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					 NORTH SANTA CRUZ COUNTY SELPA
  ORTH ANTA RUZ OUNTY




SPECIIAL EDUCATIION FORMS HANDBOOK
 PEC AL DUCAT ON ORMS ANDBOOK
                 2006



        REVISED July 1, 2006



                    Dan Cope
        Assistant Superintendent, SELPA
               809 H Bay Avenue
              Capitola, CA 95010
                 (831) 464-5677
              FAX (831) 464-5678
                      ACKNOWLEDGEMENTS

Special thanks to the following people for the time spent, expertise freely shared and
dedication to support students, teachers and parents in the revision of the SELPA Forms and
the SELPA Forms Procedural Handbook.

Beth Leslie                          San Lorenzo Valley Unified
Hal Ledbetter                        Santa Cruz County Office of Education
Jackie Tuttle                        Live Oak District
Joanne Rude                          Soquel Union Elementary
Judy Luiz                            Scotts Valley Unified
Lenore Montegna                      Santa Cruz City Schools
Maria Milton                         Soquel Union Elementary
Debbi Nargi-Brown                    Santa Cruz City Schools
Sally Beck                           Santa Cruz County Office of Education
Kathy Borello                        Delta Charter
Wendy Bogges                         North Santa Cruz County SELPA
                                           TABLE OF CONTENTS



General Computer Information ...............................................................................................4

Student Data Entry, SELPA 1 .................................................................................................9

Procedural Check List, SELPA 2..........................................................................................11

Contact Log, SELPA 3 .........................................................................................................12

Log of Access to Pupil Records, SELPA 4...........................................................................14

Referral for Individual Assessment, SELPA 5A ..................................................................16

Classroom Intervention Log, SELPA 5B..............................................................................19

Notice of Referral and Plan to Assess, SELPA 6 .................................................................22

Assessment Plan SELPA 7A and Triennial Review of Eligibility, SELPA 7B ...................24

Parent/Guardian Authorization to Request/Release Information, SELPA 8A & B .............28

Notice of IEP Team Meeting (Parent/Guardian/Student), SELPA 9A .................................31

Notification of IEP Team Meeting (Staff) SELPA 9B .........................................................34

IEP Team Member Excusal in Whole or in Part, SELPA 9C ...............................................37

Assessment Report, SELPA 10A & B ..................................................................................36

Present Levels of Educational Performance, SELPA 11 ......................................................39

Annual Goals and Benchmarks/Short-Term Objectives, SELPA 12 ...................................43

Individual Education Program (IEP) Student Data, SELPA 13A ........................................47

IEP - Assessment and Special Factors, SELPA 13B ............................................................51

IEP - Services, SELPA 13C ..................................................................................................55

IEP - Signatures, SELPA 13D ..............................................................................................59

IEP-Continuation Page, SELPA 13E ....................................................................................62

IEP - Individual Transition Plan, SELPA 13F & G ..............................................................64



                                                                                                                                   1
                                   TABLE OF CONTENTS (Cont.)
IEP- Specific Learning Disability, Team Determination of Eligibility, SELPA 13H ..........71

IEP - Specific Learning Disability, Discrepancy Documentation Report, SELPA 13I ........73

Addendum to IEP, SELPA 14 ..............................................................................................75

Letters for IEP Meetings Without Parents, SELPA 17 .........................................................77

DIS Monitoring, SELPA 18 ..................................................................................................79

Parent Consent for Interim Placement, SELPA 19 ...............................................................81

Mental Health Review and Referral, SELPA 20, 21 A & B.................................................83

Request for Surrogate Parent, SELPA 22 .............................................................................87

Appointment of Educational Representative, SELPA 23 .....................................................89

Low Incidence Fund Expenditure Request Form, SELPA 24 ..............................................91

Application/Referral for CCS Medical Therapy Services, SELPA 25 .................................94

LCI Placement, SELPA 26 ...................................................................................................96

Interagency Referral, SELPA 27 ..........................................................................................99

Information for Classroom Teacher, SELPA 28.................................................................101

Special Education Referral Log, SELPA 29 .......................................................................103

Student Information Form (SIF), SELPA 30A, C & D ......................................................105

Behavior Support Plan Form, SELPA 31 ...........................................................................113

Emergency Behavior Report, SELPA 32A .........................................................................122

Positive Behavior Intervention Referral Information, SELPA 32B ...................................127

Interim Behavior Intervention Plan, SELPA 32C...............................................................130

Functional Assessment Forms, SELPA 33A, B & C ..........................................................132

Positive Behavior Intervention Forms, SELPA 34ABC & D .............................................138

Notice of Confidential File, SELPA 35 ..............................................................................146


                                                                                                                2
                                    TABLE OF CONTENTS (Cont.)
Monitoring for Out of District Placement, SELPA 36 .......................................................148

Private School Service Plan (ISP), SELPA 37 ...................................................................150

Appendix A Sample Transition Goals ...............................................................................152

Appendix B Matrix for developing Behavior Support Goals ............................................154

Appendix C CASEMIS (California Special Education Management Information System)
Definitions of Selected Codes .............................................................................................158




                                                                                                                 3
                                COMPUTER INFORMATION

General Computer Information is listed below. Specific information for individual forms and computer
information and tips will appear in the text before each form.

Help Using NSCC SELPA IEP 2006 Forms Program
Obtaining and Installing NSCC SELPA IEP 2006
        On-line:          Download the appropriate version (Mac or PC) of NSCC SELPA IEP 2006 from
                          the North Santa Cruz County SELPA website (www.nsccselpa.org). Be sure you
                          note where your browser is saving the program in order to find it after the download
                          is complete.

                          Hint: When downloading onto a PC it is necessary to have unzip software on your
                          computer in order to unzip the file. If your computer does not have a program to
                          unzip files, some companies have free trial software available for download from the
                          internet.

                          Hint: You can import/export your student records between the Mac and PC versions
                          (instructions below). Download the appropriate version directly unto each computer.


        On CD-R:          Obtain a copy of CD-R from the SELPA office. Specify whether you need Mac or
                          PC version. Follow instructions printed on disks.
                          Both versions are zip files that will need to be unzipped (see Hint above)/ Once you
                          have installed the program onto your computer, please pass the disks along to a
                          colleague in the SELPA or return to the SELPA office. This is freeware for teachers
                          in our SELPA.

                          Hint: Be sure and note where you are saving the files on your computer.

Database Terminology/NSCC SELPA IEP 2006
        Database          Each SELPA form is a separate database. You open a new database each time you
                          call up a different SELPA form.

        Record            Add New Record EACH time you need another copy of a SELPA form. Instead of
                          reaching for a clean NCR copy, you just create a New Record. New Student = New
                          Record.

        Field             A field is a box on a form where you are to enter information. There are several ways
                          to enter information in a field. (See “Data Entry”, below) Use Tab to move from
                          field to field.

        Modes             You have three Mode options: Browse, Find and Preview. These are working
                          modes. Changing modes does not affect the data you have entered.

                          1.   Browse: Add New Records and fill out fields in Browse Mode. This is the main
                               working mode of NSCC SELPA IEP 2006. The Browse mode is the only mode
                               you can enter data on SELPA forms.




                                                                                                    4
                         2.   Find: Use this mode to navigate through your records. Once you are in Find
                              mode, you can type information in any field to locate all- records that match that
                              field. For example, type a name in the name fields to go directly to that student’s
                              record.

                         3.   Preview: Use Preview mode before you print to see what the finished form will
                              look like. Save paper – use Preview!

        Flipbook         The little “rolodex” icon in the left sidebar is called the flipbook. This represents all
                         the records (i.e. Students) in the current SELPA Form (database). Clicking on the
                         upper or lower pages of the flipbook moves you forward or backward one record at a
                         time.

        Sort             Notice that under the Mode menu you also have a Sort option. You can sort all your
                         records by any of the fields on that record by moving them over to the Sort Order
                         box and clicking on Sort. You can Sort your students by first or last name, but also
                         by birthdate, IEP date, Case manager, or any field on the form.

                         Each time you close a form, by default, the program is set to sort by last name, first
                         name and creation date. This enables you to quickly locate specific forms next time
                         you open the form.


Opening SELPA forms When entering the NSCC SELPA IEP 2006 program, it is important to enter through
                    the IEP 2006 START HERE.exe file which will lead into the SELPA 1 form. By
                    using the “entrance” it enables the links that have been set up as part of the program
                    to work properly. Many users find it easiest to make a shortcut (Windows) or alias
                    (Mac) on their desktop upon first installing the program.

                         When navigating within the program to various forms (databases) there is no Open
                         option under the File Menu in NSCC SELPA IEP 2006.

                         However, there are several ways to Open SELPA forms:

                         1.   Click on the Open SELPA Forms button to the right of the SELPA 1 form.
                              This will open a window dialog enabling you to choose the proper form.
                         2.   Use the SELPA 2 button at the top of any form, this will take you to the SELPA
                              2 the procedural checklist form, then click on the button that corresponds to the
                              desired form.
                         3.   Once a form (database) has been opened during a single session you may return
                              to it any time by going to Window. This will give you a list of all open forms.
                              Hint: Once NSCC SELPA IEP 2006 has been closed this list will be reset.




                                                                                                    5
Closing SELPA forms   To close an individual form each SELPA form includes an orange button at the top
                      of each page to close just that form. This can be useful while working on multiple
                      forms when the computer does not contain enough memory to keep all forms open.
                      Keep in mind that if you are going to be going back and forth between the forms, and
                      your computer has enough memory for it, it is easier to keep them open and use the
                      Window feature at the top of the screen to move between forms.


The importance of using SELPA 1

                      In order for the internal links within NSCC SELPA IEP 2006 to work properly, it is
                      necessary to create a SELPA 1 form for each new student on your caseload. After a
                      SELPA 1 has been created for a student you can then open a new form, create a new
                      record, and a drop down list will appear in the upper left hand corner of all students
                      with a SELPA 1 (sorted by first name). By selecting the student of your choice,
                      certain fields within the form will “automatically” fill in based on the information
                      entered into the SELPA 1.
                      Hint: Sometimes it takes a few minutes for the computer to save new student
                      information in SELPA 1. If you the student you are creating a form for does not
                      appear in the drop down list and you just entered a SELPA for that student, either
                      wait a few minutes and try again, or exit out of the program and try again.



Data Entry            There are basically five ways that data can be entered into a field in NSCC SELPA
                      IEP 2006.

                      1.   Type directly into the field in which you want to write. First select the field by
                           clicking on it, and then type in your information.

                           Hint: You can always change the font size, style, or format in any text field if
                           you need more room or want to change the style.

                      2.   Use a Pull Down Menu: On certain fields, a list of options will appear the first
                           time you click on that field. You enter data into that field by clicking on the
                           option you want to select. If the list of options disappears before you make your
                           selection, click anywhere else on the page and then return to click on the field
                           again and the list will reappear. If what you are looking for does not appear in
                           the pull down menu, you can type directly in the field, you do not have to select
                           from the pull down menu.

                      3.   Lookups: Once you have entered information in SELPA 1, certain fields will
                           pull in information automatically from other forms when you select a student’s
                           name in the upper left hand corner. You can type over a lookup and enter
                           updated information.

                      4.   Calculations: Certain fields have been assigned calculations. Chronological
                           age is a calculation, as is the 50-day limit. You cannot edit information in a
                           calculation field. (A message will appear saying that the information in the field
                           is not modifiable.) The only way to change the information in a calculation field
                           is to edit the information that is being used in the calculation. See “Specific
                           Notes about the SELPA Forms” below for more information on which fields are
                           calculation fields.

                      5.   Check boxes and/or Radio buttons: Fields that have been formatted so you
                           can select one or more of the listed options by clicking in the box or circle next
                           to your choice(s). Fields with check boxes will allow you to choose one or


                                                                                                  6
                            more options (for example the various people invited to an IEP); radio buttons
                            will only allow you to select only one (for example gender or primary
                            disability).

                       6.   Writing a narrative (usually SELPA 11, 10A, 10B or SELPA 13E) longer than
                            one page: at the bottom of the page (the end of the printable area of the field)
                            you will see a double black line extending slightly past the field, this will
                            indicate that it is time to start a new page. Just below the line is a blue button
                            called Next Page, by pressing this button you may continue your report for the
                            same student.

                            (For SELPA 11 Next Page will automatically create a new SELPA 11 with the
                            same student information as the page you are working on; for SELPA 10A Next
                            Page will bring you to a new SELPA 10B and you must select the student name
                            from the drop down list, enter date and teacher information, then continue with
                            your report; for SELPA 10B, Next Page will create a new SELPA 10B with the
                            same student information as the one you were working on)




Saving and Printing NSCC SELPA IEP 2006 automatically saves all your work. You need not worry
                       about stopping to save; however, be aware that any changes you make to your
                       student information will be permanent. If you accidentally delete a record, it is gone.

                       DO NOT USE “SAVE COPY AS….”“Save a Copy As…” will save a copy of the
                       entire database/form, the record (student) you are currently in and all the other
                       records (students) you have entered into that form. This is not for regular saving. If
                       used it leads to multiple copies of the database, and once any updates or changes are
                       made the copies no longer contain the same information, often causing users to think,
                       “The computer ate it,” when actually the updated information is in one of the other
                       copies of the database.



                       To Print,
                       Select Print from the File menu. Note there are three print options:
                       1. Records Being Browsed (prints all your students forms, not just the one you are
                           looking at.)
                       2. Current Record (prints only the student’s form you are looking at.)
                       3. Blank Record, Showing Fields (prints a blank form with no student
                           information on it at all.)

                       For most purposes, use Current Record to print one student’s form. Note Print
                       Range and Number of Copies. Most SELPA Forms in NSCC SELPA IEP 2006 are
                       one page long. If you need more room, create a new record and select the student’s
                       name from the pull down menu in Student Name. Make sure you notice how many
                       copies are to be printed.




                                                                                                   7
Importing and Exporting:

      Sometimes it is necessary to work on multiple computers (i.e. at home and at school). To do this, you
      will need to export from the computer your work in progress is currently on and import it into your
      other computer. (Be aware that when you do this, any work you subsequently do may need to be
      exported/imported back to the original computer to keep a complete record for future reference).

      Due to fields being added, deleted, or moved to different forms during revision, it is recommended that
      only SELPA 1 be imported into NSCC SELPA IEP 2006 from previous versions of the software.

To Export:
                     1. Go to form you would like to export (each form needs to be exported separately).

                     Hint: This export will export all files contained within the form. If there are records
                     you do not wish to have you can delete them later once export/import process is
                     completed.

                     2. Go to File
                             Export Records
                     An Export Files to File window will pop-up.
                     This is asking you where you would like to save your export to and what you would
                     like to name it.
                     DO NOT SELECT ONE OF THE FILES LISTED IN YOUR IEP FORMS FOLDER.
                     · In box labeled Save In navigate to where you would like to save your files (3 1/2
                        floppy, Desktop, etc.).
                     · In box labeled File name, type in name for export file
                        Hint: include the SELPA form number as part of the name for easier identification
                        later--especially important if you are exporting more than one form.

                     3. The next window is asking you what fields you would like to export.
                     If you are transferring files from one IEP program to another, you would:
                     · Select Current File and Move All.
                     · Make sure Character Set is correct for location you are moving it to (Windows
                     format, Macintosh format, etc.)
                     · Format Output using current format is checked.
                     · Click on Export

   To Import:
                     1. Go to form you would like to import
                     Hint: each form needs to be imported separately

                     2. Go to File
                               Import Records
                     An Open File window will pop-up.
                     Navigate to and select the file you would like to import (previously exported and saved
                     onto disk, desktop, etc.)
                     Click Open

                     3. If importing from NSCC SELPA IEP 2006 (See below for directions when
                     importing from another version of NSCC SELPA IEP 2006)
                     Arrange by should be Matching Names.
                     Add new records should be checked (this insures that existing records are not
                     overwritten)

                     4. Click Import




                                                                                                 8
                         5. Perform auto-enter options while importing should be unchecked.
                         Import values in repeating fields should be Keeping them in the original record.
                         Click OK.

                         6. Your files should be imported. They will be separated from your original files as if
                         you had done a Find. To bring all your files, including the ones imported back up go
                         to Select, Find All

If you do import from previous version of NSCC SELPA IEP 2006:              #3 above should read Arrange by
should be Custom import order. The fields listed on the left are the fields are in the form you are importing
from or bringing into the database, the fields on the right are the fields you are importing into-where it is going.
You will need to move fields around by the double arrows in order to import into the correct fields, be aware
that some fields may no longer be part of the same form, or there may be entirely new fields not in previous
versions of the software. Use  to tell the program to import the field,  to tell the program don’t import the
field, by clicking on symbol until correct. Add new records should be checked (this insures that existing
records are not overwritten). If you have any questions regarding this process, call the SELPA office at 464-
5677.




                                                                                                       9
                               STUDENT DATA ENTRY
                                     SELPA 1

Who fills out this form?

The case manager or teacher fills out this form first, on the computer this information will
automatically be sent to relevant SELPA forms whenever a new form is created. The fields in
this form are color-coded. It does not update existing forms.

This form is only intended for use on the computerized version of the SELPA forms, and
should not need to be printed. The SELPA 30A should be used to when it is necessary to
print out informational data on a student.


Computer Information:

There are five types of fields on this page:

Yellow         These fields are usually only entered once, and then updated only as needed
               (such as address, agencies involved, etc.)

Lavender       These fields are changeable and need to be updated on a regular basis.
               (Grade, IEP dates, etc.)

Green          These fields are stable, and should never change throughout a student’s
               education. (Gender, date of birth, etc.)

Dark Blue      These fields are infant fields. Only to be used for students ages 0-36 months.

Light Blue     These fields are teacher and case manager information fields.

Remember the more you fill in on the SELPA 1 (and keep the information updated) the less
you have to enter the same information on other forms.
Parent/Guardian Contact
               Whatever you write in this field will be used each time the form begins
               “Dear…” and also on the SIF. Use parents’ first and last names, or the
               parent’s name who usually attends the IEPs.
               Ex: “John and Jane Doe”
               Or “Jane Doe”
               Or “John Doe”




                                                                                  10
Teacher/Specialist

              Your name, title, and phone number should go in these fields, since you are
              the one filling out this form. If you are also the Case Manager, then reenter
              your name, title, and phone number in the corresponding fields.

Changes to Form from previous versions
The SELPA 1 was rearranged into four sections
             Section 1       Student Information
             Student information section contains most of the same fields as in the previous
             version of NSCC SELPA IEP 2006. Agencies Involved field now has check
             boxes, to more easily see the options. More than one field is available for
             Ethnicity, to align with state reporting requirements. CSIS # has been added
             to meet with upcoming state requirements.
             Section 2       Infant Information (for ages 0-36 months only)
             Entire Infant section is new to add in IFSP forms to NSCC SELPA IEP 2006.
             Section 3       Parent/Guardian Information
             Simplified from previous version. Parent/Guardian Contact, is for main
             caregiver information, Other Contact is flexible to include information on
             other parent, guardian, foster issues, etc. Information was added to include
             Cell Phone and Email Address for both contacts.
             Section 4       Teacher/Case Manager
             Same as previous version.




                                                                                  11
                            PROCEDURAL CHECKLIST
                                  SELPA 2


Who fills out this form?

The case manager or teacher fills this form out to document the process from the initial
referral to the IEP team meeting. Legal timelines are tracked as well as when documents are
sent to be signed and returned. Keep track of 50-day timelines and 30-day timelines on
SELPA 19.

Like the SELPA 1, this form is not intended to be printed.

Computer Information:

Student Name
            This is a pull down menu of all the names for which you have created a
            SELPA 1. To add a new student, add a new record and select the student’s
            name from the pull down menu. If you have not started a SELPA 1, you can
            enter the data manually. Always start each new form by:

Date Sent/Date Received
             Data entered in these fields must be in the form mm/dd/yyyy.

Line 16: Written consent for assessment obtained
              Once you enter the date you receive the permission to test, the Fifty-Day
              Limit on the top of the form will be calculated. This is a simple calculation; it
              does not take into account holidays longer than 5 days. It just adds 60 days to
              the date permission was received.

Changes from previous versions
             Still functions in same manner, changed only to reflect changes in numbering
             and additional forms.




                                                                                   12
                                   CONTACT LOG
                                     SELPA 3


Who fills out this form?

All school personnel are required to keep a detailed list of communication on this form.
There may be several contact logs for each student. Anytime a service provider sends written
communication, makes a phone call or discusses the student's progress, it is to be recorded
here and kept in the front of the current IEP file.

This is an extremely important document and should be used for ALL contacts. It may
be used as a legal document for fair hearings.

Computer Information:

1.     Add New Record for each new student.
2.     Selecting Student Name from the pull down menu in the upper left. (Only students
       with SELPA 1s will appear in this list.)
3.     Manually enter data that does not automatically import from the SELPA 1.

The data from the SELPA 1 transfers in automatically. These forms are intended to be
printed out and put in the student folder; contacts are to be entered manually.

Changes from previous versions
             Added Cell Phone and Email Address information for both contacts.




                                                                                13
                                        NORTH SANTA CRUZ COUNTY                        Date ____________
                                    SPECIAL EDUCATION LOCAL PLAN AREA

District/County Office of Education _________________________________________________
Student Name ________________________________ Birthdate _________________________
Parent/Guardian Name ________________________ Relationship ____________________________
Address ________________________________________________ Email Address __________________________
            Home Phone _______________________ Work Phone ___________________ Cell Phone _____________
Other Contact Name ____________________________________ Relationship ______________________________
Address ________________________________________________ Email Address ___________________________
            Home Phone _______________________ Work Phone ___________________ Cell Phone _____________
                                                 CONTACT LOG
                               (Including telephone calls and written communication)

                                                           Type of Communication
             Date/Time            Person Contacted                                       Name of Staff Member
                                                               and Comments




SELPA 3 (3/05)

                                                                                                                14
                    LOG OF ACCESS TO PUPIL RECORDS
                               SELPA 4


How should this form be used?

This form should be kept as a cover of the IEP and should be signed by anyone accessing
the file who does not have written consent to review the file.

Computer Information:

The data from the SELPA 1 transfers in automatically. These forms are intended to print out
and put in the student folder; contacts are to be entered manually.

Changes from previous versions:
             No changes.




