SIMS (Student Information Management System) Required Data by 1Eg9MBX

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									   SIMS (Student Information Management System) Required Data Elements                    R. 08-11    NC-13

Student Name:                                                          Purpose of Meeting
                                                                          Initial Eligibility, IEP, Placement
                                                                          Change (complete date and area that changed)
Effective Date of Services:                                               Three Year Reevaluation
                                                                          Dismissal from Services Date: ________
Special Education Placement Category (Please circle one)
School Age 6-21                   Preschool – Ages 3-5 (even if the    Instructional Program Type
                                  student is enrolled in K)            (This is determined by the coding used for the Cost
                                                                       Analysis completed by business manager or special
0100 – General Classroom with       310 - Early Childhood Setting-10   ed. director)
modifications 80-100%               hrs /week                          (Please circle one)
0110 - Resource Classroom           A1-services in ECH setting         A. Programs for Mild to Moderate Disabilities
40-79%                              315 - Early Childhood Setting-10   B. Programs for Severe Disabilities
0120 - Self-Contained Classroom 0-  hrs/week                           C. Speech Only
39%                                 A2-services in other location      D. Early Childhood (ages 3-5)
0130 – Separate Day School          325 - Early Childhood Setting-     E. Day Program
0140 – Residential Facility         Less than 10 hrs /week             F. Residential Program
0150 - Home/Hospital Program        B1- services in ECH setting        G. Homebound Program
                                    330 - Early Childhood Setting-
                                    Less than 10 hrs /week
                                    B2-services in other location
                                    335 - Separate Class
                                    345 - Separate School
                                    355 - Residential Facility
                                    365 - Home
                                    375 - Service Provider Location
Special Education Primary Disability Areas:                            Multiple Disability Areas:
(Please circle one)                                                    0505 - Emotionally Disturbed
0500 - Deaf-Blind                                                      0510 – Cognitive Disability
0505 - Emotionally Disturbed                                           0515 - Hearing Loss
0510 – Cognitive Disability                                            0525 - Specific Learning Disabled
0515 – Hearing Loss                                                    0530 - Multiple Disabilities
0525 - Specific Learning Disabled                                      0535 - Orthopedic Impairments
0530 - Multiple Disabilities                                           0540 – Vision Loss
0535 - Orthopedic Impairments                                          0545 - Deafness
0540 – Vision Loss                                                     0550 - Speech/Language Impairments
0545 - Deafness                                                        0555 - Other Health Impaired
0550 - Speech/Language Impairments                                     0560 - Autism
0555 - Other Health Impaired                                           0565 - Traumatic Brain Injury
0560 - Autism                                                          0570 – Developmentally Delayed
0565 - Traumatic Brain Injury
0570 – Developmentally Delayed                                         Multiple Disability 1 ________
Special Education Services:                                            Multiple Disability 2 ________
(Please indicate the number of hours or exit date)                     Multiple Disability 3 ________
                                                                       Multiple Disability 4 ________
Physical Therapy ________                                              Multiple Disability 5 ________
Recreational Therapy ________                                          Assistive Technology Yes / No
Audiological Services ________                                         Transportation Yes / No
                                                                       Significant Cognitive Disability Yes / No
Speech/Language Therapy ________
                                                                       IEP Program Exit Reason
Occupational Therapy ________                                          01 - No longer received Sped Service
Psychological Services ________                                        02- Graduated with regular high school diploma
                                                                       04 - reached maximum age
School Nurse Services ________                                         05 - died
Orientation & Mobility Services ________                               06 - moved known to be continuing
                                                                       07 - moved not known to be continuing
Counseling Services ________                                           08 - dropped out
Social Work Services ________                                          09 - refused services
                                                                       10 - Completed IFSP prior to reaching maximum age
Other Therapy Services ________ (Use for Medical Services,             for Part C
Interpreting Services, Parental Counseling/Training and Other)         11 - Change in IEP
                                                                       12 – Student Continues
                                      INDICATOR 11 DATA


SIMS # (to be completed by district)_________________________________________

Date of Birth ___________________________________________________________

Date Permission Received ________________________________________________

Date Last Evaluation Completed __________________________________________

School days from day permission received to last evaluation completed
(count weekdays if child is not school-aged) _______________________________

Date Eligibility Determined _______________________________________________

Eligible for Special Education?   Yes/No

								
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