New Jersey State Department of Education
Office of Special Education Programs
NOTIFICATION OF PLACEMENTS
Districts must complete this form and send it to the county office of education within 10
days of placement (include IEP) with a copy to the receiving school.
A. Identifying Information: County _________________ District _______________________
Student’s Name ____________________ Date of Birth _________
B. Name of School or Facility ______________________________ Date Placed _________
C. Placement Setting:
Receiving school placement, check one (N.J.A.C. 6A: 14-7.5 (b))
_____ Educational Services Commission
_____ Jointure Commission
_____ Katzenbach School for the Deaf
_____ DHS Regional Day School
_____ DOE Regional Day School
_____ Special Services School District
_____ Public College Operated Program
_____ Approved Private School for the Disabled
_____ Community Rehabilitation Program (N.J.A.C. 6A: 14-4.7(f))
Certification: I certify that this information is complete and in compliance with N.J.A.C. 6A:
14. Send one copy to the county office of education and one to the receiving school.
Chief School Administrator or Designee
Typed Name and Signature
Date
Receiving School Acknowledgement: Send one copy to the district and one copy to the
county office of education.
__________ Date of student’s first day of attendance (N.J.A.C. 6A: 14-7.5 (c ))
Receiving School Director Date
Typed Name and Signature