                                                                                          15
                                                         NORTH SANTA CRUZ COUNTY                                                  Date ____________
                                                     SPECIAL EDUCATION LOCAL PLAN AREA
                                                          LOG OF ACCESS TO PUPIL RECORDS

Name _________________________________________________________ Birthdate ______________________
District/County Office of Education ________________________________ School ________________________
E.C. SECTION 49064. A record shall be kept of parties requesting or obtaining access to such records and the legitimate interests thereof. The only exception will be
school officials, and their respective clerical assistants, the school counselor/psychologist/nurse, the student’s current teacher(s) (including Speech), appropriate
government officials and parties to whom directory information is released.
Excepted also are qualifying parents and pupils (E.C. 49069 and 49067a,6) and parties for whom written consent has been executed by the parent (E.C. 49075). Note
their access will be noted by the written request form which will have been filled out (by parent or school) prior to access and attached to this log kept in the pupil’s
folder.
CONFIDENTIAL: THIS LOG IS ABAILABLE FOR REVIEW ONLY BY THE CUSTODIAN OF RECORDS (OR DESIGNEE) AND THE PARENT OR
ELIGIBLE STUDENT. IT IS TO BE FORWARDED (SEALED) TO THE CALIFORNIA PUBLIC SCHOOL OF NEW ATTENDANCE. IT MAY BE
FORWARDED TO OTHER SCHOOLS.
Specific Reason for access to this record:
                                                                                                                              Title
                                                                                                                              Signature
                                                                                                                              Date
Specific Reason for access to this record:
                                                                                                                              Title
                                                                                                                              Signature
                                                                                                                              Date
Specific Reason for access to this record:
                                                                                                                              Title
                                                                                                                              Signature
                                                                                                                              Date
Specific Reason for access to this record:
                                                                                                                              Title
                                                                                                                              Signature
                                                                                                                              Date
Specific Reason for access to this record:
                                                                                                                              Title
                                                                                                                              Signature
                                                                                                                              Date
Specific Reason for access to this record:
                                                                                                                              Title
                                                                                                                              Signature
                                                                                                                              Date
Specific Reason for access to this record:
                                                                                                                              Title
                                                                                                                              Signature
                                                                                                                              Date
Specific Reason for access to this record:
                                                                                                                              Title
                                                                                                                              Signature
                                                                                                                              Date
SELPA 4 (3/05)

                                                                                                                                                                            16
                REFERRAL FOR INDIVIDUAL ASSESSMENT
                             SELPA 5A


Who fills out this form?
School personnel and agency representatives will typically fill out this form when a disability
is suspected. If a parent requests an assessment orally or in writing, a SELPA 5A must be
completed and becomes part of the student's confidential file. This form must also be
completed if a referral comes from the Student Study Team. SELPA 5B will be completed if
the referral is school generated.

What happens with this form?

 • The referral is entered into the Special Education Log, (SELPA 29) and a case manager
   is assigned.
 • The case manager should notify their administrator if a Surrogate Parent may be needed.
   If a Surrogate Parent is needed, the Administrator should refer to form SELPA 22 for
   procedures.
 • The assessment plan is developed within 15 days of the referral.

Identifying Information              Complete all identifying information. Check box for
                                     the title of the person(s) representing the student (Parent
                                     or Guardian).
Special Concerns                     Complete this section with all known information
                                     related to birth history, traumatic injuries, congenital
                                     defects, as well as current health status.
Reason for Referral                  Consider all areas of academic, social and
                                     communication skills. Include a specific statement
                                     describing the student's strengths. This statement can
                                     address academic learning style as well as
                                     personal/social skills. If there is other known
                                     information that is relevant to the Special Education
                                     assessment, include it here.
                                     If you have completed all the areas of information
                                     covered by this form during the Student Study Team
                                     meeting, you may attach the summary in lieu of
                                     completing this form.
Interventions                        Any modifications and/or accommodations which
                                     have been considered and/or tried should be listed
                                     here.




                                                                                              17
Computer Information For:
Fill in any fields that do not transfer over from the SELPA 1. Most information should
transfer; including Agencies involved if completed on the SELPA 1.

Changes from previous versions:
             Allows computer entry in other ethnicity and special concerns section.




                                                                                 18
                                              NORTH SANTA CRUZ COUNTY
                                          SPECIAL EDUCATION LOCAL PLAN AREA
                                      REFERRAL FOR INDIVIDUAL ASSESSMENT
Parent/Guardian Referral    No  Yes           (If yes, please complete boxed areas only)        Date __________________

 Name ______________________________ Birthdate ____________ Chron. Age ________ Sex                     Male  Female
 Address _____________________________ Parent’s Work Phone ________________ Home Phone ________________
 Name of:  Parent      Guardian  Foster ____________________________________________________________
 School ______________________________ Grade _________ Teacher _____________________                        Room ________
  EL  FEP  EO            Home Language _________________ District _____________________________________
 Ethnic Background      Native American         Filipino  White
                        Asian                   Hispanic  Other __________________ (specify)
                        Pacific Islander        Black
 Special Concerns          Vision          ___________________          Hearing             ___________________
                           Health          ___________________          Speech/Language     ___________________
                           Medications     ___________________          Grade Retentions    ___________________
                           Academics       ___________________          Other               ___________________
 Agencies involved with Student ____________________________________ Contact _____________________
                                   ____________________________________                      _____________________
                                   ____________________________________                      _____________________
                                   ____________________________________                      _____________________
 Also describe the specific behaviors of the child which prompted this referral and areas that you feel warrant assessment for
 special education (Title 5, 3021 (b)(1).
 School Staff should include current levels of performance if Student Study Team forms are not attached.




 Parent/Guardian, please describe specific concerns which you believe warrant assessment for special education.




Who has discussed these concerns with the parent? ________________________________ Title _________________________
Date when conferences were held ____________________________________________________________________________
Referred by ___________________________________________________ Position __________________________________
Received by __________________________________ Date received _________________ Assigned to ___________________
Attached are intervention documents  SELPA 5B  Student Study Team Action Plan
AN ASSESSMENT PLAN MUST BE DEVELOPED AND REVIEWED WITH THE PARENT WITHIN 15 CALENDAR
DAYS OF THE RECEIPT OF THE REFERRAL FOR ASSESSMENT (E.C. 56321)
SELPA 5A (3/05)

                                                                                                                                 19
                      CLASSROOM INTERVENTION LOG
                               SELPA 5B



Who fills out this form?

When a regular education teacher or parent is referring a student to the student study team, a
Classroom Intervention Log should be reviewed to ensure that several interventions have
been tried over a period of time.

When is this form used?

Prior to a Student Study Team meeting, the parent and/or teacher documents interventions
and strategies that have been attempted. The Student Study Team reviews, makes suggestions
and decides if further evaluation is necessary.

If the SST recommends referral for assessment to begin the IEP process, this completed form
will be attached to SELPA 5A, Referral for Individual Assessment.

Computer Information For:

Complete any fields that do not transfer over from the SELPA 1.

Changes from previous versions
     No changes.




                                                                                             20
                                      NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                                        CLASSROOM INTERVENTION LOG
Student ____________________________ Birthdate _______________ Grade ______________ Date __________
Federal and State laws require that a pupil shall be referred for special education instruction and services only after the resources of the regular education program have
been considered, and where appropriate, utilized. In addition, there must be documentation and interventions used for students who are referred for special education.
Please complete this form by checking the major strategies you have tried with the students, along with an indication of the duration, frequency and effectiveness of the
strategy.

I/We have:         Reviewed the cumulative record  Conferred with student                 Conferred with other staff members                          Conferred with parents
                  Date of most recent parent contact: _________________________________ Student Study Team has met previously                             Yes  No
                                                                                                                         USED                RESULTS

                                                                                     INCLUSIVE




                                                                                                                                                           No Progress
                       INTERVENTIONS                                                                                                                                     COMMENTS




                                                                                                                          Monthly
                                                                                       DATES




                                                                                                                                             Positive
                                                                                                                                    Weekly




                                                                                                                                                           Noted
                                                                                                                 Daily
CLASSROOM ENVIRONMENT STRATEGIES
1. Change groupings/setting/seat assignment
2. Consider health problems
3. Consider routine
4. Create more physical space/special study are/carrel
5. Other:
CURRICULUM STRATEGIES
1. Allow the Student to Make Choices
2. Provide Materials Geared to Student’s Level
3. Reduce Quantity of Material/individualize
4. Special Materials: Video & Cassette Tapes, Slates,
   Manipulatives
5. Teach Functional Skills
6. Thematic Teaching
7. Use Diagnostic Materials
8. Other:
MOTIVATIONAL STRATEGIES
1. Academic/Behavior contingency contracts
2. Clearly define rules & expectations w/consistent consequences
3. Correct assignments by highlighting student’s correct answers
4. Conduct a functional analysis of the student’s behavior
5. Give increased responsibility
6. Give immediate and frequent feedback on correctness of work
7. Keep graphs & charts of student progress
8. Monitor student often
9. One-to-one time with teacher, aide peer (circle)
10. Point system
11. Target behavior problems
12. Time-out
13. Use of eye contact, hand on shoulder, close proximity (circle
14. Vary voice volume
15. Other:

ORGANIZATION STRATEGIES
1. Allow additional time to complete tasks/take tests
2. Ask student to verbally repeat/model directions
3. Computer/typewriter
4. Focus on important information
5. Highlight main facts in the book
6. List assignments and/or instructions on board
7. Provide advance organizers
8. Provide and organized notebook system
9. Provide study guide
10. Provide written instructions
11. Teach note taking/outlining skills
12. Time limits for assignments
13. Other:
SELPA 5B (3/05)
                                                                                                                                                                                   21
                               NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                                                                           USED                RESULTS

                                                                 INCLUSIVE




                                                                                                                          No Progress
                  INTERVENTIONS                                                                                                         COMMENTS




                                                                                            Monthly
                                                                   DATES




                                                                                                               Positive
                                                                                                      Weekly




                                                                                                                          Noted
                                                                                   Daily
PARENT INVOLVEMENT STRATEGIES
1. Parent conferences
2. Parent volunteer
3. Teacher-parent communication system
4. Consistent home-school strategies
5. Other:
PROGRAMMING STRATEGIES
1. Activity breaks/earned free time
2. Adjust length of period/school day
3. Change of teacher/class
4. Teacher and/or Student and/or Parent consult with:
        APE Specialist
        LSH Specialist
        School Nurse
        School Psychologist
        Resource Specialist
        School Counselor
        Student’s other teachers
        Community Agencies:
5. Use of ancillary programs/resources:
        Bilingual
        Counseling: Teacher Principal School Counselor
        School Psychologist Peer (Please circle)
        ESL
        GATE
        Math (Type of Program:___________________)
        Migrant
        Peer Tutors
        Reading (Type of Program: ___________________)
        Speech and Language
6. Other:

TEACHING STRATEGIES
1. Address preferred learning modality
         Auditory
         Kinesthetic
         Tactile
         Visual
2. Allow student to have extra drill/practice test
3. Buddy system
4. Cooperative Learning
5. Cross-age/peer tutors
6. Learning games
7. Learning strategies
8. Non-graded assignments
9. Present lesson on overhead/cassette recorder/VCR/Laser Disk
    player
10. Repeat/modify instructions
11. Review concepts frequently
12. “Show me” cards or other whole class participation methods
13. Vary pace
14. Visual aides/modeling
15. Other:

COMMENTS:
____________________________________________________________________________________________________________
_______________________________________________________________________________________________
REFERRING TEACHER: _____________________________________________________________
SELPA 5B (3/05)
                                                                                                                                         22
              NOTICE OF REFERRAL AND PLAN TO ASSESS
                             SELPA 6


Who fills out this form?

The case manager fills out and sends this form to the parent with a copy of Parent’s Rights.
A 15- day timeline begins to develop an assessment plan (SELPA 7A).


When is this form filled out?

As soon as you receive SELPA 5A, which is the referral, send home SELPA 6 and start
planning for SELPA 7A.


What happens with this form?

The parent keeps the form and the case manager records in the Procedural Checklist (SELPA
2). The case manager determines what the assessment plan will include by discussing with
parents and other team members.


Computer Information for:

Case manager’s name and contact number transfer automatically to the “Please contact…”
portion of the form. You can change that name by typing directly in the field.

Changes from previous versions:
             Minimal changes in wording and making more room for typing in the reasons
             for referral.




                                                                                          23
                                        NORTH SANTA CRUZ COUNTY
                                    SPECIAL EDUCATION LOCAL PLAN AREA
                          NOTICE OF REFERRAL AND PLAN TO ASSESS


Date: _____________________________
To the Parent/Guardian of: ___________________________________________________
                                                            DOB: ____________________
Your child is being considered for an individualized assessment to determine his/her eligibility for special
education services. We need to assess your child in all areas of suspected disability. The reason(s) your child is
being referred for assessment for special education include:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Parents/Guardians of children being considered for special education services or subsequently being placed for
special education services must be informed of their rights. Attached is a Notification of Parent/Guardian/Child
Rights.

You will be contacted by school staff to develop an assessment plan within 15 days. Your written consent must
be obtained before the assessment can begin.

After the assessment is completed, you will be requested to attend and participate in a meeting to discuss the
results of the evaluation. As a team, we will determine your child’s eligibility for special education services.
We will discuss the range of program options available and make recommendations for your child’s educational
program services.

If you have any questions regarding this Notice of Referral and Plan to Assess or your rights as a parent, please
contact the person listed below.


Sincerely,


                 Name                                                  Title

                 Telephone Number

                 School                                                District
SELPA 6 (3/05)


                                                                                                                24
                                 ASSESSMENT PLAN
                                   SELPA 7A&7B


Who fills out this form?

SELPA 7A is completed by school personnel with the team, or with the parent following a
staffing, or with the parent after an agency referral. The written assessment plan must be
developed and given to the parent within 15 calendar days of the accepted referral for
assessment. This does not count days between the student’s regular school sessions/terms in
excess of five school days during the 15-day time period.

The parent is an integral part of the assessment planning. At this point, determine the areas of
concern requiring assessment. This assessment may include any of the following: reviewing
records, school performance, observation and standardized assessment. However, to
determine eligibility for most students, standardized assessments are required to ascertain a
disability. If you have questions regarding eligibility, please refer to the district special
education administrator, school psychologist or a program specialist.

When it becomes near time for the triennual assessment to be due, the school psychologist
and/or case manager fills out a SELPA 7B, with parent input and relevant information from
student files, to determine what additional assessment is required.


When is this form filled out?

Whenever a new standardized assessment is given, parental consent must be obtained.
Otherwise, the parent's consent for the assessment plan is in effect for one year. Use SELPA
7A for this purpose.

For three-year reviews, the IEP team determines what areas of information are necessary to
assess in order to provide appropriate supports and services for the student. SELPA 7B is to
be used to review existing evaluation data and, with parent input, will identify if additional
data is needed to determine eligibility. In some cases, eligibility may not need to be re-
considered.


What happens with this form?

 • An assessment plan can be created at a Student Study Team meeting or in a team
   discussion with the parents. If this plan is mailed to a parent, it is best practice to discuss
   the plan with the parents, either by phone or in person, prior to the mailing.
 • Allow 15 days for the parent's written consent. If the form has not been signed and
   returned within 15 days, keep in mind some of the reasons parents may not sign the form
   (including their own educational history, fear of labeling, agency involvement with
   families, etc.) Follow-up communication with the parent, in person, is strongly
   recommended with documentation on Parent Contact Log (SELPA 3) about these

                                                                                                25
         ASSESSMENT PLAN, SELPA 7A & SELPA 7B (Continued)


   attempts to secure consent. If a parent refuses to sign the assessment plan, this is an
   important issue to refer to your special education director for next steps.
 • When the form is received, note the date received on SELPA 7A or SELPA 7B and
   SELPA 2 and begin 60-day timeline.


Title of Evaluator           Do not list individual names of assessors. State the title of
                             person completing that section of the evaluation. If a
                             multidisciplinary team will complete the assessment, write
                             “team” and denote what staff members, by title, will be on that
                             team under “Other.”

Parent/Student Rights        Be sure that a copy of the Parent/Student Rights has been given
                             to the parent with a discussion of bolded points prior to
                             obtaining their consent and check the box.


Copy of Summary of Assessments          If a parent wishes to receive a copy of their child's
                                        assessment reports and this box is checked, you
                                        must send them a copy of SELPA 10A (and
                                        SELPA10B as appropriate). All people involved
                                        with the assessment should contribute to the
                                        completion of these reports.

Computer Information for:

Case manager’s name and contact number transfer automatically to the “Please contact…”
portion of the form. You can change that name by typing directly in the field. Enter
information for primary language, areas of assessment, and title(s) of evaluator(s).

Changes from previous versions:
             Added line to clarify for parents to check appropriate box (es), sign and return
             copy to district office.
             Revised Areas of Assessment choices to be consistent across forms.




                                                                                 26
                                                      NORTH SANTA CRUZ COUNTY
                                                  SPECIAL EDUCATION LOCAL PLAN AREA                                Date received _______________
                                                          ASSESSMENT PLAN                                                (60-day timeline begins)


To the Parent/Guardian of: ________________________________________________                                   Birthdate: _______________________
School: __________________________________ District/County Office of Education _________________________________
Primary Language: _________________________                     English Language Learner (EL)                   Ethnicity: ____________________
                                                                Fluent English Proficient (FEP)                 Grade:     ____________________
                                                                English Only (EO)
To Parent/Guardian: Your child has been referred for assessment to determine his/her educational needs and to plan an appropriate
education program. The assessment will be limited to the areas checked below. The assessment may include individual testing,
observations, school records, student study team findings, and parent input, plus a review of any reports you have authorized. The
assessment may or may not result in a recommendation for special education placement or services. If you have any questions about
this assessment plan, please contact:
____________________________________                 Title: __________________________ Phone: ________________________
For further information, you may contact your school principal, special education director, or the SELPA office.
This assessment will be administered in primary language:  English             Spanish  Braille  Sign Language  Other _______________

AREAS OF ASSESSMENT:
 Pre-Academic/Academic                                                                                                           Title of Evaluator
      Tests in this area measure academic readiness and/or achievement in reading, math, writing and/or spelling
      skills. For students with visual impairment, an assessment will be conducted to determine the most
      appropriate reading medium (e.g. Braille, large or regular print).
 Social/Emotional/Adaptive
      Assessment in this area describes social/behavioral responses in the home, school, and/or community.
 Cognitive/Intellectual
      Tests in this area measure the ability to remember what has been seen and heard and the ability to solve
      problems. They also reflect learning rate and assist in predicting how well a student will do in school.
 Perceptual/Motor
      Tests in this area measure visual and auditory perception skills and how well an individual coordinates
      body movements in small and large muscle activities.
 Language/Speech/Communication
      Tests in this area measure the ability to understand and use language appropriately and speak clearly.
      When the student has a hearing impairment, the appropriate mode of communication is considered and
      utilized.
 Pre-vocational/Vocational
      Tests in this area measure interests and aptitudes as they relate to future job and life skills.
 Medical/Health and Development
      To gather information about medical and health factors affecting school performance.
 Other _______________________________________________________________________
       ____________________________________________________________
Please check the appropriate box(es) below, sign and return one copy as soon as possible:
 I give my consent for the assessment indicated above in my child’s primary language.
    I understand that the results will be kept confidential and that I will be invited to attend a meeting to discuss the results.
    I further understand that no educational placement will result from this assessment without my written permission.
 I DO NOT give my consent for the assessment.
 I have received a summary of the Child and Parental Rights.
 I request a copy of the assessment reports before the IEP meeting (optional)

__________________________________________________________________                                            _______________________
            Signature of Parent/Guardian/Surrogate (circle one)                                                         Date

Enclosures:  Parent and Child Rights and Procedural Safeguards  Parent Assessment of child  Return Envelope
SELPA 7A (3/05)                          Distribution   Copy 1 - LEA Office           Copy 2 - Student File          Copy 3 - Parent

                                                                                                                                                       27
                                                       NORTH SANTA CRUZ COUNTY
                                                   SPECIAL EDUCATION LOCAL PLAN AREA
                                                                  TRIENNIAL ASSESSMENT PLAN


           Student Name                              Birthdate                                    School                            District/County Office of Education

Dear __________________________________,
We have developed the following plan to meet the requirements that your child’s educational needs be reassessed every three years.
This assessment will be administered in:  English  Spanish  Braille  Sign Language  Other _______________
Language Proficiency (check one):  English Language Learner (EL)  Fluent English Proficient (FEP)  English Only (EO)
                                                         AREAS OF ASSESSMENT                                                                   TITLE OF EVALUATOR
  Recommended           Not Recommended                Pre-Academic/Academic: Tests in this area measure academic readiness
                                                         and/or achievement in reading, math, writing and/or spelling skills. For
                                                         students with visual impairment, an assessment will be conducted to
                                                         determine the most appropriate reading medium (e.g. Braille, large or
                                                         regular print).
  Recommended           Not Recommended                Social/Emotional/Adaptive: Assessment in this area describes
                                                         social/behavioral responses in the home, school, and/or community.
  Recommended           Not Recommended                Cognitive/Intellectual: Tests in this area measure the ability to remember
                                                         what has been seen and heard and the ability to solve problems. They also
                                                         reflect learning rate and assist in predicting how well a student will do in
                                                         school.
  Recommended           Not Recommended                Perceptual/Motor: Tests in this area measure visual and auditory
                                                         perception skills and how well an individual coordinates body movements
                                                         in small and large muscle activities.
  Recommended           Not Recommended                Language/Speech/Communication: Tests in this area measure the ability
                                                         to understand and use language appropriately and speak clearly. When the
                                                         student has a hearing impairment, the appropriate mode of communication
                                                         is considered and utilized.
  Recommended           Not Recommended                Pre-vocational/Vocational: Tests in this area measure interests and
                                                         aptitudes as they relate to future job and life skills.
  Recommended           Not Recommended                Medical/Health and Development: To gather information about medical
                                                         and health factors affecting school performance.
  Recommended           Not Recommended                Functional Analysis of Behavior: Tests in this area analyze the function
                                                         of serious behaviors which may be dangerous to the student and/or others
                                                         (for students previously identified as eligible for special education services).
Explanation of Areas Waived:                Sufficient information exists to continue to plan an educational program and provide services.
                                            Other: ______________________________________________________________________________
State and federal laws guarantee you a number of rights concerning your child’s education. Please refer to your copy of PARENT AND CHILD RIGHTS AND
PROCEDURAL SAFEGUARDS. It is important that you understand these rights including your right to request a full assessment in any areas in which testing is not
recommended. Please call me if you have any questions.


                           Name & Title                                                      Phone                           Date Sent                 Date Received
Please check the appropriate box(es) below, keep one copy of this Assessment plan for your records, sign and return the others
in the envelope provided as soon as possible. Thank you.
 I have received a summary of the PARENT AND CHILD RIGHTS AND PROCEDURUAL SAFEGUARDS.

 I give my consent for the assessment indicated above in my child’s primary language.
    I understand that the results will be kept confidential and that I will be invited to attend a meeting to discuss the results.
    I further understand that no educational placement will result from this assessment without my written permission.
 I give my consent for the area(s) of assessment indicated above and request additional assessment in the area(s) of:
____________________________________________________________________________________________________________
 I DO NOT give my consent for the assessment.

__________________________________________________________________                                                    _______________________
            Signature of Parent/Guardian/Surrogate (circle one)                                                                 Date

Enclosures:  Parent and Child Rights and Procedural Safeguards  Parent Assessment of Child  Return Envelope
SELPA 7B (3/05)                           Distribution      Copy 1 - LEA Office               Copy 2 - Student File               Copy 3 - Parent
                                                                                                                                                         28
                PARENT/GUARDIAN AUTHORIZATION TO
                  REQUEST/RELEASE INFORMATION
                          SELPA 8A & 8B


Who fills out these forms?

Before or during the IEP, school personnel and parents list other agencies that may be
serving the pupil. These are used when sending requests to update current information.


When are these forms used?

Anytime you may need to exchange information with an agency or another school you need
to complete SELPA 8A. To obtain written consent use SELPA 8B as a cover sheet with
SELPA 8A attached to send to other agencies and file in the confidential file.
This consent is valid for one year.


Computer Information for:

For SELPA 8A case manager’s name (You can change that name by typing directly in the
field), contact number and address transfer automatically to the “Please return to…” portion
of the form. LEA will fill in automatically from SELPA 1, if not you can enter District of
Service manually. The parent fills out the remainder of form.

For SELPA 8B information for Case Manager, Student name, birthdate, and LEA (District of
Service fill in automatically from SELPA 1. Complete “To” information from SELPA 8A,
“From” will automatically enter Case Manager name and address from SELPA 1.


Changes from previous versions:
             SELPA 8A Revised to meet legal requirement of 14-point type, and to
             include type of information to be disclosed.
             SELPA 8B Case Manager address automatically transfers from SELPA 1.




