCATIONAL DEVELOPMENT PLAN.
PUPILS ENROLLED IN SPECIAL EDUCATION TRANSITION
Attendance & Time Verification
SCHOOL
BUILDING/ YEAR: 2011-2012
DISTRICT:
PROGRAM:
COUNT: Sept. Feb.
PUPIL: TITLE: GRADE:
MONTH & SERVICE LOCATION
YEAR: AREA: (Room No.):
I certify that this record of hours worked was recorded each day by the pupil and verified by me. The descriptions of tasks performed and
reasons for absences are accurate.
Certified Title of
Date:
Supervisor: Supervisor:
Record hours & tasks performed or reason for absence for each day. Everything highlighted in yellow
INSTRUCTIONS:
must be completed.
----- Time -----
Date In Out In Out Total Hours Tasks Performed or Reason for Absence
M
T
W
TH
F
M
T
W
TH
F
M
T
W
TH
F
M
T
W
TH
F
M
T
W
TH
F
Grand Total
PUPILS ENROLLED IN SPECIAL EDUCATION TRANSITION
Student Name:
Grade: School Year: 2011-2012
Work Site:
Supervisor Name:
The above named student has received on (date)
appropriate safety training for all aspects of the work site and equipment
or process that are involved with the student's safe conduct and management
of the working environment for this work-based placement.
Supervisor Signature:
Date:
Student Signature:
Date:
I have visited the site and determined, after discussion with the site supervisor, that the site is an
appropriate placement for the above named student. I further acknowledge that the student will not
be placed more than 1/2 of the total school daily instructional time in all combined placements.
School Placement Coordinator's Signature:
Date: