New Jersey Deapartment of Education

							                             New Jersey Department of Education
                               Office of Special Education Programs

                              NOTIFICATION OF PLACEMENTS
Districts must complete this form, attach a copy of the student’s IEP and forward these to the
county office within 10 days of placing a student with a disability on home instruction or in a
receiving school. When placing a student in a receiving school, forward a copy of the
notification to the receiving school. Please note: Notification of placement in the same
receiving school is not required each school year. Notification is not required, if the out-of-
district placement is another public school district.

District of Residence                                                   County
Student’s Name                                                       Date of Birth

Placement Setting:
Home Instruction:            Initial notification for 60 days      Renewal #              for 60 days

Check whether the notification of home instruction is an initial notice. If a renewal, indicate whether
this is the 2nd, 3rd, etc. notification of renewal.

Receiving school placement, check one [N.J.A.C. 6A:14-7.5(b)]

Name of School or Facility                                                  Date Placed

         Educational Services Commission                           Special Services School District
         Jointure Commission                                       Katzenbach School for the Deaf
         Public College Operated Program                           Regional Day School
         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
                                            Elizabeth Maddalena, Director                          Date

Phone Number       973-669-5400 Ext. 231

Receiving School Acknowledgment: Sign and send 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

                                                                                           Revised 10/03
                           New Jersey Department of Education
                             Office of Special Education Programs

                            NOTIFICATION OF PLACEMENTS
This form will be used by the resident district to notify the county office of education when a
student with a disability is placed on home instruction according to N.J.A.C. 6A:14-4.8(a) or in
a receiving school as described in N.J.A.C. 6A:14-7(a) and N.J.A.C. 6A:14-4.7(f). It will also be
used by the receiving school to notify the county office of education of the student’s first day
of attendance as required by N.J.A.C. 6A:14-7.5(c).

For home instruction, please indicate whether the notification is for initial placement or
renewal. A copy of the IEP is not required with a notification of renewal, unless the IEP has
been revised.

The resident district will enter the identifying information and the name of the facility and date
of the anticipated placement of the student. Check the type of receiving school [N.J.A.C.
6A:14-7.5(b) or N.J.A.C. 6A:14-4.7(f)] in which the student is to be placed. Send this notice
along with the IEP to the county office of education within ten days of placement with a copy
to the receiving school.

The receiving school will use their copy of this notice to acknowledge the student’s first day
of attendance by entering the date and sending a copy to the county office of education.

                                                                                    Revised 10/03