                                                                                               29
                                       NORTH SANTA CRUZ COUNTY
                                   SPECIAL EDUCATION LOCAL PLAN AREA
                   Parent/Guardian Authorization to Request/Release/Exchange Information
Date _______________________ Student _____________________________ Birthdate _________________
 With your written consent, team members who represent community agencies and school districts
 may share specified information with one another in order to complete an assessment and develop
 a coordinated service plan with your family. Information will be shared on a need-to-know basis.
 This exchange of information helps the team to plan with you, to keep communication about your
 needs clear, and to eliminate or decrease duplication when dealing with more than one agency.
 I understand that:
      I have a right to receive a copy of this authorization.
     · Information about my child and family is strictly confidential and will only be released
       to/from those agencies and/or persons indicated below.
     · I have the right to look at and provide clarification to records.
     · I may refuse to sign this exchange form.
     · This information can/will become part of the student’s educational record and may not be
       protected by Federal privacy rules.
 In order to assist the Individualized Education Program Team in making a comprehensive
 educational assessment and coordinate my child’s educational plan, I hereby authorize the sharing
 of information with the following agencies:
 1. Name ______________________________ 3. Name _______________________________
     Address ____________________________               Address _____________________________
     ___________________________________                ____________________________________
 2. Name _____________________________               4. Name _______________________________
    Address ____________________________                Address _____________________________
    ___________________________________                 ____________________________________
 Indicate type of information to be disclosed:
  Medical             Medication                    Psychiatric        Mental Health
  Drug/Alcohol        STD/HIV Test Results          Educational        Other:______________
 Any and all information with regard to the above records may be released except as specifically
 provided here: _________________________________________________
 Please check if pupil is receiving services from the following:
  County Mental Health            San Andreas Regional Center       California Children’s Services
  Juvenile Probation Service  Department of Social Services  Other _________________
 I agree to the sharing of information between __________________________________ (LEA)
 and person(s) or agencies listed above. This authorization is valid for one year from the date of
 signature and may be revoked by written notification at any time.
   ___________________________________________________________________________
   Signature                       Relationship to Student                Date
    Please return this within 15 days to:
 SELPA 8A (3/05)
                                        Distribution   District   Parent
                                                                                                   30
                                         NORTH SANTA CRUZ COUNTY
                                     SPECIAL EDUCATION LOCAL PLAN AREA
                                  REQUEST FOR CONFIDENTIAL RECORD




Date: _____________________________
To:                                                          From:




                                                      Re: ______________________________________
                                              Birthdate: ______________________________________
The above named pupil is receiving services from the _________________________________________
District/County Office of Education. Please provide this office with all relevant information to assist our staff in
determining the educational needs of this student.


A signed Parent/Guardian Authorization to Request/Release Information form is attached.

COMMENTS:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Thank you for your assistance.


                                                                        Signed: _________________________
                                                                                 _________________________
                                                                                 _________________________
                                                                                 _________________________




SELPA 8B (3/05)



                                                                                                          31
      NOTICE OF IEP TEAM MEETING (Parent/Guardian/Student)
                          SELPA 9A

When is this form used?

To notify parent/guardian/student (16 years and older) of a scheduled IEP.

The notice must include the purpose of the meeting (transition, pre-expulsion, annual review,
triennial, etc.) time, location of the meeting, and who will be in attendance.

Parents must be notified in writing early enough to ensure an opportunity to attend. It is
recommended that written notice be sent approximately two weeks prior to the meeting date.

Who must attend the IEP?

Check all participants who have been invited to attend the IEP.
Please be reminded that California Ed Code, Section 1414 (d)(1)(A) specifies that the legally
required participants for an IEP meeting are: (See SELPA 9C for information on IEP team
member excusal)

 • The parent, legal guardian, parent surrogate, or parent designee of the student;
 • At least one special education teacher, or if appropriate, at least one special education
   provider of the student;
 • At least one general education teacher of the student if the student is, or may be,
   participating in the general education environment;
 • A representative of the school district who is qualified to provide, or supervise the
   provision of, specially designed instruction to meet the unique needs of students with
   disabilities and is knowledgeable about the availability of district resources. Usually this
   person is an administrator or another staff member, authorized as the administrative
   designee, who is qualified to provide or supervise special education services (i.e. a
   special education teacher). Whoever participates in the IEP meeting in this role must be
   authorized to commit district resources to ensure the provision of the services determined
   by the IEP team to be necessary for the student;
 • An individual(s) who can interpret the instructional implications of the assessment
   results. This may be one of the educators named above.




                                                                                             32
      NOTICE OF IEP TEAM MEETING (Parent/Guardian/Student)
                          SELPA 9A
 Non-mandated participants:
 • At the discretion of the parent or district, other individuals who have knowledge or
   special expertise regarding the student, including related services as appropriate;
 • If appropriate, the student. The student, aged 16 or older, must be invited to attend all
   IEP meetings where Transition is discussed. Additionally for students 16 years and
   older, agency representatives who will be involved in the transition process must be
   invited (if they do not attend, it is the teachers’ responsibility to communicate with them
   after the IEP/ITP).

Fill out case manager as contact. Parent will sign and return. The form must be logged in
SELPA 2 and SELPA 3.

Computer Information for:

Notice of IEP Team Meeting: Note that the date, time, and place of the meeting will transfer
automatically to SELPA 9B (Notice for other IEP team members).


Changes from previous versions:
SELPA 9A Revised to include child’s last name and to allow typing into “Other” for
             purpose of meeting, and multiple other participants.
             Now includes anticipated end time for meeting.




                                                                                  33
                                                  NORTH SANTA CRUZ COUNTY
                                              SPECIAL EDUCATION LOCAL PLAN AREA
                                                   Notice of IEP Team Meeting

 Initial Review      Annual Review  Other Review _______________________                                Date: ___________________

Dear: _________________________________________________________________
A meeting of the Individualized Education Program Team is planned concerning your child, ________________________________.
You are encouraged as a participating member of this team to attend this very important meeting. Your child is also invited to attend,
if you feel it is appropriate.
The meeting is scheduled for:
Date: ________________________________________ Start Time: _______________ End Time: _________________
Place: _______________________________________________________________________________________________
The purpose of the meeting is:
           To discuss your child’s test results and determine eligibility for special education services
           To review your child’s IEP and discuss your child’s progress
           To meet the requirements that special education pupils be reassessed every three years
           To discuss the possible changes in your child’s education placement
           To ___________________________________________________________________________________________________

We anticipate that the following members will be in attendance:
           Special Education Administrator/Designee         Resource Specialist
           Special Education Teacher                        DIS Vocational Education
           Regular Classroom Teacher                        Student
           Psychologist                                     Other __________________________________________
           Nurse                                                     __________________________________________
           Adaptive Physical Education Specialist                    __________________________________________
           Representative of District of Residence                   __________________________________________
           Speech and Language Specialist                            __________________________________________
           Program Specialist

You may bring a representative with you or you may designate another person to be your representative if you are unable to attend.
Please review the summary of your rights and procedural safeguards which are attached. No special education placement will be
made without your written consent. If you would like further information about your rights or the purpose of this meeting, please
contact: __________________________________
            at _________________________________
                                                          Sincerely,   ____________________________________
                                                                       _______________________
                                                                       ____________________________________
Please check the appropriate boxes and return as soon as possible:
    I request a copy of assessments before the IEP meeting.
    I plan to attend the meeting.
    Please provide an interpreter. Specify: _____ Spanish _____Sign Language        ______Other ___________________
    I do not plan to attend the meeting.
    I request a different time/place
    Please contact me. Phone: _______________________________
            Date: __________________________ Time: _______________________
      My representative _________________________________________(name) will attend.


______________________________________________________                 _________________________________________________
Parent/Guardian/Surrogate Signature                                                  Student’s Signature

SELPA 9A (3/05)                    Distribution: Copy 1 - LEA Office      Copy 2 - Student File            Copy 3 - Parent
                                                                                                                                       34
                    NOTIFICATION OF IEP MEETING/Staff
                               SELPA 9B


When is this form used?

To notify participants (other than parents) of scheduled IEP.
There are two SELPA 9Bs on a page.

Who must attend the IEP?
(See SELPA 9A)

Computer Information for:

Notice of IEP Team Meeting/Staff: Note that the date, time, and place of the meeting will
transfer automatically from SELPA 9A. Student information will automatically transfer
from SELPA 1. For each half of page, enter To: individually (this allows you to send two
notices out for each page printed).

Changes from previous versions:
SELPA 9B More specialists listed.
             Allows entry into two “other” fields (previously only allowed entry into one
             of the “other” fields).
             Now includes anticipated end time for meeting.




                                                                                            35
                                                NORTH SANTA CRUZ COUNTY
                                            SPECIAL EDUCATION LOCAL PLAN AREA
                                              NOTIFICATION OF IEP MEETING
To: ______________________________________________ From: ___________________________________________
Student: ______________________________________________________                    Birthdate: __________________________
Meeting Date: _______________________________ Start Time: _________________ End Time: __________________
Location: ____________________________________________________________________________________________

Invited Participants:
    Administrator              Speech & Language Specialist                 Teacher for the Visually Impaired
    Psychologist               Adaptive Physical Education Specialist       Interpreter
    Special Class Teacher      Occupational Therapy Specialist              DIS Vocational Education
    Teacher (s)                Physical Therapist                           Agency Representative ________________________
    Resource Specialist        Teacher for the Hard of Hearing              Other1 ____________________________________
    Nurse                      Teacher for the Orthopedically Impaired      Other2 ______________________________________
Purpose of Meeting:
 Initial Eligibility Placement  Annual Review        3 year review
 Requested Review               Transition Planning  Discipline
 Other ________________________________________________________________________________________________________
Please return results of Assessment and/or Summaries of Present Levels of Performance to:

____________________________________________ by (date) ________________________
If you are unable to attend, please contact _____________________________ Phone ___________________________
SELPA 9B (3/05)




                                                 NORTH SANTA CRUZ COUNTY
                                            SPECIAL EDUCATION LOCAL PLAN AREA
                                              NOTIFICATION OF IEP MEETING
To: ______________________________________________ From: ___________________________________________
Student: ______________________________________________________                    Birthdate: __________________________
Meeting Date: _______________________________ Start Time: _________________ End Time: __________________
Location: ____________________________________________________________________________________________

Invited Participants:
    Administrator              Speech & Language Specialist                 Teacher for the Visually Impaired
    Psychologist               Adaptive Physical Education Specialist       Interpreter
    Special Class Teacher      Occupational Therapy Specialist              DIS Vocational Education
    Teacher (s)                Physical Therapist                           Agency Representative ________________________
    Resource Specialist        Teacher for the Hard of Hearing              Other1 _____________________________________
    Nurse                      Teacher for the Orthopedically Impaired      Other2 _____________________________________
Purpose of Meeting:
 Initial Eligibility Placement  Annual Review        3 year review
 Requested Review               Transition Planning  Discipline
 Other ________________________________________________________________________________________________________
Please return results of Assessment and/or Summaries of Present Levels of Performance to:

____________________________________________ by (date) ________________________
If you are unable to attend, please contact _____________________________ Phone ___________________________
SELPA 9B (3/05)




                                                                                                                                36
                          IEP TEAM MEMBER EXCUSAL
                                   SELPA 9C


When is this form used?

When by mutual agreement between the parent/adult student and the district the presence and
participation of certain team member(s) is/are determined to be not necessary will be excused
from being present and participating in the meeting in part or in whole because:

                 (1) the member’s area of the curriculum or related services is not being
                     modified or discussed in the meeting or
                 (2) the meeting involves a modification to or discussion of the member’s
                     area of curriculum or related services and the member submitted, in
                     writing to the parent and the IEP team, input into the development of the
                     IEP prior to the meeting.

This form must be completed and signed by parent and district.

If either parent or district do not agree that a member’s presence is not required, by law, that
member must remain for the entire meeting or the meeting must be rescheduled.


Computer Information for:

Complete information for all team members to be excused from the meeting. Attach signed
form to IEP.

Changes from previous versions:
SELPA 9C New form.




                                                                                              37
                                            NORTH SANTA CRUZ COUNTY
                                        SPECIAL EDUCATION LOCAL PLAN AREA
                                             IEP Team Member Excusal
                                            From a Meeting in Part or in Whole

Student’s Name _________________________________ Date of Meeting ______________________

By mutual agreement between the parent/adult student, and designated representative of the local education agency,
the presence and participation of the Individual Education Program team member(s) identified below is/are not
necessary and has/have been excused from being present and participating in the meeting scheduled on
_____/_____/_____ because (1) the member’s area of the curriculum or related services is not being modified or
discussed in the meeting or (2) the meeting involves a modification to or discussion of the member’s area of
curriculum or related services and the member submitted, in writing to the parent and the IEP team, input into the
development of the IEP prior to the meeting.

                                                                          Check appropriate column explaining why the IEP
                                                                          team member is being mutually excused from the IEP
                                                                          meeting in whole or part:
                                                                                                            Written input has been
                                                                                                            submitted to the parent and the
                                                                          Area Of Curriculum Or Related     IEP team prior to the meeting
Individual Education Program Team         Area Of Curriculum Or           Services is Not Being Discussed   regarding Area Of Curriculum
Member(s)                                 Related Services                Or Modified                       Or Related Services




By mutual agreement the IEP team members identified above, have been excused from being present and
participating in my child’s IEP meeting.

Circle relationship to student, sign, and date below.
Signature of Parent/Guardian/Surrogate: _______________________________________ Date: _____/_____/_____
Signature of Parent/Guardian/Surrogate: _______________________________________ Date: _____/_____/_____
Signature of Adult Student (ages 18-21): _______________________________________ Date: _____/_____/_____


Signature of Designated District Representative: _________________________________ Date: _____/_____/_____
Title/Position: _____________________________________________________________________


―IDEA Section 614 (d) (1) (c) IEP TEAM ATTEDANCE-
‗(I) ATTENDANCE NOT NECESSARY – A member of the IEP team shall not be required to attend an IEP meeting, in whole or in
part, if the parent of a child with a disability and the local educational agency agree that the attendance of such a member is not
necessary because the member‘s area of the curriculum or related services is not being modified or discussed in the meeting, ‗(ii)
EXCUSAL- A member of the IEP Team may be excused from attending an IEP meeting, in whole or in part, when the meeting
involves a modification to or discussion of the member‘s area of curriculum or related services, if—‗(I) the parent and the local
educational agency consent to the excusal; and ‗(II) the member submits, in writing to the parent and the IEP team, input into the
development of the IEP prior to the meeting. ‗(iii) WRITTEN AGREEMENT AND CONSENT REQUIRED- A parent‘s agreement
under clause (i) and consent under clause (ii) shall be in writing.‖

SELPA 9C (10/05)



                                                                                                                                       38
                               ASSESSMENT REPORT
                                  SELPA 10A & B


Who fills out these forms?

Each individual assessor prepares a report within the 60-day timeline. With district approval
some reports may be combined.

When should these forms be filled out?

An assessment report needs to be done at each initial IEP. Following the initial IEP, an
assessment should be completed for every 3-year review, unless school district and parent
agree that assessment is not needed at that time. When requested, this report(s) should be
given to the parents prior to the IEP.

Computer Information For:

Assessment Reports: This is basically a text box to type in your present levels. Note that all
paste/copy functions will work here if you want to paste information from a different
program or your own format. If you need additional pages, open SELPA 10B and attach
pages as necessary.

               Writing a report that is longer than one page: when you reach the bottom of
               the page (the end of where the field will print to) you will see a double black
               line extending slightly past the field, this will indicate to you that you need to
               start a new page. Just below is a blue button called Next Page, by pressing
               this button you may continue your report for the same student. (For SELPA
               10A Next Page will bring you to a new SELPA 10B and you must select the
               student name from the drop down list, enter date and teacher information, then
               continue with your report; for SELPA 10B, Next Page will create a new
               SELPA 10B with the same student information as the one you were working
               on).

Note that you can always change the font style and size in any text box. By choosing a
smaller font size, your report may fit onto one page. By default, the font is set to 12 pt Times
New Roman.

Changes from previous versions:
     SELPA 10A Ability to use Next Page button as described above. Changed
     assessment type headings to be consistent with other forms.
     SELPA 10B. Ability to use Next Page button as described above.




                                                                                               39
                                                    NORTH SANTA CRUZ COUNTY
                                                SPECIAL EDUCATION LOCAL PLAN AREA
                                                      ASSESSMENT REPORT           Date of Report __________________

LEA: ____________________________________ School: ________________________________________
Student Name: ____________________________________________________________________________
Grade Level: _________________________ Chronological Age: ______________ Birthdate: ___________
 Pre-Academic/Academic                        Perceptual/Motor               Medical/Health and Development
 Social/Emotional/Adaptive                    Language/Speech Communication  Functional analysis of Behavior
 Cognitive/Intellectual                       Pre-Vocational/Vocational      3-Year Evaluation

Examiner: ____________________________________                                            Position: __________________________

This report shall include but not be limited to (a) background information, including the reason for referral; (b) a list of assessment tools utilized and
results obtained including grade level, standard scores and interpretation; (c) relevant behavior during observation and its relationship to academic
and social functioning; (d) whether the pupil has a specific disability and the basis for making that determination; (e) any discrepancy between
achievement and ability that cannot be corrected without special education and/or related services; (f) effects of environmental, cultural, or economic
disadvantage, where appropriate; (g) educationally relevant medical finding if any.
                   Summary of Present Levels of Performance and Recommendations:




                                                                                                               Attach SELPA 10B pages as necessary
SELPA 10A (3/05)        Distribution: Copy 1 - LEA Office            Copy 2 - Student File          Copy 3 - Parent
                                                                                                                                                        40
                                         NORTH SANTA CRUZ COUNTY
                                     SPECIAL EDUCATION LOCAL PLAN AREA

                                SUPPLEMENTARY ASSESSMENT REPORT

Name: _____________________________________________ Birthdate: __________________________

Examiner: _______________________________________                       Position: ___________________________




SELPA 10B (3/05)   Distribution: Copy 1 - LEA Office   Copy 2 - Student File   Copy 3 - Parent

                                                                                                     41
         PRESENT LEVEL OF EDUCATIONAL PERFORMANCE
                           SELPA 11
This information should be prepared and filled in prior to the meeting. Address each
pertinent area. The team should verify the accuracy of this information, add data, and modify
as needed during the meeting.

Performance Areas Addressed:

Pre-Academic/Academic:       Focus on the most applicable areas for the student. For students
                             at the pre-academic level (SH, preschool, etc.), include a
                             description of the skills at that developmental level and
                             indicate priority areas for improvement.

                             Academic skills should include:

                                 1. Results of initial or most recent evaluation
                                 2. Classroom performance reflecting each specific
                                    academic area. For example, state the level of word
                                    attack skills and comprehension in reading,
                                    computation and application in math, and specific
                                    writing skills.
                                 3. For students with visual impairment, an assessment will
                                    be conducted to determine the most appropriate reading
                                    medium (e.g., Braille, large or regular print).

                             Functional skills could include:

                                 1. Cognitive constructs such as: cause/effect, object
                                    permanence, seriation, matching, sorting,
                                    1:1 correspondence, classification
                                 2. Components of task completion such as the student's
                                    ability to understand directions, work completion, and
                                    requesting assistance when needed
                                 3. Daily living skills, community, recreation/leisure skills,
                                    and mobility training
                                 4. Other skills pertinent to the child's independence

Social/Emotional/Adaptive    Describe the student's social and emotional strengths and
                             needs. Consider factors such as relative maturity, social
                             interaction with peers and adults, frustration tolerance, etc.
                             Utilize data from specific observed behaviors as much as
                             possible. When appropriate, indicate that social/emotional
                             development is age/grade/or developmentally appropriate or
                             indicate no reported concerns at this time.



                                                                                            42
            PRESENT LEVEL OF EDUCATIONAL PERFORMANCE
                         SELPA 11 (continued)

Cognitive/Intellectual              Tests in this area measure the ability to remember what has
                                    been seen and heard and the ability to solve problems. They
                                    also reflect learning rate and assist in predicting how well a
                                    student will do in school.
                                    Cognitive skills should include:

                                       1. Results of most recent evaluation
                                       2. How cognition affects student's ability to access the
                                          general education curriculum
                                       3. How cognition affects peer relations

  Perceptual/Motor                  For students who have been identified with areas of motor
                                    needs, describe the specific skills and/or needs the student has.
                                    Include both gross and fine motor, including manipulative
                                    abilities and handwriting. When appropriate, indicate that gross
                                    and fine motor skills are age appropriate or that no concerns
                                    have been reported at this time. At this time report any
                                    assessments done for visual, auditory, kinesthetic processing
                                    abilities.

  Language/Speech/Communication     For those students with identified areas of need in
                                    communication, describe the child's articulation, voice, fluency
                                    and language needs as appropriate. Differentiate between
                                    receptive and expressive language, as appropriate. Describe the
                                    student's written language if a concern exists or if it is a
                                    strength to be utilized. Also address his/her ability to use
                                    language functionally and/or use of alternative modes of
                                    communication. If appropriate, indicate that no speech or
                                    language concerns have been reported at this time. When the
                                    student has a hearing impairment, the appropriate mode of
                                    communication is considered and utilized.

  Pre-Vocational/Vocational         Include strengths, interests, and needs related to vocational
                                    skills. Include traits such as work habits, initiative, completion
                                    of classroom or school site jobs, following directions,
                                    time/money skills, etc. For older students, interests noted here
                                    should also be reflected on the ITP, SELPA 13F & 13G.

  Medical, Health and Development   Describe pertinent information as it relates to the student's
                                    educational progress. Recent vision and hearing results should
                                    be included. The district is responsible for providing
                                    screenings. Also, list medications. At this time a SELPA 8A


                                                                                          43
          PRESENT LEVEL OF EDUCATIONAL PERFORMANCE
                       SELPA 11 (continued)

                                  form may be filled out to share up-to-date information from
                                  medical staff and services.

Functional Analysis of Behavior   For those students with needs in this area, address skills such as
                                  dressing, toileting, feeding. (Include functional living skills
                                  training for pupils who require differential proficiency
                                  standards, see SELPA 16). If no concerns have been noted,
                                  indicate that self-help skills are age or grade appropriate.
Strengths/Interest/Learning Preference:
                                  Address the student's academic and personality strengths,
                                  current interests, and preferred learning style. It may be
                                  appropriate to include references to the most recent evaluation
                                  information pertaining to strengths and learning style, as well
                                  as information from the parents, staff and the student.

Areas of Need/Present Levels      List the broad areas that have been identified as negatively
                                  affecting educational progress. Each area of need must be
                                  addressed by a goal (Example: reading, expressive vocabulary,
                                  handwriting, and frustration tolerance). The goals and
                                  objectives (SELPA 12) must be developed prior to placement
                                  and services in any program addressing these areas of needs.
                                  Goals and objectives must be written with the IEP team,
                                  including the parent. Then the IEP team determines the extent
                                  of services and location.

Computer Information For:

SELPA 11        Present Levels of Performance: Is a text box into which you type your present
                levels. Use copy/paste if you would like to bring in your present levels from a
                different format/program.

                Writing a report and you need to use more than one page: when you reach the
                bottom of the page (the end of where the field will print to) you will see a
                double black line extending slightly past the field, this will indicate to you that
                you need to start a new page. Just below is a blue button called Next Page, by
                pressing this button you may continue your report for the same student. (Next
                Page will create a new SELPA 11 with the same student information as the
                one you were working on).

Changes from previous versions:
     SELPA 11 Ability to use Next Page as described above. Changed assessment type
     headings to be consistent with other forms.


                                                                                       44
                                             NORTH SANTA CRUZ COUNTY                                       Page ____ of _____
                                         SPECIAL EDUCATION LOCAL PLAN AREA

                  INDIVIDUALIZED EDUCATION PROGRAM FOR SPECIAL EDUCATION
                         PRESENT LEVEL OF EDUCATIONAL PERFORMANCE

LEA: _____________________________________________ Date of IEP Meeting: ____________________
Name: ____________________________________________ Date of Birth: __________________________
Completed by: ______________________________________ Position: ______________________________
                         PRESENT LEVELS OF EDUCATIONAL PERFORMANCE (A Summary of all assessment reports)
Performance Area              Pre-Academic/Academic; Social/Emotional/Adaptive; Cognitive/Intellectual; Perceptual/Motor;
Address as appropriate        Language/Speech/Communication; Pre-Vocational/Vocational; Medical/Health and Development
                              (Include both student strengths and needs)




SELPA 11 (3/05)    Distribution: Copy 1 - LEA Office    Copy 2 - Student File     Copy 3 - Parent

                                                                                                                            45
ANNUAL GOALS AND BENCHMARKS/SHORT-TERM OBJECTIVES
                       SELPA 12


Every student's IEP must be directed towards assisting the child to make progress in the
general education curriculum. For many students, this means that they will be learning the
scope and sequence of the state and district-adopted curriculum, but perhaps at a lower level,
using alternative materials or through specialized instructional methodology. Goals and
objectives should also address other educational needs resulting from the disability, such as
behavior, motor development, self-help skills, etc. The Annual Goals and Benchmark Short-
Term Objectives must be written in measurable terms. Goals may be measured by progress
toward grade level competencies, specific skill attainment, or other quantifiable standards. If
additional goals are added subsequent to the IEP meeting an Addendum IEP should be held.
(SELPA 14) These new goals then become part of the previous IEP.

Who fills out this form?
Goals and objectives are written with the IEP team including the parent.                 The
teacher/specialist should have draft goals written prior to the IEP, and once reviewed by the
IEP team, and revised as necessary, they can become part of the IEP.

How to fill out this form
The Areas of Need should be identified on the left upper box of the Annual Goals and
Benchmarks/Short-Term Objectives (SELPA 12). These may be specific academic areas
(reading, math, etc.), behavior (attention span, impulse control, etc.), motor (gross motor,
handwriting, etc.), or any other area of educational need. Baseline data should reflect where
the student is presently functioning related to the area of need, and should be measurable. A
goal must be developed for each area of need identified.

Long-term annual goal
Goals need to be measurable. Include references to the general education curriculum where
appropriate. (Example: “The student will improve mathematics computation to the 5th grade
level according to the California Math Standards.”) Goals may also be measured by criteria
such as completion of curricular units, pre/post tests, specifying rubric scores on portfolios,
etc. At times, the goals can reflect specified progress on the benchmarks. (Example: “The
student will improve his self-esteem as measured by attainment of 2 of 3 of the following
short-term objectives.”) Check the appropriate box indicating whether the goal is related to
the general curriculum, other educational needs or both.

Linguistically Appropriate Goals:
If the student is an English language learner the goals must be linguistically appropriate.
Check the box that indicates linguistically appropriate goals.

The schedule for informing parents of their child's progress on IEP goals and objectives
should coincide with the regular report card grading periods. The team should determine how
this will be accomplished. Options for meeting this requirement include annotated progress
on the goals pages, progress summary reports, or other methods of informing the parents of


                                                                                              46
ANNUAL GOALS AND BENCHMARKS/SHORT-TERM OBJECTIVES,
                  SELPA 12 (continued)

their child's progress towards meeting the annual goals. If progress is not commensurate with
the team's expectations, the teacher and parent should determine whether an IEP meeting
should be held.

It is legally required to regularly inform parents about progress towards the annual goals. In
general, noting progress on objectives on a regular basis should suffice to meet this
requirement. Use this section only if you indicate that parents will be informed of progress
through annotated Goals/Objectives.

Benchmark/Short-term Objectives should be measurable and lead to achievement of the
goal. A minimum of two Benchmarks (objectives) is required for each goal. Each objective
must address what the student will do, under what conditions, the timeline for meeting the
objective, and how it will be evaluated.

Example:

   1. By 3/06, the student will compute two-digit subtraction problems, with regrouping,
      with 80% accuracy as measured by: teacher selected tests.
   2. By annual review, the student will write a final draft expository essay on a word
      processor, with no more than 5 grammatical errors, as measured by: classroom work
      samples.

See sample goals and objectives in glossary for other samples.

At the annual review of the IEP, the progress on each objective should be noted. If the
objective is met as written, check MET. If not, check NOT MET and indicate current levels.
An objective that has not been met may or may not be appropriate to be continued for the
following year.

Computerized Information For:

SELPA 12       Goal statements, measurement statements, and objective statements can be
               entered automatically in a field by typing in a key # in the green colored
               boxes. (Note: these boxes do not print on the final form.) When you type in a
               key #, the corresponding statement from the SELPA 12 Goals and
               Objectives will fill in automatically.

               To generate your own list of Goals and Objectives, go to SELPA 12 Goals
               and Objectives. In this database, each new goal or objective is a new record.
               Type in a key number for each statement you write in the textbox. To add
               another goal, create a new record by selecting New Record under the Mode
               Menu, or by clicking on the Add New Goal/Obj/Meas button.



                                                                                  47
ANNUAL GOALS AND BENCHMARKS/SHORT-TERM OBJECTIVES,
                  SELPA 12 (continued)
             Hint: To organize your goals, you may want to systemize your key numbers.
             For example, put the letter g, m, or o before or after your key number lets you
             know whether the statement will be a long term goal, way of measuring, or
             short-term objective. Additionally, by grouping your goals, measurements,
             and objectives according to categories, you can more easily organize your list.

             Ex:    g100, g101, g102, etc are reading goals
                    m200, g201, g202 are math measurement statements
                    o300, etc are writing objectives
                    G400, etc are behavioral goals

             You can always go back later and renumber your list, but you’ll be happy in
             the long run if you take the time to add each new goal and objective into the
             SELPA 12 Goals and Objectives database. That way the goals you write will
             be there for the next IEP.

             Once you have generated a list of goals and objectives, print out a hard copy
             to refer to as you write your SELPA 12 so you can see all your goals on paper
             and select the appropriate goal for your student.

Changes from previous versions:
SELPA 12     Added space to enter general curriculum/state standard # if appropriate.
             Added check box for linguistically appropriate.
             Added ability to type into Other specialist field (up to two specialists)
             Increased space available for writing in long-term annual goal, and
             benchmarks.
             Made periodic review dates section less crowded.




                                                                                48
                                    NORTH SANTA CRUZ COUNTY
                               SPECIAL EDUCATION LOCAL PLAN AREA                                                   Page ____ of _____
Annual Goals and Benchmarks/Short-Term Objectives

Student Name _________________________________________ Birthdate ____________ Date of Meeting: _______________

         Area of Need           Long-Term Annual Goal:                                                       Persons Responsible
                                By (date) ____________ student will:                                          Gen. Ed. Teacher
______________________          _______________________________________________________
______________________          _______________________________________________________                       Sp. Ed. Teacher
______________________          _______________________________________________________                       Student
______________________          _______________________________________________________
______________________          _______________________________________________________                       Parent
______________________          As measured by:                                                               Other ___________________
______________________          _______________________________________________________
                                _______________________________________________________                                 ___________________
______________________
                                 Enables student to be involved/progress in general curriculum/state standard #
                                 Addresses other educational needs resulting from the disability
                                 Linguistically appropriate
Parents will be informed of
                                Periodic Review Dates     Progress Toward Annual Goal      Sufficient Progress to Meet Annual Goal
progress:
 Quarterly  Semester          1.   ______________       1. ___________________            Yes  No        __________________________
 Trimester  Other
How?                            2.   ______________       2. ___________________            Yes  No        __________________________
 Annotated Goals/Objectives
 Progress Summary Report       3.   ______________       3. ___________________            Yes  No        __________________________
 Other:
                                4.   ______________       4. ___________________            Yes  No        __________________________
Baseline:                       Benchmark/Short-Term Objective:                                              Date: ___________________
______________________          By (date) ____________ student will:                                          Met  Not Met
______________________          _______________________________________________________                      Comments:
______________________          _______________________________________________________                      ______________________
______________________          _______________________________________________________                      ______________________
______________________          _______________________________________________________                      ______________________
______________________          _______________________________________________________                      ______________________
______________________          As measured by:                                                              ______________________
______________________          _______________________________________________________                      ______________________
                                _______________________________________________________
Baseline:                       Benchmark/Short-Term Objective:                                              Date: ___________________
______________________          By (date) ____________ student will:                                          Met  Not Met
______________________          _______________________________________________________                      Comments:
______________________          _______________________________________________________                      ______________________
______________________          _______________________________________________________                      ______________________
______________________          _______________________________________________________                      ______________________
______________________          _______________________________________________________                      ______________________
______________________          As measured by:                                                              ______________________
______________________          _______________________________________________________                      ______________________
                                _______________________________________________________
Baseline:                       Benchmark/Short-Term Objective:                                              Date: ___________________
______________________          By (date) ____________ student will:                                          Met  Not Met
______________________          _______________________________________________________                      Comments:
______________________          _______________________________________________________                      ______________________
______________________          _______________________________________________________                      ______________________
______________________          _______________________________________________________                      ______________________
______________________          _______________________________________________________                      ______________________
______________________          As measured by:                                                              ______________________
______________________          _______________________________________________________                      ______________________
                                _______________________________________________________

SELPA 12 (3/05)                Distribution: Copy 1 - LEA Office        Copy 2 - Student File         Copy 3 – Parent
                                                                                                                                          49
                                    ANNUAL GOALS
                                      SELPA 12A


New California and Federal law allow for writing goals without including
benchmarks/objectives for special education students, with the exception of students taking
the CAPA. For students taking the CAPA please go to SELPA 12 Annual Goals and
Objectives/Benchmarks. Even without objectives/benchmarks progress towards the goal is
still required to be tracked and reported to parents at the same time intervals as general
education students. PLEASE CHECK WITH YOUR DISTRICT ADMINISTRATOR
PRIOR TO USING THIS ALTERNATIVE FORM.

The schedule for informing parents of their child's progress on IEP goals and objectives
should coincide with the regular report card grading periods. The team should determine how
this will be accomplished. Options for meeting this requirement include annotated progress
on the goals pages, progress summary reports, or other methods of informing the parents of
their child's progress towards meeting the annual goals. If progress is not commensurate with
the team's expectations, the teacher and parent should determine whether an IEP meeting
should be held.

See SELPA 12 Annual Goals and Objectives for information regarding goal writing.

Who fills out this form?
Goals are written with the IEP team including the parent. The teacher/specialist should have
draft goals written prior to the IEP, and once reviewed by the IEP team, and revised as
necessary, they can become part of the IEP.

How to fill out this form
A goal must be developed for each area of need identified. This form allows for two goals to
be written per page. The Areas of Need should be identified in the appropriate box(es).
These may be specific academic areas (reading, math, etc.), behavior (attention span, impulse
control, etc.), motor (gross motor, handwriting, etc.), or any other area of educational need.
Baseline data should reflect where the student is presently functioning related to the area of
need, and should be measurable.

Long-term annual goal
Goals need to be measurable. Include references to the general education curriculum and/or
state standards where appropriate. (Example: “The student will improve mathematics
computation to the 5th grade level according to the California Math Standards.”) Goals
may also be measured by criteria such as completion of curricular units, pre/post tests,
specifying rubric scores on portfolios, etc. At times, the goals can reflect specified progress
on the benchmarks. (Example: “The student will improve his self-esteem as measured by
attainment of 2 of 3 of the following short-term objectives.”) Check the appropriate box
indicating whether the goal is related to the general curriculum, other educational needs or
both.



                                                                                                  50
ANNUAL GOALS AND BENCHMARKS/SHORT-TERM OBJECTIVES,
                  SELPA 12 (continued)
 Linguistically Appropriate Goals:
If the student is an English language learner the goals must be linguistically appropriate.
Check the box that indicates linguistically appropriate goals.

Computerized Information For:

SELPA 12A Goal statements can be entered automatically in a field by typing in a key # in
          the green colored boxes. (Note: these boxes do not print on the final form.)
          When you type in a key #, the corresponding statement from the SELPA 12
          Goals and Objectives will fill in automatically.

              To generate your own list of Goals and Objectives, go to SELPA 12 Goals
              and Objectives. In this database, each new goal or objective is a new record.
              Type in a key number for each statement you write in the textbox. To add
              another goal, create a new record by selecting New Record under the Mode
              Menu, or by clicking on the Add New Goal/Obj/Meas button.

              You can always go back later and renumber your list, but you’ll be happy in
              the long run if you take the time to add each new goal and objective into the
              SELPA 12 Goals and Objectives database. That way the goals you write will
              be there for the next IEP.

              Once you have generated a list of goals and objectives, print out a hard copy
              to refer to as you write your SELPA 12A so you can see all your goals on
              paper and select the appropriate goal for your student.

Changes from previous versions:
SELPA 12A New Form




                                                                                 51
                                                  NORTH SANTA CRUZ COUNTY
                                             SPECIAL EDUCATION LOCAL PLAN AREA                                  Page ____ of _____
                                                        Annual Goals

Student Name _________________________________________ Birthdate ____________ Date of Meeting: _______________

 Area of Need:                 Measurable Annual Goal #___                                                Persons Responsible:
 Baseline:
                                                                                                           Gen. Ed. Teacher
                                                                                                           Sp. Ed. Teacher
                                                                                                           Student
                                                                                                           Parent
                                                                                                           Other ______________________
                                                                                                                    ______________________

                                Enables student to be involved/progress in general curriculum/state standard # ____________
                                Addresses other educational needs resulting from the disability
                                Linguistically appropriate
 Progress Report 1: __/__/__      Progress Report 2: __/__/__        Progress Report 3: __/__/__    Goal: Annual Review
 Summary of progress              Summary of progress                Summary of progress            Date: ___/___/___
                                                                                                    Goal met    Yes  No
                                                                                                    Comments:
                                                                                                    ____________________________________
                                                                                                    ____________________________________
 Comment                          Comment                            Comment
                                                                                                    ____________________________________
                                                                                                    ____________________________________
                                                                                                    ____________________________________
                                                                                                    ____________________________________
                                                                                                    ____________________________________

 Area of Need:                 Measurable Annual Goal: #____                                              Persons Responsible:
 Baseline:
                                                                                                           Gen. Ed. Teacher
                                                                                                           Sp. Ed. Teacher
                                                                                                           Student
                                                                                                           Parent
                                                                                                           Other ______________________
                                                                                                                    ______________________

                                Enables student to be involved/progress in general curriculum/state standard # _____________
                                Addresses other educational needs resulting from the disability
                                Linguistically appropriate
 Progress Report 1: __/__/__       Progress Report 2: __/__/__       Progress Report 3: __/__/__    Goal: Annual Review
 Summary of progress               Summary of progress               Summary of progress            Date: ___/___/___
                                                                                                    Goal met    Yes  No
                                                                                                    Comments:

                                                                                                    ____________________________________
                                                                                                    ____________________________________
 Comment                           Comment                           Comment                        ____________________________________
                                                                                                    ____________________________________
                                                                                                    ____________________________________
                                                                                                    ____________________________________
                                                                                                    ____________________________________


SELPA 12A (12/05)                Distribution: Copy 1 - LEA Office         Copy 2 - Student File       Copy 3 - Parent


                                                                                                                                        52
      INDIVIDUAL EDUCATION PROGRAM (IEP) STUDENT DATA
                         SELPA 13A


Who fills out this form?

Prior to meeting the case manager/designee can fill out as much current student data as
possible. Student's strengths and parental concerns can be added to at the time of the meeting.

DATES
Initial Placement in Sp. Ed   Fill in Date/Month/Year for all dates. Initial Placement in
Next IEP                      Special Education means the date of the very first IEP or IFSP
Last Triennial
Next Triennial
                              that identified the year the student was eligible for special
                              education services. “Triennial” is the term for the three year re-
                              evaluation. In most cases, the “Next IEP date” will be one year
                              from date of meeting. The IEP Team should review dates for
                              accuracy and make adjustments as necessary.
PURPOSE OF MEETING
(Upper Left)                  Check the purpose(s) of the meeting. “Transition” can include
                              infant to preschool, middle school to high school, NPS to public
                              school, etc. In addition, when the student is age 16, a transition
                              IEP meeting must be held to address transition service needs. If
                              “Other” is checked, indicate reasons. (Examples: “parent
                              request,” “teacher request,” “progress review,” “30 day interim
                              placement,” etc.)
STUDENT INFORMATION
Name                          Utilize the most current MIS data (student information), and
Birthdate                     verify accuracy at the meeting. Provide the social security
Gender
Social Security Number
                              number if available.
CSIS #
Parent/Guardian               CSIS# was added to the form to meet with the state’s future
Address                       intention to use a statewide number for each student. Once
Home/Student Language         incorporated across the state this will become a required field.
Fluency in English
Ethnicity
Residency                     Residency is based on the setting where a child is currently
                              residing (i.e. parent/guardian, foster care, etc.)

                              Identify the student's Home Language and Student language
                              based on the parent response to the Home Language Survey.

                              Ethnicity, list up to four ethnicities based on parent response.




                                                                                                 53
     INDIVIDUAL EDUCATION PROGRAM (IEP) STUDENT DATA
                    SELPA 13A (continued)
SCHOOL INFORMATION
District of Residence            If the student attends a school other than his/her school of
Attending school                 residence, identify the district and the school. If the student
Federal School Setting
District of Service
                                 attends a nonpublic school, write “NPS” and name of the school.
Grade                            (Example: NPS/Any School.)
Preschool Setting
Student Strengths
                                 Identify the federal school setting according to pull-down menu
Parent Concerns                  for all students age 6-22.
Eligible for Special Education
based on..
                                 List current grade at time of IEP.
                                 For Preschool students (age 3-5) list preschool setting based on
                                 pull-down menu.
                                 The IEP team determines the student's eligibility for Special
                                 Education services based on all of the information discussed at
                                 the IEP. Check the appropriate box and write a brief statement
                                 regarding the team's rationale, such as “...based on having a
                                 Learning Disability with a processing deficit in the area of
                                 visual perception” (for a student with a learning disability) or
                                 “...based on global delays in all areas of functioning” (for a
                                 student who is mentally retarded).
                                 If the student is not eligible, stop here; check appropriate boxes
                                 and sign SELPA 13C.
PRIMARY DISABILITY CATEGORY
Primary Disability     Check one box                 only. This is an IEP team decision, which is
Low Incidence          made following                 each initial assessment or reevaluation. The
Secondary Disabilities
                                 members of the team determine if the student meets the
                                 eligibility criteria as a child with a disability who requires special
                                 education and related services. The team determines the child’s
                                 primary disability through consensus. (Note: If at least one of
                                 the student’s disabilities is Hard of Hearing, Deaf-Blind,
                                 Visually Impaired, or Orthopedically Impaired, this should be
                                 listed as the primary disability. The Established Medical
                                 Disability category only applies to infants and preschoolers ages
                                 0 to 5.)
                                 A child only qualifies for low incidence if their primary
                                 disability is marked as Hard of Hearing, Deaf-Blind, Visually
                                 Impaired, or Orthopedically Impaired. (On the computerized
                                 version, this will fill in as “Yes” automatically when one of these
                                 primary disabilities is marked. If any other primary disability is
                                 marked it will automatically fill in as “No”).
                                 List any relevant Secondary disabilities that may affect how a
                                 student is able to participate in the general education program.


                                                                                          54
    INDIVIDUAL EDUCATION PROGRAM (IEP) STUDENT DATA
                   SELPA 13A (continued)


Computer Information For:
SELPA 13A Only one choice can be made for primary disability. Once this is chosen,
          qualifies for low incidence will fill in as appropriate based on the primary
          disability.

SELPA 13 ABCDE
           Depending on your situation at your site and your access to computers,
           copiers, and the like, use of the electronic version of this form will vary. If
           you have access to a computer, printer, and copier in the room where you hold
           your IEPs, it would be possible to complete the IEP electronically, print one
           copy and have the participants sign, then make photocopies of the signature
           page (SELPA 13D). On the other end of the technology spectrum, you can fill
           out as much as you can before the IEP, print one copy, complete the IEP by
           hand, and then make photocopies.


Changes from previous versions:
SELPA 13A Moved program information, agencies and transition information to SELPA
             13C Services page.
             Added some student information fields newly required by law (ethnicity,
             CSIS#)
             Added cell phone to parent address.
             Listed primary disabilities and residency codes as radio buttons, rather than
             pull-down menu, to allow for viewing selections when writing IEP by hand.
             On computerized version, dates no longer fill-in automatically. Often dates on
             the SELPA 1 were not updated prior to holding IEP, so dates were filled in
             improperly.




                                                                                55
                                        NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                                                                                                              Page ____ of _____
                                        INDIVIDUALIZED EDUCATIONAL PROGRAM (IEP)
PURPOSE OF MEETING:
   Initial IEP        Pre-Expulsion
                                                                      Student Data
   Annual Review      Interim
   Triennial          Expanded IEP
   Transition         Other ____________________



__________________________________________________________                                              Dates:         This IEP: _________________
Student’s Legal Name:             First     Middle         Last                                      Initial Placement in Sp. Ed. _________________
 Male  Female Birthdate: __________________ Chron Age ___________                                                   Next IEP: _________________
Social Security # ________________________ CSIS # _______________________                                       Last Triennial: _________________
Name of Parent/Surrogate/Guardian ________________________________________________                             Next Triennial: _________________
Address ______________________________________________________________________
Mailing Address ________________________________________________________________
Home Phone _________________________ Work Phone ________________________ Cell Phone _________________________
Home Language ______________________ Student Language ____________________ Fluency in English                          EL  FEP  EO
Migrant      Yes  No           Ethnicity ___________________ ___________________ ___________________ ____________________
RESIDENCY
 Parent or Legal Guardian 10                         Hospital (Medical) 40                 State Hospital 70
 Licensed Children’s Institution 20                  Residential School 50                 Developmental Center 72
 Foster Family Home 30                               Incarcerated Institution 60           Other 90
SCHOOL INFORMATION
District of Residence _________________________________________ Attending School ___________________________________________
Federal School Setting (Ages 6-22) _________________________________________________________
District of Service ____________________________________________ Grade ___________ Preschool Setting                      ________________________
                                                                                                                          ________________________
Student Strengths:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Parental concerns regarding educational needs:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
The IEP team finds the student  is  is not eligible for special education services based on
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PRIMARY DISABILITY
Indicate PRIMARY Disability:
 210 Mentally Retarded (MR)                           260 Emotional Disturbance (ED)                   300 Deaf/Blindness (DB)
 220 Hard of Hearing (HH)                             270 Orthopedic Impairment (OI)                   310 Multiple Disabilities (MD)
 230 Deafness (DEAF)                                  280 Other Health Impairment (OHI)                320 Autism (AUT)
 240 Speech or Language Impairment (SLI)              281 Established Medical Disability (3-5 only)    330 Traumatic Brain Injury (TBI)
 250 Visual Impairment (VI)                           290 Specific Learning Disability (SLD)           Not Eligible for Special Education
Qualifies for Low Incidence:      Yes  No
If any secondary                 ________________________________________________________________________________________________
Disabilities please indicate:    ________________________________________________________________________________________________
 The disability is not due to factors of environment, cultural difference, economic disadvantage, limited school experience, or attendance
 The disability cannot be accommodated through other regular or categorical services offered within the regular instructional program
SELPA 13A (3/06)         Distribution: Copy 1 - LEA Office              Copy 2 - Student File       Copy 3 - Parent
                                                                                                                                                    56
              IEP - ASSESSMENT and SPECIAL FACTORS
                             SELPA 13B

DISTRICT AND STATE WIDE TESTING

   Check Full Participation if the student will be taking the California Standards Test and
   CAT-6 under the same conditions as non-disabled peers. Specify which accommodations
   or modifications will be provided. (Note: accommodations do not fundamentally alter the
   test and modifications fundamentally do alter what the test measures). Please check with
   your District STAR coordinator to verify which accommodations or modifications are
   allowable for the current year (these are changed/updated on a yearly basis).
   If it is inappropriate for the student to participate in any of the standardized state
   assessments, check CAPA and indicate why the California Standards Test CAT-6 and/or
   other state assessments are inappropriate (Example: “The student is participating in a
   functional skills curriculum.")
   If the student is below grade 2 or above grade 11 check the grade exempt box.

   Note: Even if parents do not wish to allow their child to participate in statewide testing,
   the IEP team is required to recommend how the child should be tested. The parent right
   to request an exemption from testing is not part of the IEP process, since it is not a
   special education issue, but is a separate issue concerning the parent and the school site
   administrator usually addressed in the form of a parent letter.

LEAST RESTRICTIVE ENVIRONMENT

A and B.      If student’s special education services are not provided within general
   education classroom, check all pertinent boxes.

C. Some possible examples of modifications/aids/supports include:
   • Needs simple directions with restatement due to learning disability in auditory
     processing.
   • Needs reduced assignments and increased time allowed due to _____________.
   • Needs structured, predictable environment with frequent redirection due to (emotional
     disturbance) (autism), etc.
   • (disability) impairs student's ability to integrate and generalize learning.
   • Needs functional skills curriculum due to cognitive level (MR).
   • Disability (e.g. hard of hearing) impairs students ability to understand oral directions.
   • Needs small group instruction in reading due to learning disability in visual processing.
   • Needs special education support to modify classroom materials due to orthopedic
     impairment.
   More detail can be added under Additional Comments or on SELPA 13E (Continuation
   Page)

                                                                                                 57
                       IEP - ASSESSMENT and SPECIAL FACTORS
                                 SELPA 13B (continued)
    D. Appropriate statements for preschoolers should reflect how their disability impacts
       their interaction with peers, language development, acquisition of readiness skills, etc.
       What is stated here must be addressed by goals and objectives to the student.

PROVISION FOR SPECIAL FACTORS

    Any necessary activity or support for the student or school personnel should be indicated
    here. If the student utilizes a communication book, it should be noted here, as well as any
    specialized curriculum modifications. Everything indicated must be provided, so it is
    imperative that all members of the IEP team be aware and supportive of the decision. If
    appropriate, indicate the projected date for the beginning of these services or supports,
    and the anticipated frequency, location, and duration. (Examples: note taker, consultation
    to the classroom teacher by Special Education staff at least one time per semester,
    training in behavior management for autistic students for teacher and aide weekly for the
    first two months, consultation from special education teacher regarding curriculum
    modification monthly, consultation from school psychologist regarding behavior
    management strategies, etc.).
    More detail can be added under Additional Comments or on SELPA 13E (Continuation
    Page)

If the student is blind or          The presumption is that all blind or visually impaired students
visually impaired, instruction      will receive instruction in Braille unless the IEP team determines
in Braille and in the use of will
be provided
                                    it is not appropriate, such as for a student who is considered
                                    visually impaired due to limitations in the visual field. This is the
                                    only place in IDEA where curriculum or teaching strategies is
                                    specified. Braille might not be provided to a student whose
                                    cognitive level or multiple disabilities preclude the use of Braille
                                    at this time.

Does the child have                 The need of the student to progress in the general education
communication needs?                curriculum as well as to develop English proficiency must be
                                    addressed. Examples of ways to address this need to include
                                    instruction in native language for certain concepts, use of
                                    interpreters, consultation from Bilingual Specialist, sheltered
                                    English instruction, English language development, etc.

If the student is Deaf/Hard of      The DHH students should be able to communicate directly with
Hearing (DHH), what is the          peers and staff and be instructed in his/her primary mode of
mode of communication: Are
specialized communication
                                    communication (Example: Total Communication, ASL, Oral,
strategies required?                etc.). A DHH teacher should be a primary participant in this
                                    determination.




                                                                                            58
                   IEP - ASSESSMENT and SPECIAL FACTORS
                             SELPA 13B (continued)
Language Needs                 For English Language Learners – Check this box if special provisions
                               need to be made for an English Language Learner and have been
                               considered in the IEP.
                               If this box is checked, please be sure to include the Student’s
                               CELDT.

Assistive technology devices   The use of technology must be considered for each student with a
                               disability. A professional familiar with assistive technology should be
                               consulted. There may be no special technology required or a student
                               may need to use items such as a calculator or basic word processor. If
                               the student has a low incidence disability, the equipment and materials
                               may be more specialized, such as an auditory trainer or voice activated
                               computer. The child's teacher or case manager needs to ensure that the
                               equipment indicated is provided in a timely fashion. For low incidence
                               students requiring new assistive technology, a request for low
                               incidence equipment (SELPA 24) should be completed by the
                               student's IEP team. Assistive technology is listed on the IEP only if it
                               is required by the student to meet the educational goals and objectives.

Behavior                       The IEP team must consider if the student's behavior interferes with
                               his or her learning or that of others. Strategies to address the behavior
                               could include activities such as specifying the classroom management
                               system or developing a behavior contract for the student that addresses
                               positive behavior intervention strategies. Goals and objectives should
                               be included to identify positive alternative behaviors to be developed.
                               If the student requires a Behavior Support Plan check BSP. If the
                               behavior is more severe, including behavior that is dangerous to the
                               child or others, check the Behavior Intervention Plan (BIP) box. (A
                               Behavior Intervention Plan requires a SELPA certified BICM
                               (Behavior Intervention Case Manager))


PROMOTION CRITERIA
    Check the appropriate boxes to address the promotional criteria to be used.
ADDITIONAL COMMENTS

This is for any information agreed upon at the IEP, which does not have a space provided, or
there is not enough room to include elsewhere.

Changes from previous version:
SELPA 13B Updated Participation in State/District Wide Assessments section to reflect
             legal changes.
             Added promotion criteria section.
             Added space for CELDT score.




                                                                                           59
                                        NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                    INDIVIDUALIZED EDUCATION PROGRAM (IEP) - ASSESSMENTS AND SPECIAL FACTORS
Student’s Legal Name _________________________________________________ Birthdate ______________ IEP Date __________________

PARTICIPATION IN STATE/DISTRICT WIDE ASSESSMENTS (STAR): (Check all that apply)
 CAT-6/California Standards Test
         Full Participation - No Accommodations/Modifications
         With Accommodations _______________________________________________________________________________________
         With Modifications __________________________________________________________________________________________
         Will not participate in CST/CAT-6 because _______________________________________________________________________
             Describe how child will be assessed: ____________________________________________________________________________
 California Alternate Performance Assessment (CAPA) – Level  1  2  3  4  5
 Grade Exempt (before grade 2 and after grade 11)
Other State-Wide Assessments -- Accommodations/Modifications ________________________________________________________________
Other District-Wide Assessments -- Accommodations/Modifications ______________________________________________________________
LEAST RESTRICTIVE ENVIRONMENT: (Check all that apply)
A. The student is not able to benefit from full participation with non-disabled peers for the following reason(s):
         To progress in the general curriculum, the student requires modified or intensive instruction not feasible in the regular classroom
         The student requires an alternative curriculum to meet assessed needs.
         The student requires a setting with a high level of structure and supervision
         The student requires a highly restrictive setting to provide for the safety of self or others
         Other _________________________________________________________________________________________________________
                  _________________________________________________________________________________________________________
B.    The student will participate with non-disabled peers in the general education setting for:
       Physical Education            Academic and Non-Academic Subjects/Periods  Recess/Breaks/Lunch
       School-Wide Activities  Extra Curricular Activities                                     Other
      ____________________________________________________________________________________________________________________
      ____________________________________________________________________________________________________________________
C.    List any program modifications and supplemental aids/support necessary:
      ____________________________________________________________________________________________________________________
D.    For Preschool - How the child’s disability affects participation in age appropriate activities:
      ____________________________________________________________________________________________________________________

PROVISION FOR SPECIAL FACTORS: (Check all that apply and elaborate below, as needed)
    Large print (for a student with visual impairment)
    Instruction in use of Braille (for a student with visual impairment or blindness)
    Other modifications for reading and writing (materials, medical, etc.)
   Communication (for a student with hearing impairment, opportunities for direct communication with peers and professionals in the
student’s communication mode and at his/her academic level)
 Language needs (for English Language Learners) CELDT score (if English Language Learner) _______________
 Assistive Technology (for a student requiring equipment and/or services in order to meet goals and objectives or to access the core curriculum)
 Behavior: Does the student’s behavior impede his/her learning and/or the learning of others?  Yes  No
     If yes,    Behavioral goals/objectives are included in the IEP          Positive Behavioral Intervention Plan is attached to IEP
                Individualized Behavior Support Plan is attached to IEP  Classroom behavior management plan
SPECIFIC PROVISIONS:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

PROMOTION CRITERIA:  District                     Substantial Progress on Goals           Other _______________________________________
Parents will be informed of progress at the same frequency as students without disabilities.
 Quaterly            Trimester          Semester         Other ___________________________________
How?  Annotated Goals/Objectives              Progress Summary Report  Other _______________________________________

ADDITIONAL COMMENTS:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SELPA 13B (3/06)        Distribution: Copy 1 - LEA Office            Copy 2 - Student File     Copy 3 - Parent
                                                                                                                                                    60
                 INDIVIDUAL EDUCATION PLAN SERVICES
                               SELPA 13C


SERVICES:

List all services (e.g. Specialized Academic Instruction-SDC/RSP, speech/language etc.) as
recommended by the IEP team; indicate the personnel responsible, the exact initiation date,
expected ending date, duration, frequency and location where these services will occur. If
the parents do not agree with the services recommended by school staff, list the specific
services offered by school staff and ask parent to write their concerns on the SELPA 13D
Signature Page, or on the SELPA 13E Continuation Page.
If there is not enough room to include all services in this section an additional SELPA 13C
can be used: be sure to include it in the numbering of the IEP.
Extended School Year: ESY is appropriate for students who are likely to continue in special
ed. indefinitely or for a prolonged period. Interruption of the their educational programming
may cause regression, when coupled with limited recoupment capacity, rendering it
impossible or unlikely that the they will attain the level of self-sufficiency and independence
that would otherwise be expected in view of their disability. Usually due to the shortened
school day for ESY, services provided during this time will have a different frequency and/or
duration than during the regular year.
Service                     For those students receiving services on a consultation basis, use
                            the Services column and note that service as consultation. For
                            example, a Resource Specialist teacher may be serving a student
                            within a general education classroom for two 45 minute periods
                            and also provide consultation to the classroom teacher on a
                            weekly basis for 30 minutes. The services would be listed
                            separately with consultation stated as RSP/consult.

Start and End Date          Write the date (month/day/year) that the IEP service(s) will
                            begin and end. The duration of services/modifications should be
                            one year, or shorter if determined by IEP team consensus. Some
                            services may start and end at different times. For example, RSP
                            may be one year, but the IEP team may determine that OT
                            services will be provided during the Fall semester only.

Duration                    Number of minutes per session.

Frequency/Time              Identify the number of sessions per week, month, or year.




                                                                                              61
                     INDIVIDUAL EDUCATION PLAN SERVICES
                             SELPA 13C (Continued)
Location/Setting              Select the place where the service will be provided, according to
                              the drop down menu. For example, if the student is receiving
                              RSP services in a pullout program, the location would be
                              “Separate classroom in a public integrated facility.” If the
                              program is SDC but the student is “fully included,” “Regular
                              classroom public day school” would be the primary placement
                              location. For “push-in” DIS services, “Regular classroom public
                              day school” would be the location where the service is being
                              provided.

Service Options Considered    Make sure to start with general education when considering
                              options. Document all options considered. List all educational
                              services and options that might be appropriate for the student.

PROGRAM INFORMATION
Physical Education:           Specify the type of physical education. Check the type(s) of
                              physical education the student will receive. “General Education”
                              means the student participates in the regular P.E. program with
                              no modifications. “Specially Designed” means a modified
                              general P.E. program, such as utilizing the services of a signing
                              aide during P.E., or provided as part of the student's SDC
                              program. If “Adapted P.E.” is being provided, include in the
                              Services section above.

Agencies involved:            List the names of the agencies that are serving the student.
                              Representatives from these agencies may be invited to attend
                              IEP meetings, as appropriate. (For students age 16 and older,
                              representatives from agencies must be invited.)

Mental Health                 New state requirement for reporting and tracking purposes.
eligible/services included:   Check the boxes yes or no as appropriate.




                                                                                   62
                    INDIVIDUAL EDUCATION PLAN SERVICES
                             SELPA 13C(Continued)
Percentage Student will/will   Record the percentage of time which represents the student's total
not participate in general     time the student WILL be participating in the general education
education:
                               program, including lunch, recess, etc., with non-disabled peers
                               and the total time student WILL NOT be participating in the
                               general education program (These should always equal 100). For
                               example: If a student attends school 325 minutes per day and is
                               included with typical peers for lunch (45 minutes) recess (15
                               minutes) and 1 regular class per day (55 minutes), this student is
                               participating in the general education program for 115 minutes of
                               325 minutes which equals 35% of his day (115/325=.35=35%),
                               therefore is WILL NOT participate in general education 65%
                               of the day and WILL participate 35% of the day. Any time
                               spent with typical peers is considered participation in the general
                               education program.
Special Education              Mark the appropriate boxes following your district's procedures
Transportation                 and policies.
Activities To Support          Document activities to support transition. This does not include
Transition:                    the 16 year old transition plan (Individual Transition Plan-
                               SELPA 13F&G)
Secondary School Students      If yes boxes are checked, refer to SELPA 13F&G.
Only                           For all students 15 years and older the IEP team should consider
                               the student's interests and need for development of prevocational
                               skills to assist in determining the course of study at the secondary
                               level (Example: word processing, automotive, food trades, etc.).
                               The student must be invited to attend all IEP meetings where
                               transition is discussed.
Students in 8th Grade or       Enter projected graduation date from high school or secondary
Higher Graduation              completion date (for those students who will be in special
Requirements
                               education through age 22.) And check the box for which goal the
                               student is currently working towards (diploma, certificate, GED
                               or other; other no diploma, but skills learned through ROP, etc.).
                               Parent and student must have a copy of all high school graduation
                               requirements, including CAHSEE, credits required and Algebra
                               requirements. If district/school of attendance has any other
                               requirements for obtaining a diploma, be sure to explain to both
                               parent and student and include in the space provided on the form.
                               Have student or parent initial box if they have received a copy of
                               the district graduation requirements, and initial on the appropriate
                               line.




                                                                                      63
               INDIVIDUAL EDUCATION PLAN SERVICES
                        SELPA 13C(Continued)



Changes from previous versions:
SELPA 13C           Added Program Information, and Secondary Students Only sections.
                    Moved Signatures to SELPA 13D, to allow room for parent
                    comments.
                    Revised service codes to reflect new reporting requirements.
                    Added drop down menu for new location codes.
                    Added in information to be addressed for students in 8th grade or
                    higher (moved from Individual Transition Plan).




                                                                            64
                                       NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA                                       Page ____ of _____
                              INDIVIDUALIZED EDUCATION PROGRAM (IEP)
                                              Services                           IEP Date _____________
Student Name ____________________________________________________________ Birthdate ______________
SERVICES:
                                                                              Start Date
           Service(s)                                Provider                 End Date         Duration            Frequency                     Location




                                                            Extended School Year (ESY)




Service Options Considered:           ______________________________________________________________________________________________
                                      ______________________________________________________________________________________________

PROGRAM INFORMATION:
Physical Education:  General  Specially designed (describe)_________________________________________________________________
Other agencies involved:  California Children’s Services (CCS)     Department of Rehabilitation  Other
                          San Andreas Regional Center (SARC)       Dept. of Social Services (DSS) _________________________
                          Probation                                County Mental Health (CMH)
Is student eligible for Mental Health Services under AB3632?        Yes        No
Are Mental Health Services included in IEP?          Yes      No
Student WILL participate in general education and extra curricular activities _____%of the time and WILL NOT participate _____% of the time.
Transportation:    None  General Ed.  Special Ed.                     Provided by:    District  Parent  Other ________________________
 Activities to support transition (e.g. preschool to kindergarten, special education and/or NPS to general education class, 8 th to 9th grade, etc.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SECONDARY STUDENTS ONLY:
Student is 14 years of age:  Yes              No
An Individual Transition Plan (SELPA 13F & 13G(16 & older)) is included in the IEP:               Yes      No
Student is under 14 years of age, however, the IEP Team determines transition services are necessary:             Yes         No
                   TH
STUDENTS IN 8           GRADE OR HIGHER:
Projected graduation date and/or secondary completion date: _____________________
Student is working towards:  Diploma 10  Certificate (not diploma) 20  GED 20  Other(specify) 20 _______________________
GRADUATION REQUIREMENTS: The requirements to receive high school diploma have been explained to me, including: passing
the CAHSEE (California High School Exit Exam), Algebra, credits required and any other district requirements listed below.
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
 I have received a copy of the district graduation requirements, including required courses.                      __________           __________
                                                                                                                    (Parent Initial)     (Student Initial)
Credits required for graduation _______________         Credits earned    _______________         Credits needed    _______________
Recommended Classes _____________________________________________________________________________________________________
                         _____________________________________________________________________________________________________
                   SELPA 13C (3/06)          Distribution: Copy 1 - LEA Office             Copy 2 - Student File             Copy 3 - Parent
                                                                                                                                                             65
           INDIVIDUAL EDUCATION PLAN SIGNATURE PAGE
                           SELPA 13D


SIGNATURES and PARTICIPANTS

It is critical that someone review the Parent's Rights/Procedural Safeguards with the parents
before they check the boxes or initial the statements. Have them initial if they have a copy of
their Parent's Rights and if they request the IEP to be translated. The chairperson of the IEP
meeting should review each of the statements with the parent(s) and ask them to check each
of the statements with which they agree. Any of the three statements with which they
disagree will require a written explanation of the parent's concerns relative to the issue(s) in
dispute.

The Parent/Guardian/Surrogate(s) sign and date on the first line under the statements.
Signatures here do not necessarily imply agreement with the entire IEP if the
unresolved issues are documented. Everyone else who participated in the IEP meeting
should sign on the lines indicated. “Other Participants” should write their title beside their
signature.

If the parents do not agree with the services recommended by school staff, list the specific
services offered by school staff on the services page (SELPA 13C) and parents' concerns
and/or recommendations, either on the space provided or if more room is needed use the
SELPA 13E Continuation Page. If consensus cannot be reached, the district or parents must
request an informal hearing, mediation, or due process hearing to resolve the disagreement.

Section 1414(d)(1)(A) of the California Ed Code specifies that the legally required
participants for an IEP meeting are:

   • The parent, legal guardian, parent surrogate, or parent designee of the student;

   • At least one special education teacher, or if appropriate, at least one special education
     provider of the student;

   • At least one general education teacher of the student if the student is, or may be,
     participating in the general education environment;

   • A representative of the school district who is qualified to provide, or supervise the
     provision of, specially designed instruction to meet the unique needs of students with
     disabilities and is knowledgeable about the availability of district resources. Usually
     this person is an administrator or another staff member, authorized as the
     administrative designee, who is qualified to provide or supervise special education
     services (i.e. a special education teacher). Whoever participates in the IEP meeting in
     this role must be authorized to commit district resources to ensure the provision of the
     services determined by the IEP team to be necessary for the student;

   • An individual(s) who can interpret the instructional implications of assessment results.
     This may be one of the educators named above.

                                                                                              66
                    INDIVIDUAL EDUCATION PLAN
                SIGNATURE PAGE, SELPA 13D (Continued)

NON-MANDATORY PARTICIPANTS:

   • At the discretion of the parent or district, other individuals who have knowledge or
     special expertise regarding the student, including related services personnel as
     appropriate;

   • The student, aged 16 or older, must be invited to attend all IEP meetings where
     Transition is discussed.


CAC Mailing   The check box for Community Advisory Committee (CAC) indicates that the
              parent would like to be added to an automated email list to receive
              announcements of meetings and trainings sponsored by CAC. This check box
              and email address will trigger an invitation to be sent to the email address
              listed for the parent to join the automated email group. This email group is
              confidential, requiring only an email address to sign up. It is a one-way
              communication group, so that members of the group will only receive
              CAC/SELPA approved notices, rather than a discussion group, which would
              allow any member to post comments. If any participants or interested parties
              would like to join the email group they should notify the SELPA office at
              464-5677 or see the CAC page on the SELPA website,
              www.nsccselpa.org/cac/cac.htm.

Changes from previous:
SELPA 13D New form, added to allow more room for parent comments, and to expand
             forms SELPA 13ABC, to include new legal requirements.
             Added CAC email group.




                                                                               67
                                     NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA                               Page ____ of _____
                                                INDIVIDUALIZED EDUCATION PROGRAM (IEP)
                                                             Signature Page

     Student Name ________________________________________ Birthdate ______________ IEP Date _____________

PARENT CONSENT:
This plan is in no way intended to limit the student’s educational program, but rather indicates priorities the team considered essential. As a members
of the team, I have had an opportunity to review and provide input for the Individual Education Program.
I understand that this plan does not guarantee the accomplishment of these goals and objectives.
(Signature indicates participation in IEP and ONLY those items checked below as “Parent Agrees”)
 I understand the IEP, including any assessment results
 I have received a copy of PARENTS’ RIGHTS AND RESPONSIBILITIES AND DUE PROCESS/APPEAL PROCEDURES _______
 I participated in the IEP meeting as a full team member                                                                                       Initial


                       Eligibility    Parent Agrees    Parent Disagrees (Attached comments as appropriate)
                                     _____________________________________________________________________________________________
                                     _____________________________________________________________________________________________
                   Developed IEP      Parent Agrees    Parent Disagrees (Attached comments as appropriate)
                                     _____________________________________________________________________________________________
                                     _____________________________________________________________________________________________
          Program Placement           Parent Agrees      Parent Disagrees (Attached comments as appropriate)
                                     _____________________________________________________________________________________________
                                     _____________________________________________________________________________________________
                                      I understand that my child is not eligible/no longer eligible for special education
                                      Student enrolled in private school by their parents. Refer to Individual Service Plan, if appropriate.
               IEP Translation   Yes  No            If yes, which language ______________________________________
                            CAC  I would like to be added to CAC email list    Email address _________________________________________
                                 I prefer to receive CAC notices from my child’s special education teacher

                                     _________________________________________________________________
                                      Parent  Guardian  Surrogate  Adult Student
                                     _________________________________________________________________
                                      Parent  Guardian  Surrogate  Adult Student
IEP MEETING PARTICIPANTS:


                   ________________________________________________             ________________________________________________
                         LEA Representative         Date                              Administrator/Designee      Date

                   ________________________________________________             ________________________________________________
                         Student                    Date                              Special Education Teacher   Date

                   ________________________________________________             ________________________________________________
                         General Education Teacher  Date                              Additional Participant      Role

                   ________________________________________________             ________________________________________________
                         Additional Participant     Role                              Additional Participant      Role

                   ________________________________________________             ________________________________________________
                         Additional Participant     Role                              Additional Participant      Role

                   ________________________________________________             ________________________________________________
                         Additional Participant     Role                              Additional Participant      Role

                   ________________________________________________             ________________________________________________
                         Additional Participant     Role                              Additional Participant      Role

                   ________________________________________________     ________________________________________________
                         Additional Participant          Role                   Additional Participant              Role
SELPA 13D (3/05)                    Distribution: Copy 1 - LEA Office Copy 2 - Student File         Copy 3 - Parent
                                                                                                                                                    68
                             IEP CONTINUATION PAGE
                                    SELPA 13E



This page is for any additional information or minutes that would not fit on the previous
pages.

Computer Information For:

If you need to use more than one continuation page, when you reach the bottom of the page
(the end of where the field will print to) you will see a double black line extending slightly
past the field, this will indicate to you that you need to start a new page. Just below is a blue
button called Next Page, by pressing this button you may continue your report for the same
student. (Next Page will create a new SELPA 13E with the same student information, IEP
date, etc, as the one you were working on).

Changes from previous versions:

SELPA 13E New form.




                                                                                                69
                             NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA                     Page ____ of _____
                                       INDIVIDUALIZED EDUCATION PROGRAM (IEP)
                                                 CONTINUATION PAGE

     Student Name ________________________________________ Birthdate ______________ IEP Date _____________

Notes/Additional Comments:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

SELPA 13E (3/05)             Distribution: Copy 1 - LEA Office   Copy 2 - Student File   Copy 3 - Parent
                                                                                                                            70
                         IEP INDIVIDUAL TRANSITION PLAN
                                  SELPA 13F & 13G

Who completes this form?
This form is to be completed by the student’s primary teacher.
When is this form completed?
        For students 15 years and older, a full Transition Plan must be developed with the
         IEP team including agency representatives and student-requested participants who
         can assist in the transition plan and a statement of transition needs related to
         instruction (which may include vocational classes and/or college prep course work)
         must be made. Vocational interest inventories, learning style assessment, job shadows
         and other career exploration activities may be part of the plan at this age. Use SELPA
         13G to develop long-range goals and activities in the areas listed. If goals and
         activities have been addressed in one or more of these areas on the SELPA 12 Goals
         and Objectives form, check the box “Addressed in Goals” for that area.

The student must be invited to attend and participate in all IEP/ITP meetings at the age
of 14 years or older.
SELPA 13F
SELPA 13F must be completed for all students 15 and older, it may also be used for
younger students as appropriate. The IEP team should describe the transition service needs
of the student based on his or her interests and need for development of prevocational skills.
The IEP team could recommend specific courses at the high school level, such as "word-
processing," "automotive," "food trades”, advanced placement, etc.
How the student participated   The student must be invited to the IEP. If, for some reason the student
in the process                 was not able to attend indicate how the student’s preferences, interests
                               and goals were developed. (E.g. survey, interview, interest, etc.)

Post school                    This statement must refer to the student’s long range career/vocational
preferences/interests/goals    goal.

Transition service             This is a required data field. The primary transition service program
                               in which the student is participating. If the student is in more than one
                               transition service program, use the primary transition program.
                               None: Parent(s) refuse transition services.
                               Workability: All students 14 or older qualify to receive workability
                               services.
                               TPP (Transition Partnership Program): is a cooperative program
                               between Department of Rehabilitation (DOR) and the schools.
                               Check with your school site to see if the student is a client with DOR.
                               Students are selected for this program their last year of school.
                               Post-Secondary: Students age 18-22 that are enrolled in the post-
                               secondary program.


                                                                                                 71
                             IEP INDIVIDUAL TRANSITION PLAN
                                  SELPA 13F & 13G (continued)
Transition service (cont.)      Other: Any other transition service a student is receiving (i.e. from
                                San Andreas Regional Center)
                                Check with your vocational education specialist if you have any
                                questions which service should be reported as the primary transition
                                service for a student.

Other Transition                This section will not be applicable to all students.
Considerations:                 If Daily Living Skills is an area of concern you must check the box
                                addressed in goals and include a SELPA 12 page(s) with a goal(s)
                                for Daily Living Skills.
                                If a functional vocational evaluation is needed, notate what agency
                                will be responsible for conducting and by what date. An example of a
                                functional vocational evaluation is work readiness checklist,
                                situational assessment, etc.

Related Services                This box should be check if student is receiving any services related
                                to transition, these services need to be included on their SELPA 13C
                                Services page. Could include any of the designated instructional
                                services related to transitional services. As a general guideline all
                                SDC students in Special Day Class at middle school/junior high level
                                or above, and RSP students in grades 11 and 12, receive DIS
                                vocational counseling services.

Needed linkages to outside      List any support services the student may need from outside
Agencies/Providers              agencies/providers in order to attain their post-secondary goals, and
                                who will help them connect with the group(s) indicated, and by
                                when. See Transition Guide for more information on outside
                                agencies and services they provide.

CAHSEE (California High         If the student is in Grade 10 or higher and has not passed the High
School Exit Exam)               School Exit Exam, indicate whether the student will take the exam in
                                the standard format or with accommodations. Do not mark any box
                                for CAHSEE for students who are younger than Grade 10, who have
                                already passed the CAHSEE, or for whom the CAHSEE is not
                                appropriate since they are participating in a functional skills
                                curriculum. If the student passed the CAHSEE note the date that
                                they passed.




                                                                                      72
                     IEP INDIVIDUAL TRANSITION PLAN
                          SELPA 13F & 13G (continued)
Age of majority:           On or before the student’s 17th birthday, if a student turns 17 before
                           his next IEP, the team must advise the parents and the student that
                           educational rights transfer from the parents to the student at the age
                           of 18, unless the parent has conservatorship. Conservatorship is a
                           legal process where the parent has retained the right to make
                           decisions for the student past 18 years of age. Have the student sign
                           and date.


SELPA 13G
SELPA 13G is for all students 15 years and older, it may also be used for younger students
as appropriate. Write a goal for each of the 4 areas of Transition Activity indicated, for your
convenience a bank of sample goals are included (SELPA 13G Transition Goals) see
“Computerized Information for…” below. These areas of need may also be addressed using
a goals and objectives form (SELPA 12), if so check the box “Addressed in Goals” for that
area of activity).
Areas of Need:

Instruction:                Instruction is the use of formal techniques to impart knowledge.
                            It is typically provided in schools (e.g., general education
                            classes, vocational classes, academic instruction, tutoring
                            arrangements, etc.). These services may include career
                            vocational exploration activities, pre-employment skills, work
                            maturity skills, and student advocacy skills. There may be other
                            instructional activities that could be provided by other entities or
                            in other locations (e.g., adult basic education and post-secondary
                            schools).

Community Experiences:      These are the services provided in community settings by
                            schools or other agencies (e.g. work experience, job shadows,
                            tours, banking, shopping, transportation, independent living
                            centers, adult services providers, transportation, etc.) This is a
                            section of the plan in which needs related to family planning;
                            alcohol other drug counseling/programs and other health related
                            needs should be addressed.

Employment                  These are services that include activities that will lead to student
                            employment and may include community-based work
                            experiences, job site training programs, and/or other job
                            preparation activities.




                                                                                    73
                          IEP INDIVIDUAL TRANSITION PLAN
                               SELPA 13F & 13G (continued)
Post Adult Living:            These services include activities that will assist the student after
                              they leave school.       Some of the activities may include
                              independent living skills, successful transition to college or
                              vocational training program. Could include registering to vote,
                              filing taxes, renting an apartment, accessing medical insurance,
                              etc.

For menu of sample activities for transition, see Appendix A.

COMPLETING THE FORM

Area of need:                 The area of need is already specified for the four required
                              Individualized Transition Plan components.

By ____________ student       The date that it is anticipated that the transition goal will be met,
will:                         usually one year from date goal written. The ITP must contain
                              goals that extend past the time the student is in school. Usually
                              found in the post adult living section.
Measurable annual goal:       The annual goals must be written in measurable terms. Goals
                              may be measured by progress toward grade level competencies,
                              specific skill attainment, or other quantifiable standards.

This goal focuses on:         New reporting requirement by the state, to identify area the goal
                              focuses on based on the options in the pull-down menu. For the
                              sample transition goals, these have been completed for you and
                              will fill in automatically.

Person responsible:           Note the person responsible. Do not give specific name; give
                              title e.g. teacher, vocational specialist.

Method of Evaluation          Check the method of evaluation for tracking progress towards
                              goal. If not included write in on the line for other method.

Date                          There are four progress-reporting periods. Note the exact date of
                              the report. This should correspond to the general education
                              reporting periods.

Progress                      For each of the four reporting dates, note the progress towards
                              meeting the goal. Codes for reporting progress are: 1 -
                              Completed; 2 - Substantially Completed; 3 - Partially
                              Completed; 4 - Not Completed.




                                                                                      74
                    IEP INDIVIDUAL TRANSITION PLAN
                         SELPA 13F & 13G (continued)

Computerized Information For:

SELPA 13G Transition Goals from the Sample Transition Goal list (Appendix A) can be
          entered automatically in a field by typing in a key # in the green colored
          boxes. (Similar to SELPA 12) (Note: these boxes do not print on the final
          form.) When you type in a key #, the corresponding statement from the
          SELPA 13G Transition Goals will fill in automatically.

              To generate your own list of Goals and Objectives, go to SELPA 13G
              Transition Goals. In this database, each new goal is a new record.
              Type in a key number (Currently set up for IN# for instruction; CO# for
              Community; EM# for Employment; PA# for Post Adult) for each statement
              you write in the textbox. To add another goal, create a new record by selecting
              New Record under the Mode Menu, or by clicking on the Add New
              Transition Goal button.

Changes from previous versions:
SELPA 13F & G (previous version SELPA 15A&B)
                Completely revised to meet requirements that transition be formatted as
                    measurable goals and objectives.
                Renumbered to emphasize that the Individual Transition Plan is part of
                    every IEP for students 15 and older.
                Moved graduation requirements to SELPA 13C to address for all 8th
                    graders.
                Include Transition Service Code for primary transition service.




                                                                                 75
                              NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA                        Page ____ of _____
                                         INDIVIDUALIZED EDUCATION PROGRAM (IEP)
                                     INDIVIDUAL TRANSITION PLAN - TRANSITION SERVICES

     Student Name ________________________________________ Birthdate ______________ IEP Date _____________
          Beginning at age 15, or younger if appropriate, describe the student’s transition service needs that focus
                                              on the student’s course of study.
Describe how the student participated in the process
 Present at IEP meeting  Student Interview/Survey                 Other __________________________________________________
Student’s Post School Preferences/Interests/Goals
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Transition Service (Check One):
                   None 10                     TPP Program 30  Other Transition Services               50
                   WorkAbility             20  Post Secondary Education 40
OTHER TRANSITION CONSIDERATIONS: IF APPROPRIATE
Daily Living Skills:  Not Applicable  Addressed in Goals
Functional Vocational Evaluation Needed:               Yes  No
                    If yes, responsible agency ____________________________________ By: ___________________
RELATED SERVICES                    Yes        No
If yes, see IEP Services Page (SELPA 13C)

NEEDED LINKAGES TO OUTSIDE AGENCIES:

     WorkAbility I                       Hope Rehabilitation Center       County Mental Health
     San Andreas Regional Center         Community Options                Special Olympics
     Department of Rehabilitation        SSI                              Metro/Mobility Training
     TPP                                 Workforce Santa Cruz             Other _____________________
                                                                                     _____________________
                                                                                      _____________________

CAHSEE (CALIFORNIA HIGH SCHOOL EXIT EXAM): ADDRESS FOR STUDENTS IN 10TH GRADE OR HIGHER
 No Accommodations/Modifications
 With Accommodations __________________________________________________________________________________
 With Modifications (waiver required) _____________________________________________________________________
Student Passed CAHSEE on:            _____________________
                                            (date)



    RIGHTS OF MAJORITY: (ADDRESS ONLY IN IEPS FOR STUDENTS REACHING AGE 17):
The North Santa Cruz County Special Education Local Plan Area has informed the parent(s) and the student, upon
reaching age 17 of rights which will transfer to the student upon reaching the age of majority (18) unless a legal guardian
or conservator has been appointed.

_____________________________________________________________________                    Date ___________________________
                             Student Signature


SELPA 13F (3/06)                     Distribution: Copy 1 - LEA Office    Copy 2 - Student File    Copy 3 - Parent



                                                                                                                                76
                                     NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA                               Page ____ of _____
                                             INDIVIDUALIZED EDUCATION PROGRAM (IEP)
                                         INDIVIDUAL TRANSITION PLAN GOALS & BENCHMARKS

     Student’s Legal Name _______________________________ Birthdate ______________ IEP Date _____________

 Beginning at age 15, or younger if appropriate, describe the student’s transition services that are designed within
           an outcome oriented process that promotes movement from school to post school activities:
                   Describe activities to be completed during the next year that will lead to the post school goals of this student.

                     Description of Transition Activity                           Method of Evaluation                 Date             Progress*
INSTRUCTION:                                                                        Work Samples
By ________________ student will:                                                                                 _______________       _________
                                                                                    Data Collection
                                                                                    Informal Tests               _______________       _________
                                                                                    Other                        _______________       _________
                                                                                 _____________________            _______________       _________
                                                        Addressed in Goals      _____________________
                                                                                 _____________________
This goal focuses on: _________________________________

Person Responsible: __________________________________
COMMUNITY:                                                                          Work Samples
By ________________ student will:                                                                                 _______________       _________
                                                                                    Data Collection
                                                                                    Informal Tests               _______________       _________
                                                                                    Other                        _______________       _________
                                                                                 _____________________            _______________       _________
                                                        Addressed in Goals      _____________________
                                                                                 _____________________
This goal focuses on: _________________________________

Person Responsible: __________________________________
EMPLOYMENT:                                                                         Work Samples
By ________________ student will:                                                                                 _______________       _________
                                                                                    Data Collection
                                                                                    Informal Tests               _______________       _________
                                                                                    Other                        _______________       _________
                                                                                 _____________________            _______________       _________
                                                        Addressed in Goals      _____________________
                                                                                 _____________________
This goal focuses on: _________________________________

Person Responsible: __________________________________
POST ADULT LIVING:                                                                  Work Samples
By ________________ student will:                                                                                 _______________       _________
                                                                                    Data Collection
                                                                                    Informal Tests               _______________       _________
                                                                                    Other                        _______________       _________
                                                                                 _____________________            _______________       _________
                                                        Addressed in Goals      _____________________
                                                                                 _____________________
This goal focuses on: _________________________________

Person Responsible: __________________________________
            *Progress Codes          1 - Completed       2 - Substantially Completed    3 - Partially Completed     4 - Not Completed
SELPA 13G (3/06)                    Distribution: Copy 1 - LEA Office         Copy 2 - Student File        Copy 3 - Parent
                                                                                                                                    77
                  SPECIFIC LEARNING DISABILITY TEAM
                    DETERMINATION OF ELIGIBILITY
                              SELPA 13H


When is this form used?
This form is to be used at initial evaluations and 3-year reviews to determine eligibility for
students suspected of being eligible for special education under the disability of specific
learning disability.

Changes from previous versions:
SELPA 13H           New Form.




                                                                                                 78
                                   NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                                                                                                          Initial Evaluation
                                                                                                                          3-Year Re-evaluation
                                                    SPECIFIC LEARNING DISABILITY
                                                 TEAM DETERMINATION OF ELIGIBILITY

Student Name ______________________________________________________________________                           Birthdate _______________

School of Attendance ________________________________________________________________                         Date ___________________

I.          Presence of Severe Discrepancy. (Select either A or B)

                  A. The IEP Team finds a severe discrepancy between measures of intellectual ability and one or more of the following areas of
                      achievement:
                       Oral Expression       Listening Comprehension  Basic Reading Skills                Reading Comprehension
                       Written Expression  Mathematics Calculation  Mathematics Reasoning
                  B. Standard measures do not reveal a severe discrepancy, but the IEP Team finds that a severe discrepancy does exist based upon
                      the additional documentation provided in the attached report.
                      (Complete and attach Specific Learning Disability Discrepancy documentation report (SELPA 13I)


II.         The discrepancy identified in Item I (above) is directly related to a processing disorder:  Yes  No
            Check appropriate area(s):
             Auditory Processing          Visual Processing          Cognitive Abilities (including association, conceptualization and expression)
             Sensory Motor Skills         Attention

III.        If any of the items below (A-E) are checked “Yes”, the student may not be identified as having a specific learning disability.
            A.        The discrepancy is due primarily to limited school experience or poor school attendance            Yes  No
            B.        The discrepancy is a result of environmental, cultural difference or economic disadvantage.        Yes  No
            C.        The discrepancy is due primarily to mental retardation or emotional disturbance.                   Yes  No
            D.        The discrepancy is due primarily to a visual, hearing, or motor disability.                        Yes  No
            E.        The discrepancy can be corrected through other regular or categorical services offered within the  Yes  No
                      regular instructional program.



IV.         The student has a specific learning disability:             Yes  No
V.          Basis for determination of eligibility
             Psychoeducational Evaluation utilizing multiple measures. See attached Psychoeducational report.
             Other (specify) ___________________________________________________________________________________________
                                  ___________________________________________________________________________________________



VI.         Relevant behavior related to academic functioning, noted during observation.
            _____________________________________________________________________________________________________________
            _____________________________________________________________________________________________________________
            _____________________________________________________________________________________________________________
             See attached Psychoeducational report

VII.        Educationally relevant medical findings, if any (describe)
            _____________________________________________________________________________________________________________
            _____________________________________________________________________________________________________________
            _____________________________________________________________________________________________________________




SELPA 13H (3/05)                      Distribution: Copy 1 - LEA Office         Copy 2 - Student File           Copy 3 - Parent
                                                                                                                                                     79
         SPECIFIC LEARNING DISABILITY DISCREPANCY
      DOCUMENTATION REPORT - IEP TEAM CERTIFICATION
                         SELPA 13I

When is this form used?

This form is to be used to document the presence of a specific learning disability in instances
where the student does not exhibit a severe discrepancy between ability and achievement as
measured by standardized test.
This form is to be attached to the IEP Team Determination of Eligibility Form (SELPA
13H).

Changes from previous versions:
SELPA 13I New Form.




                                                                                             80
                               NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA

                     SPECIFIC LEARNING DISABILITY DISCREPANCY DOCUMENTATION REPORT
                                    TEAM DETERMINATION OF ELIGIBILITY

Student Name ______________________________________________________________________                   Birthdate _______________
This form is to be completed and attached to the IEP Team Determination of Eligibility of Specific Learning Disability Form
(SELPA 13H) in order to document the presence of s Specific Learning Disability in instances when the student does not exhibit
a severe discrepancy between ability and achievement as measured by standardized test. (Ed Code Section 3030 Paragraph C)

Statement of the area, the degree, and the basis and method used in determining the discrepancy:

1.     Data from assessment instruments (ability and achievement):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
2.     Information provided by the parent:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
3.     Information provided by the pupil’s present teacher:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
4.     Summary of the pupil’s classroom performance:
       a.      Observations:
       ____________________________________________________________________________________________________
       ____________________________________________________________________________________________________
       ____________________________________________________________________________________________________
       b.      Work Samples:
       ____________________________________________________________________________________________________
       ____________________________________________________________________________________________________
       ____________________________________________________________________________________________________
       c.      Group Test Scores:
       ____________________________________________________________________________________________________
       ____________________________________________________________________________________________________
       ____________________________________________________________________________________________________
5.     Consideration of the pupil’s age:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
6.     Additional Relevant Information:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

SELPA 13I (3/05)                Distribution: Copy 1 - LEA Office       Copy 2 - Student File          Copy 3 - Parent
                                                                                                                                  81
                      ADDENDUM TO IEP
                           SELPA 14
             AMENDMENT TO IEP Without IEP Team Meeting
                          SELPA 14A


When are these forms used?

SELPA 14 – Addendum to IEP - Requires IEP team meeting. Use this form to add/drop
           services or when making any changes that substantially affect a student’s
           educational program.

SELPA 14A – Amendment to IEP Without IEP Team Meeting– Does not require the IEP
           team to meet; the teacher and/or administrator can meet with parent
           individually. Use this form to make small adjustments to the existing IEP.

SELPA 14 Addendum to IEP should be used when adding or deleting services other than at
an annual review, or adding or changing goals and objectives. Such services may include a
behavior plan, nursing service, assistive technology, or updating frequency/duration of
services. This should be attached to the most current IEP. Addendum cannot be conducted
by mail, or any other method without a meeting being held. Include all services on this page,
even services discussed at previous IEP meeting(s). DO NOT write “REPEAT ALL
SERVICES LISTED IN IEP DATED…..” in services section.

SELPA 14A Amendment to the IEP can be made (SELPA 14A) in certain circumstances
(with parent approval) for minor adjustments to the IEP, without having to convene the entire
IEP team. An amendment is not appropriate to use when adding/dropping services, or
when making any changes that substantially affect a student’s educational program.
PLEASE CHECK WITH YOUR DISTRICT ADMINISTRATOR FOR MORE
GUIDELINES PRIOR TO USING THE SELPA 14A FORM.

If more room is needed for comments attach SELPA 13E Continuation Page.

Changes from previous versions:
SELPA 14     Services section changed to mirror services table on SELPA13C.
             Dates rearranged to be in more logical sequence.
SELPA 14A New form.




                                                                                           82
                                NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                                 IEP TEAM ADDENDUM PAGE


Note: For addendum IEP team MUST convene
To be attached to IEP dated: ___________________                   Date of Addendum Meeting: ___________________
District of Attendance _________________________________      District of Residence _________________________________
Student Name ______________________________________________ Birthdate ____________________
Purpose of Meeting:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Attach SELPA 13E IEP Continuation page if necessary for Notes/Additional Comments.
SERVICES:
                                                                 Start Date
           Service(s)                     Provider               End Date      Duration       Frequency              Location




                                                  Extended School Year (ESY)




Percentage of time in regular class _______ Percentage of time out of regular class ________ (total should always equal 100%)
The addendum translation is requested  No  Yes Specify Language: ______________________________
 I understand this IEP including assessment results.
1.    Eligibility                    Parent Agrees  Parent Disagrees (Attached comments as appropriate)
2.    The Developed IEP              Parent Agrees  Parent Disagrees (Attached comments as appropriate)
3.    Program Placement              Parent Agrees  Parent Disagrees (Attached comments as appropriate)
4.     I have received a copy of PARENT’S RIGHTS AND RESPONSIBILITIES AND DUE PROCESS/APPEAL PROCEDURES
5.     I participated in the IEP meeting

_____________________________________________________                 _____________________________________________________
Parent/Guardian                     Date                              Parent/Guardian                     Date
_____________________________________________________                 _____________________________________________________
Student                                                               LEA Representative/Administrator/Designee
_____________________________________________________                 _____________________________________________________
Special Education Teacher                                             General Education Teacher

_____________________________________________________                 _____________________________________________________
Other Participant                   Role                              Other Participant                   Role
_____________________________________________________             _____________________________________________________
Other Participant                      Role                       Other Participant                   Role
SELPA 14 (3/05)   Distribution: Copy 1 - LEA Office  Copy 2 - Student File        Copy 3 – Parent
                                                                                                                                83
                                   NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA                     Page 1 of ______
                                             AMENDMENT TO IEP WITHOUT IEP TEAM MEETING


Student Name _______________________________________ Date of Meeting ___________________________
□Parent of the student, □Adult Student, or □Local Education Agency initiated contact to discuss making changes to
amend or modify the annual Individualized Education Program (IEP) document dated _____/____/____ without
convening an IEP meeting.
Purpose of Meeting:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Rationale for changes in the IEP dated: ____________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Attach SELPA 13E IEP Continuation page if necessary for Notes/Additional Comments.
SERVICES:
                                                                      Start Date
              Service(s)                         Provider             End Date         Duration      Frequency          Location




Percentage of time in regular class _______ Percentage of time out of regular class ________ (total should always equal 100%)

     Signatures below document the mutual agreement to meet without an IEP Team meeting to amend
      or modify the annual IEP and permission to implement the changes described in this document.

Signature of District Designated Representative:_________________________________ Date: _____/_____/_____
Title/Position: _____________________________________________________________________
Circle relationship to student, sign, and date below.
Signature of Parent/Guardian/Surrogate: _______________________________________ Date: _____/_____/_____
Signature of Parent/Guardian/Surrogate: _______________________________________ Date: _____/_____/_____
Signature of Adult Student (ages 18-21): _______________________________________ Date: _____/_____/_____

Signature of Others Present: _______________________________________ Title/Position: ____________________________
Signature of Others Present: _______________________________________ Title/Position: ____________________________
Signature of Others Present: _______________________________________ Title/Position: ____________________________

SELPA 14A (12/05)          Distribution: Copy 1 - LEA Office   Copy 2 - Student File        Copy 3 - Parent
                                                                                                                        84
           LETTERS FOR IEP MEETINGS WITHOUT PARENTS
                            SELPA 17


When do you use this form?

This form should only be used after several documented attempts at planned meetings (Use
SELPA 3). Please note that according to legal requirements, if a district is unable to hold an
IEP within the designated timeline, due to an inability to contact parent or the parents
inability attend the meeting, the district is then required to hold the IEP without the parent (A
“Timeline Extension” is not a legally acceptable alternative). Copy signed IEP and send
home with case manager's name delineated. If parent consents, the IEP is then filed and
activated as the current IEP. If the parent does not consent, another meeting must be planned.

Copies of previous meeting notices should be attached.

Carefully keep contact log up-to-date, including contacts with parents regarding their
consent that the meeting proceeds without them or of their non-response.


Changes from previous versions:
SELPA 17       Check boxes and parent signature section revised to align with options on IEP
services page (SELPA 13D)




                                                                                               85
                                                      NORTH SANTA CRUZ COUNTY
                                                SPECIAL EDUCATION LOCAL PLAN AREA
                                            Letters for IEP Meetings Held Without Parents

Dear Parent/Guardian/surrogate:                                                                            Date: ___________________

Since you were unable to attend the IEP meeting on __________ for _______________________________________,
you will find attached the Individualized Education Program (IEP) completed by the school team members. Your input,
including any questions or concerns about this plan, is important to us.

At the time that you received the conference notice for this meeting, you received a copy of your Procedural Safeguards
(Parent/Student Rights). If you have any questions regarding these, please call us.

If you agree with the proposed goals and objectives and the educational placement and services, please sign and date
below and return one copy of this form to ______________________________________.

Please do not hesitate to call us if you have any questions or concerns regarding this letter or any of the enclosed
materials. If you would like to meet with a member of the IEP team to discuss the IEP, please contact me.

                                                                                         Sincerely,

                                                                                         ______________________________________
                                                                                         __________________________
                                                                                         Title

                                                                                         ______________________________________
                                                                                         School                  Telephone

                                                                                         ______________________________________
                                                                                         Address


My signature indicates that: (Please check the appropriate boxes)
 I understand the IEP, including any assessment results
 I have received a copy of PARENTS’ RIGHTS AND RESPONSIBILITIES AND DUE PROCESS/APPEAL PROCEDURES _______
                                                                                                                                     Initial

                       Eligibility    Parent Agrees      Parent Disagrees (Attached comments as appropriate)
                                     _____________________________________________________________________________________________
                                     _____________________________________________________________________________________________
                   Developed IEP      Parent Agrees    Parent Disagrees (Attached comments as appropriate)
                                     _____________________________________________________________________________________________
                                     _____________________________________________________________________________________________
           Program Placement          Parent Agrees      Parent Disagrees (Attached comments as appropriate)
                                     _____________________________________________________________________________________________
                                     _____________________________________________________________________________________________
                                      I understand that my child is not eligible/no longer eligible for special education
                                      Student enrolled in private school by their parents. Refer to Individual Service Plan, if appropriate.
                                 Yes  No
                  IEP Translation                     If yes, which language ______________________________________
                            CAC  I would like to be added to CAC email list    Email address _________________________________________
                                 I prefer to receive CAC notices from my child’s special education teacher

DATED: __________________________ for _____________________________________________________
                                                      (Student’s name)

______________________________________________________________ ___________________________
       Parent/Guardian/Surrogate Signature                             Date

SELPA 17 (3/05)                        Distribution: Copy 1 - LEA Office     Copy 2 - Student File          Copy 3 - Parent
                                                                                                                                               86
    MONITORING DESIGNATED INSTRUCTION SERVICES (DIS)
                       SELPA 18



When is this form used?

The LEAs are required to monitor DIS caseloads to ensure adequate implementation of IEPs
as well as compliance with federal law. This information can also be utilized for MediCal
billing.

Who fills out this form?

Designated Instructional Service (DIS) providers include: Speech and Language Specialists,
APE Specialists, Visually Impaired Specialists, Orthopedically Impaired Specialists, Hard of
Hearing/Deaf Specialists, and Occupational Therapy Specialists.

DIS staff are responsible for recording missed sessions and makeup sessions on the record-
keeping forms provided. These forms will be collected and reviewed as often as monthly but
at least quarterly by the LEA administrator responsible for monitoring DIS services.

Each LEA will designate an administrator who is responsible for monitoring DIS services, to
review DIS records, and to ensure that services are provided to students based on each
student’s individual needs. The special education administrator shall complete the review of
the submitted forms each month.

How to complete this form?

This form covers attendance for one month. Delivery of services will address the individual
needs of the students and are to be specified in the student’s IEP. DIS services will be
scheduled to avoid conflict in the implementation of other IEP goals and to avoid conflicts
with integration opportunities in the regular education classes. Use the code at the bottom of
the form to indicate the type of service delivered.

DIS service providers will schedule any missed sessions or services promptly to ensure that
the achievement of educational goals is not disrupted. The appropriate administrator of
special education shall review the submitted forms each month.


Changes from previous versions:
SELPA 18     No changes from 2002 version




                                                                                            87
                                                                        North Santa Cruz County SELPA
                                                                    Daily Attendance Roster (DIS Monitoring)
Service (Choose One):             Plan:                                                                                                 District Code: __________________________________
 Speech/Lang.                     None
 OT                               IEP                                                                                                 Site Code: _____________________________________
 PT                               IFSP                           Service Dates: from            thru
 Psych                            IHSP                                                                                                Provider Code: _________________________________
 Nurse                            ITP                        Signature

ID         Name                                    G/I* DOB:               M T      W T      F      M T      W T      F      M T      W T      F     M T       W T      F     M T      W T   F

                                                          Date:




*G/I – Group or Individual therapy or both. Indicate number of minutes of treatment. For consultative services mark a “C” in the date/column provided when consultation is accomplished.
                                                Assume all services are direct services unless marked as consult. CODE For Students: A=Absent; M= Makeup Session
                   CODE for Teacher: 1 - Illness/PN      2 - School Business        3 - Jury Duty     4 - Leaves      5 - Professional Growth     6 – Other


SELPA 18 (3/05)

                                                                                                                                                                                             88
             PARENT CONSENT FOR INTERIM PLACEMENT,
                            SELPA 19


Who fills out this form?

This form is used as an administrative placement. It should be recorded in the procedural
checklist (SELPA 2) and an IEP should be held within 30 days of signing.

This form is typically used for student's transferring into a district from another SELPA. It is
important to review all IEPs on new students, to determine if additional assessments are
warranted and if goals and objectives are consistent with the assessment information and the
services indicated. If a student transfers from one school/district to another within the North
Santa Cruz County SELPA, the district is not required to hold an IEP because their current
IEP is valid. An administrator completes this form with the parent, as part of the registration
process. If the IEP is not provided at this time or if additional information is needed from the
student's previous IEP team members, Consent for Release of Information (SELPA 8A)
should be secured. An IEP must be held within thirty days of placement.


Changes from previous versions:
SELPA 19     Made previous services/placement sections more clear.
             Added Primary Disability field, as a pull-down list.
             Added percentage of time inside of general class.




                                                                                              89
                              NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA

                                       PARENT CONSENT FOR INTERIM PLACEMENT

Student’s Legal Name ___________________________________________        Birthdate _______________ Date _________________
District ___________________________________ School _____________________________ Grade ______________
Home Language ______________________________              EL  FEP  EO                 Male  Female
Parent/Guardian/Surrogate _______________________________________________________ Home Phone _____________________
Address ______________________________________________________________________ Work Phone _____________________
Interim placement in a comparable program will be provided for students who were in a special education program immediately prior
to moving to the district. This is an administrative placement which shall not exceed thirty (30) days, at which time an IEP meeting
will be held to determine the appropriate program and services to meet the child’s special needs.
Prior Special Education Placement:
Name of Previous School _______________________________________                  District _________________________________
Previous School Type _____________________________________________________________________________________
Address ________________________________________________________________________________________________
Contact Person ________________________________________________ Phone ___________________________________
Dates enrolled in Special Education: From: __________________ To: __________________
Primary Disability   _____________________________________________________________
 IEP (copy attached)  IEP not available, complete the following and call previous placement to verify
Least restrictive environment or extent to which pupil was able to participate in the general school program:
         Student was in general program majority of the school day
         Student was not in general program majority of the school day
         Other programs (Explain) ______________________________________________________________________
Percentage of time inside of general class __________ % Percentage of time outside of general class ____________%
Previous Services:
         Special Day Class               Occupational Therapy          Special Transportation
               LH                        Vision Services               Other
               SH                        Hearing Services                    ___________________________________________
               ED                        Interpreter                         ___________________________________________
         Resource Specialist             Adaptive Physical Education         ___________________________________________
         Language and Speech  Extended Year
Type of Physical Education:
             General Education          Specially Designed (Describe)
            ____________________________________________________________________________________________________
Specialized Services, equipment, and materials for low incidence disabilities:
            ____________________________________________________________________________________________________
            ____________________________________________________________________________________________________
            ____________________________________________________________________________________________________
Interim Placement:
Type of Program: ________________________________________ Date of Placement ___________________________________
School _________________________________________________ Teacher ____________________________________________
Date Services to Begin _____________________________________
Parent Consent:
 I give my consent for interim placement with the above identified program for thirty (30) days.
Parent/Guardian/Surrogate Signature _________________________________________________ Date _____________________
Special Education Administrator       _________________________________________________ Date _____________________

SELPA 19 (3/05)                Distribution: Copy 1 - LEA Office      Copy 2 - Student File        Copy 3 - Parent
                                                                                                                                   90
               MENTAL HEALTH REVIEW AND REFERRAL
                    SELPA 20 & SELPA 21, 21A, 21B


Parent Notification/Request for Mental Health Review, SELPA 20
To begin a referral to Mental Health for assessment (3632), this form must be completed.

Pre-Referral for Mental Health Services
Use this form to document any of the services listed provided by the district to a student
whether or not a referral to mental health is being considered. Send to Children’s Mental
Health and district office.

Referral for Mental Health Services, SELPA 21A,B
Referral information must be completed by the School Psychologist and a copy of the referral
forwarded to Mental Health. Data needs to be collected for 6 months and a review of what
modifications have been attempted needs to be documented for mental health personnel. It is
not necessary to send referrals to the SELPA office unless a non public school placement is
being considered. In which case, follow NPS referral process via district Special Education
Coordinator.

Changes from previous versions:
             No changes.
SELPA 21     New Form




                                                                                           91
                                              NORTH SANTA CRUZ COUNTY
                                          SPECIAL EDUCATION LOCAL PLAN AREA

                                                      CONFIDENTIAL
                           PARENT NOTIFICATION/REQUEST FOR MENTAL HEALTH REVIEW

To Parent of ______________________________________________ Date ______________________
School __________________________________ Grade _______________ Birthdate __________________
District __________________________________

In order to meet your child’s individual education needs, a mental health assessment may be necessary. To determine whether such an
assessment is required, mental health staff will first review your child’s progress in special education/regular education. If mental
health assessment is indicated, an assessment plan will be developed by Santa Cruz County Mental health Services outlining areas in
which your son/daughter needs to be assessed and identifying the specialists to be involved. Assessment will be conducted by
qualified mental health personnel. The results of the assessment will help us make recommendations for program/services to be
provided, at no cost to you, in order to meet your child’s educational needs more adequately. No placement or service will occur
without your permission.

To expedite this process, your cooperation is requested in granting your permission as to the following:

_______ I do _______ I do not      give my consent to allow Santa Cruz County Mental Health Services staff to observe my
(Initial, as appropriate)          son/daughter in his/her current classroom and/or contact me for an initial appointment.

_______ I do _______ I do not      give my permission to exchange pertinent educational, medical, and psychological records relative
(Initial, as appropriate)          to my son/daughter among Santa Cruz County Mental Health Services, the school/district, SELPA,
                                   the County Office of Education, and other agencies/individuals listed below:

Please check if pupil is receiving services from the following:
           California Children’s Service                       Contact Person _______________________________________
           San Andreas Regional Center                         Contact Person _______________________________________
           Department of Social Services                       Contact Person _______________________________________
           Juvenile Probation Service                          Contact Person _______________________________________
           Mental Health                                       Address ____________________________________________
           Private Therapist                                   Address ____________________________________________
           Other ______________________________                Address ____________________________________________
           Other ______________________________                Address ____________________________________________
           Other ______________________________                Address ____________________________________________
I agree that the person(s) or agencies listed above may share information among each other. I understand that the records released will
be kept confidential and used professionally only for the purpose of evaluating the appropriateness of mental health services as a
related special education service.


______________________________________________                        ____________________________________________
Date                                                                              Signature of Parent or Guardian

                                                                               _________________________________________
                                                                                                                 Address

                                                                               _________________________________________
                                                                                   City              State           Zip

                                                                               Phone _____________________________(home)

                                                                                Phone _____________________________(work)

SELPA 20 (6/99)                Distribution: Copy 1 - Mental Health       Copy 2 - Student File       Copy 3 – Parent

                                                                                                                                     92
                                                         CONFIDENTIAL
                     NORTH SANTA CRUZ COUNTY . SPECIAL EDUCATION LOCAL PLAN AREA
                                          PRE-REFERRAL FOR MENTAL HEALTH SERVICES
  Date:
  Student Name:                                                                        Date of Birth:
  LEA of Attendance:
  LEA of Residence:
  The LEA has determined that the educational needs of this child exceed the benefits that can be achieved through the provision of related services as
  defined in Section 300.244 of Title 34 of the Code of Federal Regulation, as evidenced by the following (include duration and frequency of all
  services provided, as appropriate):
         COUNSELING AND                            This service was  provided  considered and the IEP team has determined that the service
        GUIDANCE SERVICES                          does not meet the educational needs of this student because (cite behavioral examples):

  Initiation   _________________________
  Frequency _________________________
  Duration     _________________________

           PSYCHOLOGICAL                           This service was  provided  considered and the IEP team has determined that the service
              SERVICES                             does not meet the educational needs of this student because (cite behavioral examples):

  Initiation   _________________________
  Frequency _________________________
  Duration     _________________________

      PARENT COUNSELING &                          This service was  provided  considered and the IEP team has determined that the service
           TRAINING                                does not meet the educational needs of this student because (cite behavioral examples):

  Initiation   _________________________
  Frequency _________________________
  Duration     _________________________

      REFERRAL/LINKAGE TO                          This service was  provided  considered and the IEP team has determined that the service
        OTHER RESOURCES                            does not meet the educational needs of this student because (cite behavioral examples):



  Initiation   _________________________
  Frequency _________________________
  Duration     _________________________

        BEHAVIORAL AND OR                          This service was  provided  considered and the IEP team has determined that the service
          OTHER SERVICES                           does not meet the educational needs of this student because (cite behavioral examples):

  Initiation   _________________________
  Frequency _________________________
  Duration     _________________________

  Based on the information documented above, a referral to a community mental health service in accordance with Section 7576
  of the Government Code is indicated. Distribute this form to Mental Health and COE upon completion whether or not a
  referral to Mental Health will occur at the current time. (Attach SELPA 8A - Release of Information form, signed by
SELPA 21 (9/05)
  parent/guardian)
                                                  Distribution:   Mental Health     Student File COE
                                                                                                                                        93
                                                                                                                     Page 1 of 2
                                                      CONFIDENTIAL
                         NORTH SANTA CRUZ COUNTY . SPECIAL EDUCATION LOCAL PLAN AREA

                                    REFERRAL FOR MENTAL HEALTH SERVICES

 Student                                                            Birthdate                                         Sex
 Sp. Ed. Program                                                    Disabling Condition
 School                                                   Grade     Teacher                                           Room
 LEA of Residence                                    LEP  Yes  No Primary Language
 Name of  Parent  Guardian  Foster                                                           Work Phone
 Address                                                                  Zip                   Home Phone
 County of Residence                                       LCI/FFH Pupil  Yes        No       Placing Agency
 Current Counselor/Therapist                                                                    Phone
 Date of Receipt of Parent Consent for Referral                               Projected IEP Meeting Date


                                                        Referral Information
 Describe the specific behaviors of the child which prompted this referral and reasons this child might be a candidate for Mental
 Health Services:




 Documentation demonstrates the following (check as appropriate):
   A. The behavioral characteristics of the pupil adversely affect educational performance, measured by standardized achievement
             tests (reported scores and comparisons to measured ability, when appropriate), teacher observations, work samples, grade
             reports reflecting classroom functioning and other measures to be determined to be appropriate by the IEP team.




SELPA 21A (3/05)                              Distribution: Mental Health   Student File   COE

                                                                                                                            94
                         NORTH SANTA CRUZ COUNTY . SPECIAL EDUCATION LOCAL PLAN AREA                                             Page 2 of 2

                                     REFERRAL FOR MENTAL HEALTH SERVICES


  B.The behavior of the pupil cannot be defined solely as a behavior disorder or a temporary adjustment problem
         and cannot be resolved with short term counseling.




  C.The age of onset was from 30 months to 21 years and has been observed for at least 6 months.



  D. The adverse behavioral characteristics of the pupil are severe. (Indicate rate of occurrence and intensity.)




 Attach the following documents:
  A. Parent Notification/Request for Mental Health Review and confidentiality release signed and dated by parent/guardian
             (SELPA 20), (Parent/Guardian signature for approval of the assessment plan will be the responsibility of the Mental Health
             professional.)

  B. Copies of the IEP and all assessment reports, and

  C. A written explanation which states why specialized counseling and guidance services provided at the school level have not
             been sufficient in meeting the needs of the student. (Discuss below, or attach pages.)




 Potential ED/ Day Treatment Candidate         Yes  No             Sent to M.H.                            M.H. Received
 Case Coordinator                                                                                     Date
 Address                                                       Zip                  Phone
 LEA Director                                                                                         Date
 Signature indicates agreement to provide space for services at the school site or transportation to M.H. clinic or satellite.



SELPA 21B (3/05)                               Distribution:   Mental Health    Student File          COE

                                                                                                                             95
                     REQUEST FOR SURROGATE PARENT
                                SELPA 22


Who fills out this form?

This form is filled out by a Special Education administrator after being notified that a student
may need a surrogate parent. Districts and SELPA may appoint surrogate parents following
criteria designated in the Local Plan.

The Local Educational Agency (LEA) shall appoint a surrogate parent for a child under one
or more of the following circumstances:

               1) The child is an adjudicated dependent or ward of the court either at the
                  time of a referral to an LEA for special education and related services or in
                  cases where the child already has a valid individualized education
                  program.
               2) No parent for the child can be identified.
               3) The local educational agency, after reasonable efforts, cannot discover the
                  location of a parent.

A surrogate parent shall not be appointed for a child who is a dependent or ward of the court
unless the court specifically limits the right of the parent or guardian to make educational
decisions for the child.

A surrogate parent shall not be appointed for a child who has reached the age of majority
unless the child has been declared incompetent by a court of law.

Changes from previous versions:
SELPA 22     No changes.




                                                                                              96
                          NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA

                                             REQUEST FOR SURROGATE
Person Requesting Surrogate _______________________________ Title ____________________ Phone ______________
Social Worker ___________________________________ County __________________________ Phone ______________
Position ________________________________________________ Disability of Student ____________________________
School/LEA _____________________________________________ Student Name _________________________________
Street Address ___________________________________________ Age/Birthdate _________________________________
City ___________________________________________________ Grade ________________________________________
Phone __________________________________________________ Parent/Guardian _______________________________

Residence Type:       Licensed Children’s Institution           LCI Foster Family             Relative       Foster Family
                                Parent Representation Status                                                  Please Answer
                                                                                                                 Yes/No
Parent Education rights have been limited by Court                                                             Yes  No
(The authority of the court to remove the parents’ rights is included in A.B. 1528 (Section 6, 7).
Wards or dependents of the court must continue to be represented by their parent unless the
court has specifically limited parental rights to represent the child for educational purposes.)
If yes, please explain:
___________________________________________________________________________
No parent can be identified.                                                                                   Yes  No

No parent is locatable.                                                                                        Yes  No

Both parents are not locatable after three (3) documented search attempts.                                     Yes  No

Documented History by Social Services or other agencies as having conducted a reasonable                       Yes  No
search with verification that no parent, guardian, or adult with custody of the student can be
identified.
DOCUMENTATION OF SEARCH ATTEMPTS FOR MOTHER:                                                                Date:      Method:
(Reasonable efforts shall include at least three attempted contacts by telephone, home visits,              __________ _______________
regular mail, attempted faxes or registered letters sent to the last previously known address of            __________ _______________
the parent, guardian, or conservator.)            Additional Comments:                                      __________ _______________


DOCUMENTATION OF SEARCH ATTEMPTS FOR FATHER:                                                                Date:      Method:
(Reasonable efforts shall include at least three attempted contacts by telephone, home visits,              __________ _______________
regular mail, attempted faxes or registered letters sent to the last previously known address of            __________ _______________
the parent, guardian, or conservator.)            Additional Comments:                                      __________ _______________


Is the student an emancipated minor, over 18 years of age or married? If yes, please indicate                  Yes  No
which of the above.
Was the student voluntarily placed in a residential facility?                                                  Yes  No
(This includes AB 3632 residential placements)
Is there a need for an interim Surrogate Parent for an immediate educational placement, while                  Yes  No
the status of location of the student’s parents is researched?
(For office use only)
Does this student qualify for a Surrogate Parent?  Yes  No Comment(s):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please send request to Local School District

SELPA 22 (3/05)                 Distribution: Copy 1 - LEA Office      Copy 2 - Student File

                                                                                                                                    97
        APPOINTMENT OF EDUCATIONAL REPRESENTATIVE
                         SELPA 23



Who fills out this form?

This form is filled out by the parent or guardian who chooses to delegate educational
responsibility to a chosen representative.

Prior to using this form, efforts to include and involve the parents must be documented on
the Contact Log (SELPA 3).

If a student is in a foster home placement or placed in a licensed children’s institute the
parent may still retain educational rights, unless the court specifically takes away educational
rights. If educational rights are not specifically given to another person or agency, and the
parent cannot be located then use SELPA 22, Request for Surrogate Parent. Districts and
SELPA may appoint surrogate parents following criteria designated in the Local Plan.


Changes from previous version:
SELPA 22     No changes.




                                                                                              98
                                                 NORTH SANTA CRUZ COUNTY
                                             SPECIAL EDUCATION LOCAL PLAN AREA
                              APPOINTMENT OF EDUCATIONAL REPRESENTATIVE

DIRECTIONS This form may be used when the parent remains the legal guardian but chooses to delegate
           responsibility to an educational representative.

I appoint ______________________________ to act as my representative in connection with the education of
my child, __________________________________. This representative shall have full parental authority in
matters relating to the identification, assessment, instructional planning and development, educational
placement, review and revision of the individual education program, utilization of procedural safeguards, and
other matters relating to the provision of a free appropriate education for my child.

The appointment shall remain in effect until any of the following occur:

                  1. I notify the LEA and/or the SELPA Administrator of my child’s attendance area that this
                     appointment is withdrawn.

                  2. The representative is unwilling or unable to carry out his or her responsibilities to the best
                     interest of my child.

                  3. The representative is in a position of conflict of interest in the above matters.

                  4. My child no longer resides in the “licensed children’s institution or foster family home,” owned
                     or operated by the above representative (applicable only when child is placed in a “licensed
                     children’s institution or foster family home”).




________________________________________                                    ______________________________
Parent Signature                                                            Date

________________________________________
Witness
                             ACCEPTANCE OF APPOINTMENT

I, ____________________________________, hereby accept the above appointment. At such time as any of
the conditions 2, 3, or 4 above, relating to the tenure of this appointment exists, I will notify the LEA of
attendance or SELPA Administrator and the appointing parent.

________________________________________                                    ______________________________
Representative Signature                                                    Date

________________________________________
Witness

Any specific conditions or exceptions to this appointment shall be made on a separate sheet and signed and
dated by the parent, the representative, and a witness.
SELPA 23 (3/05)                  Distribution:    Copy 1 - LEA Office   Copy 2 - Agency
                                                                                                                        99
       LOW INCIDENCE FUND EXPENDITURE REQUEST FORM
                         SELPA 24


Who fills out this form?
Members of the IEP team use this form to request specialized materials/equipment that will
help meet the goals and objectives written for a student whose primary disability is identified
as low incidence: deaf, hard of hearing, visually impaired, and severely orthopedically
impaired. Specific criteria are clearly delineated on back of SELPA 24.

This form is sent to the special education director who sends it to the SELPA office and is
reviewed by the Low Incidence Committee.


Changes from previous versions:
SELPA 24     Added Teacher Phone Number field.




                                                                                            100
                                            NORTH SANTA CRUZ COUNTY
                                        SPECIAL EDUCATION LOCAL PLAN AREA
                               LOW INCIDENCE EXPENDITURE REQUEST FORM

Instructions:
    1. Complete this form for materials/equipment only, e.g., computer, monitor, printer. Do not included general
         instructional materials or consumable supplies.
    2. If the request is for a specific student, the IEP must be attached. Program related requests must be accompanied
         by a rationale.
    3. Forward completed form(s) to the responsible LEA Special Education Director.
    4. Approved forms must be submitted to SELPA.

Submitted by: ______________________________________ Teacher Phone: _______________________
School Site: ________________________________________ Program: ____________________________
LEA __________________________________ Date _________________ Check one:                 Pupil Request  Program Request

Quantity                         Description                           Est. Cost      Extension            Invoice Amount



                                                                       Subtotal    ____________
                                                                       Shipping    ____________            Shipping____________
                                                                           Tax     ____________              Tax ______________
                                                                          Total    ____________        Total Cost ______________

Student’s Name ____________________________________________
Justification       ________________________________________________________________________________________
(Attach more sheets ________________________________________________________________________________________
if necessary)       ________________________________________________________________________________________
                    ________________________________________________________________________________________


 Urgent           Priority Level 1            Priority Level 2             Priority Level 3
Recommendation:          Approved  Denied
Comments:

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

LEA Special Education Director ________________________________________________________________________________
                                                              Signature/Date
Program Specialist/Low Incidence Committee Recommendation:     Approved  Denied
SELPA Director ______________________________________          Approved  Denied        Date _________________
Comments:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
                                                                                           For Office Use Only

SELPA 24 (3/05)             Distribution:      Copy 1 - SELPA Office       Copy 2 - LEA Special Education Director

                                                                                                                             101
The following is the State criteria checklist that you can use when submitting a Low Incidence request form. Low
Incidence equipment may only be purchased for students whose primary disability is identified as low incidence (deaf,
hard of hearing, visually impaired, severely orthopedically impaired, deaf and blind).

Pages that MUST be attached to form:

      Student has a low incidence disability, verified on the signature page of IEP/IFSP/ITP

       Item is required by IEP; specific goal or objective page attached

      Catalog page with price and vendor information (including shipping and handling information

      Request form is completely filled out and signed by Special Education Director

       Item is specialized

       Item is recommended by appropriate personnel

       Item is necessary for the child to benefit from Special Education

       Item supplements, not supplants, other funding sources

      Not medical equipment, construction of facilities, assessment of student, or inservice/parent ed.

      At least $50 per Low Incidence request form

       Item is not already available in our region




Priority Levels URGENT I, II and III are described as:


URGENT -        EQUIPMENT IS REQUIRED FOR THE STUDENT TO ATTEND SCHOOL
                SAFELY (e.g. standing tables)

LEVEL I -       EQUIPMENT IS REQUIRED FOR THE STUDENT TO PARTICIPATE IN
                EDUCATIONAL PROGRAM (e.g. Phonic Ear, Mobility Equipment, Brailler,
                Augmentative Communication Devices)

LEVEL II -      EQUIPMENT WHICH AUGMENTS THE PROGRAM OF THE STUDENT AND
                ASSISTS PARTICIPATION IN CLASSROOM ACTIVITIES (e.g. modified or adapted
                equipment or furniture)

LEVEL III -     EQUIPMENT WHICH IS USEFUL BUT NON-ESSENTIAL (e.g. toys)

                                                                                     Reverse/Low Incidence Request
                                                                                                                  102
                     APPLICATION/REFERRAL FOR CCS
                       MEDICAL THERAPY SERVICES
                               SELPA 25



Who fills out this form?

A parent, teacher, or specialist who is requesting occupational therapy, physical therapy or
other medical services fills out a SELPA 25 giving permission to California Children's
Services to begin assessment and share information with other agencies serving the student.
Check with CCS for qualifying conditions.

Changes from previous versions:
SELPA 25     No changes.




                                                                                         103
                                                NORTH SANTA CRUZ COUNTY
                                            SPECIAL EDUCATION LOCAL PLAN AREA
                         APPLICATION/REFERRAL FOR CCS MEDICAL THERAPY SERVICES


Student ___________________________________ Birthdate _________________ Social Security #: __________________
LEA _____________________________________ Special Education Program _____________________________________
School ___________________________________ Teacher ____________________________ Room _________________
LEP      Yes  No          Primary Language ___________________________________________________________________
Name of  Parent         Guardian  Foster ________________________________________________________________
Address _________________________________________________________________ Phone _______________________




Reason for Referral ____________________________________________________________________________________
Medical Diagnosis _____________________________________________________________________________________
Regular Doctor _________________________________________________________ Phone ________________________
Office Address ________________________________________________________________________________________
Medication the student is now taking: ______________________________________________________________________
Does this student have seizures?     Yes  No
                     Type and frequency (if known) _____________________________________________________________
Other pertinent medical problems: _________________________________________________________________________
                 Has this child been served by CCS previously?         Yes  No
                     Is the child receiving PT or OT presently?                     Yes  No
                     from whom? ___________________________________________________ Phone _________________
                     Has this child received therapy in the past other than from CCS?        Yes  No
                     from whom? ___________________________________________________ Phone _________________
Other Agencies involved with the student:
_____________________________________________________________________________________________________



I am applying for CCS and certify that the information I have provided is true and correct to the best of my knowledge.
I understand that the completion of this application does not assure acceptance of the application by CCS. I give my permission to
verify my residence or other circumstances required for application to CCS. I give permission for CCS to request medical information
concerning my child. I give permission for CCS to share information with my child’s school district and/or County Office of
Education.

Your signature below authorizes CCS to proceed with the application.



Signature of Parent/Guardian __________________________________________________ Date ______________________


Specialist        _______________________________________________________________ Date ______________________



SELPA 25 (3/05)                       Distribution: Copy 1 - LEA Office      Copy 2 - CCS      Copy 3 - Parent

                                                                                                                                 104
                                  LCI PLACEMENT
                                      SELPA 26


Who fills out this form?

When a child is moved to a licensed children's institution, the representative of social
services sends this information to the director of special education and SELPA director.

(Government codes are printed on back.)

Changes from previous versions:
SELPA 26     No changes.




                                                                                     105
                                                           NORTH SANTA CRUZ COUNTY
                                                       SPECIAL EDUCATION LOCAL PLAN AREA
                  NOTIFICATION OF PLACEMENT OF INDIVIDUAL WITH EXCEPTIONAL NEEDS IN
                        LICENSED CHILDREN’S INSTITUTION OR FOSTER FAMILY HOME
                                                         EDUCATION CODE SECTION 56155 et seq
                                                        GOVERNMENT CODE SECTION 7579 et seq
DIRECTIONS:              To be completed by placing agency representative at the time of placement/transfer of a school-age individual with exceptional
                         needs into a licensed children’s institution or foster family home within the Special Education Local Plan Area.
To: SELPA Administrator                                                   North Santa Cruz County                                  Date        /           /

Address: 809 H Bay Avenue                                                 City: Capitola                                           ZIP     95010

From: Placing Agency Representative (Name/Title)                          County/Agency Name:                                      Telephone: 464-5677

Address:                                                                  City:                                                    ZIP

Name of Pupil (last, first and initial)                                                                                            Birthdate
                                                                                                                                                       /       /
Case/Client No:                       Date of Placement:                  School District

Parent or Guardian (last and first)                                                                                                Telephone
                                                                                                                                   (    )
Address:                                                                  City:                                                    ZIP

Care Provider (last and first) or Facility:                                                                                        Telephone
                                                                                                                                   (    )
Address:                                                                  City:                                                    ZIP

Conservator/Position/Agency:                                                                                                       Telephone
                                                                                                                                   (    )
Address:                                                                  City:                                                    ZIP

County of client’s prior residence:                                       City:                                                    ZIP

Previous school district attended:                                                                                                 Telephone
                                                                                                                                   (    )
Address:                                                                  City:                                                    ZIP

Signature - Placing Agency Representative:                                Title:                                                   Date
                                                                                                                                                       /       /
                         Educational representation and IEP signature status (check all that apply);
                          1.         The child is a ward or dependent of the court:
                                       a. The parent/guardian/conservator retains his/her authority to represent the pupil for educational
                                                purposes.
                                       b. The court has removed parent/guardian rights to represent the pupil for educational purposes.
                          2.         The parent/guardian/conservator has appointed an Educational Representative (Form SELPA 23 or equivalent).
                          3.         The client is an adult with no conservator having educational authority.
                          4.         A conservator has been appointed to represent the student:
                                       a. General Conservatorship.
                                       b. Limited Conservatorship.
                                                 (1). Client’s educational rights have been removed.
                                                 (2). Client’s educational rights have not been removed.
                          5.         There is no parent or guardian
                          6.         The parent/guardian cannot be located.
                          7.         Other ______________________________________________________________________


                                                           FOR USE BY SELPA ADMINISTRATOR
District of Residence:                                     Notified by:                                                            Date
                                                                                                                                                   /       /

SELPA 26 (3/05)                        Distribution:               LEA Office                   Agency
                                                                                                                                                                   106
Government Code
7579
(a) Prior to placing a handicapped child or a child suspected of being disabled in a residential facility, outside the child's home, a court, regional center for
     the developmentally disabled, or public agency other than an educational agency, shall notify the administrator of the special education local plan area in
     which the residential facility is located. The administrator of the special education local plan area shall provide the court or other placing agency with
     information about the availability of an appropriate public or nonpublic nonsectarian special education program in the special education local plan area
     where the residential facility is located.
(b) Notwithstanding Section 56159 of the Education Code, the involvement of the administrator of the special education local plan area in the placement
     discussion, pursuant to subdivision (a), shall in no way obligate a public education agency to pay for the residential costs and the cost of noneducational
     services for a child placed in a licensed children's institution or foster family home.
(c) It is the intent of the Legislature that this section will encourage communication between the courts and other public agencies which engage in referring
     children to, or placing children in, residential facilities, and representatives of local education agencies. It is not the intent of the section to hinder the
     courts or public agencies in their responsibilities for placing handicapped children in residential facilities when appropriate.
7579.1
(a) Prior to the discharge of any disabled child who has an active individualized education program from a public hospital, proprietary hospital, or
     residential medical facility pursuant to Article 5.5 (commencing with Section 56157) of Chapter 2 of Part 30 of the Education Code, a licensed children's
     institution or foster family home pursuant to Article 5 (commencing with Section 56155) of Chapter 2 of Part 30 of the Education Code, or a state
     hospital for the developmentally disabled or mentally disordered, the following shall occur:
     (1) The operator of the hospital or medical facility, or the agency that placed the child in the licensed children's institution or foster family home, shall,
           at least 10 days prior to the discharge of a disabled child, notify in writing the local educational agency in which the special education program for
           the child is being provided, and the receiving special education local plan area where the child is being transferred, of the impending discharge.
     (2) The operator or placing agency, as part of the written notification, shall provide the receiving special education local plan area with a copy of the
           child's individualized education program, the identity of the individual responsible for representing the interests of the child for educational and
           related services for the impending placement, and other relevant information about the child that will be useful in implementing the child's
           individualized education program in the receiving special education local plan area.
(b) Once the disabled child has been discharged, it shall be the responsibility of the receiving local educational agency to ensure that the child receive an
     appropriate educational placement that commences without delay upon his or her discharge from the hospital, institution, facility, or foster family home
     in accordance with Section 56325 of the Education Code. Responsibility for the provision of special education rests with the school district of residence
     of the parent or guardian of the child unless the child is placed in another hospital, institution, facility, or foster family home in which case the
     responsibility of special education rests with the school district in which the child resides pursuant to Sections 56156.5, 56156.6, and 56167 of the
     Education Code.
(c) Special Education Local Plan Directors shall document instances where the procedures in subdivision (a) are not being adhered to and report these
     instances to the Superintendent of Public Instruction.
Education Code
56155
The provisions of this article shall only apply to individuals with exceptional needs placed in a licensed children's institution or foster family home by a court,
regional center for the developmentally disabled, or public agency, other than an educational agency.
56155.5
(a) As used in this article, "licensed children's institution" means a residential facility which is licensed by the state, or other public agency which has
     delegated authority by contract with the state to license, to provide non-medical care to children, including, but not limited to, individuals with
     exceptional needs. "Licensed children's institution" in addition, includes a group home as defined by subdivision (a) of Section 80001 of Title 22 of the
     California Administrative Code. A “licensed children’s institution” does not include any of the following: (1) A juvenile court school, juvenile hall,
     juvenile home, day center, juvenile ranch, or juvenile camp administered pursuant to Article 2.5 (commencing with Section 48645) of Chapter 4 of Part
     27; (2) A county community school program provided pursuant to Section 1981; (3) Any special education programs provided pursuant to Section
     56150; (4) Any other public agency.
(b) As used in this article, "foster family home" means a family residence which is licensed by the state, or other public agency which has delegated
     authority by contract with the state to license, to provide 24-hour non-medical care and supervision for not more than six foster children, including, but
     not limited to, individuals with exceptional needs. "Foster family home," in addition, includes a small family home as defined in paragraph (6) of
     subdivision (a) of Section 1502 of the Health and Safety Code.
56156
(a) Each court, regional center for the developmentally disabled, or public agency that engages in referring children to, or placing children in, licensed
     children's institutions shall report to the special education administrator of the district, special education local plan area, or county office in which the
     licensed children's institution is located any referral or admission of a child who is potentially eligible for special education.
(b) At the time of placement in a licensed children's institution or foster home, each court, regional center for the developmentally disabled, or public agency
     shall identify all of the following:
     (1) Whether the courts have specifically limited the rights of the parent or guardian to make educational decisions for a child who is a ward or
           dependent of the court.
     (2) The location of the parents, in the event that the parents retain the right to make educational decisions.
     (3) Whether the location of the parents is unknown.
(c) Each person licensed by the state to operate a licensed children's institution, or his or her designee, shall notify the special education administrator of the
     district, special education local plan area, or county office in which the licensed children's institution is located of any child potentially eligible for
     special education who resides at the facility.
(d) The superintendent shall provide each county office of education with a current list of licensed children’s institutions in that county at least biannually.
     The county office shall maintain the most current list of licensed children’s institutions located within the county and shall notify each district and
     Special Education Local Plan Area (SELPA) within the county of the names of licensed children’s institutions located in the geographical area of the
     county covered by the district and the SELPA. The county office shall notify the director of each licensed children’s institution of the appropriate person
     to contact regarding individuals with exceptional needs.

                                                                                                                                           Reverse of SELPA 26



                                                                                                                                                  107
                          INTERAGENCY REFERRAL
                                 SELPA 27



When is this form used?

This form is attached to front of current IEP when a student is referred from one LEA to
another. It is completed by the Special Education Administrator and staff.

Changes from previous versions:
SELPA 27     No changes.




                                                                                     108
                                                                                                Date ____________________
                                  NORTH SANTA CRUZ COUNTY
                              SPECIAL EDUCATION LOCAL PLAN AREA

                                        INTERAGENCY REFERRAL


Student's Name ________________________________________                       Birthdate __________________________

LEA of Residence

Current Program                                                                         Teacher

School

Case Coordinator                                                                        Phone

LEA considered for possible placement

Possible Program
The above named student is referred for possible placement in your LEA.
The following information is attached:

 1. Signed parent authorization for assessment/release of information.

 2. Student information form

 3. Copy of all assessment information (including school history)

 4. IEP dated

 5. Current case status




Completed by

Approved by
                                                                                                       Date Approved
SELPA 27   (3/05)
                                        Distribution: LEA of Residence LEA of Service

                                                                                                                       109
              INFORMATION FOR CLASSROOM TEACHER
                           SELPA 28




When is this form used?

This form is optional and serves as a method of documenting modifications and effective
strategies for the student in the regular education environment.

Changes from previous versions:
SELPA 28     No changes.




                                                                                    110
                  NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA

                           INFORMATION FOR CLASSROOM TEACHER

To:                                                         From:                            Position:

Re: Student’s Legal Name                                                 Birthdate                           Date

District                         School                                   School Phone                       Grade

          Areas Needing Accommodations                                                Effective Strategies




Refer to SELPA 12 in cum folder
The student also receives the following services:
 Resource specialist                        Vision                Other services:
 Speech and language                        Hearing
 Occupational therapy                       Interpreter
 Adaptive Physical Education                Counseling
 Physical therapy                           Other
Current medications and possible effects:
The IEP is available for further information.
SELPA 28 (3/05)
                                                                                                                     111
                  SPECIAL EDUCATION REFERRAL LOG
                              SELPA 29



When is this form used?

This form is used by staff completing intake and kept in an agreed-upon location at each
school site for all students receiving special education services. This log is required for
Coordinated Compliance Reviews (CCRs).

Changes from previous versions:
SELPA 29     No changes.




                                                                                        112
                          NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                    SPECIAL EDUCATION REFERRAL LOG

School                                     District                                  School Year


                                                              DATE
                                                                                                         IEP   OUTCOME
                                                            REFERRAL                           50 DAY
                                                            RECEIVED   REFERRED                         MTG.      OF
             STUDENT   TEACHER     DOB    GRADE       SST                         CASE MGR.    LIMIT
                                                                          BY                            DATE   REFERRAL




SELPA 29 (3/05)

                                                                                                                      113
                    STUDENT INFORMATION FORM (SIF)
                           SELPA 30A, C and D


Who fills out these form?
At the end of every IEP the case manager fills out and files a SIF with the District Office
using the OPTION CODE LIST. Codes for each form can be found on the back of the form.

This information is used by the state of California to update the MIS files (Management
Information System). These forms are for internal purposes only and are not a legal part
of the IEP, and should not be sent to parent as part of the IEP.

Computer Information For:

SELPA 30A Ages 3-22
SELPA 30C Ages 0-2 ONLY

Information from SELPA 1 will transfer to the SIF, substituting number codes for words
when called for. You must open the appropriate SIF depending on the age of your student.

More than ONE ethnicity may be listed.

SERVICES - Please list the primary service first. There are times the State will read only
the FIRST service listed on the student’s enrollment; therefore, it MUST be listed as the
primary service. Please note: services have been added, and/or changed such as intensive
individual services, behavior management, education technology services, transportation,
etc., check the service code options on the back of the form. For definitions of codes see
Appendix A.

Please check whether student has an IEP or an ISP. An ISP is an Individual Service Plan for
students attending a private school, but still receiving special education services through the
public school district (this is usually a limited amount of speech services only).

SELPA 30D

This form is used to report any suspensions or expulsions of special education students to
MIS staff. It is a state requirement to report all disciplinary actions for special education
students.




                                                                                            114
Changes from previous versions:
SELPA 30A Many fields were removed from this form. Some information was not being
properly updated prior to turning into district MIS staff. When turning in IEP information to
the district it will now be necessary to copy and turn in SELPA 13ABCD and, if applicable,
SELPA 13E, along with this form. This form is primarily to be used for reporting to the MIS
staff person at your district teacher information (teacher names are not to be included as part
of an IEP). It can also serve as a quick reference to scan services a student is currently
receiving, or to update student contact information to the MIS staff person.
SELPA 30C See above.
SELPA 30D No changes.




                                                                                  115
                             NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA

                                                       DATA PAGE (For Ages 3-22 Only)
                                                          FOR OFFICE USE ONLY


Student Information
Last Name ___________________________________________ First Name __________________________________

Gender  Female  Male Date of Birth _____________________ SSN                                      CSIS#

Parent/Guardian __________________________________________________                  Parent  Guardian  Other
Student Address ____________________________________________ Mailing Address ___________________________________

City State Zip ______________________________________________ City State Zip _____________________________________

Home Phone __________________________ Work Phone ________________________ Cell Phone _________________________


Student Demographics

Grade Level _______            Ethnicity                                 Primary Disability           Residence Status

Native Language                Student Language                District of Residence 44__________ District of Service 44__________

Federal Setting Code                                   School of Attendance Code                             School Type


SELPA 13A, 13B, 13C, 13D, 13F & G (or SELPA 14 if an addendum) MUST be attached.
TOTAL NUMBER OF SERVICES RECEIVED

PLACEMENT          TEACHER                 PLACEMENT    LOCATION   MIN/DA    SESSIONS/   PROVIDER    ADD/CONTINUE          EXIT DATE    EXIT
                                             CODE         CODE       Y        WEEK                       DATE                          REASON
PRIMARY
Service
Addt’l Services

Addt’l Services

Addt’l Services

Addt’l Services

Addt’l Services

Addt’l Services

Extd Year
Services
Extd Year
Services

Comments______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
SELPA 30A (3/05)




                                                                                                                                         116
                                                                            CODES FOR SELPA 30A (back)
 Code      (1) Grade Level                          Code     (5) Native Language &                   Code      (7) School Type (cont.)                  Code        Location (cont.)
01         First Grade                                       Student Language (cont.)               64 Private preschool                                630 Juvenile court school
02         Second Grade                             23       Hmong                                  65 Extended day care                                640 Community school
03         Third Grade                              24       Hungarian                              70 Nonpublic day school                             650 Correctional institution or facility
04         Fourth Grade                             25       Ilocano                                71 Nonpublic residential school - in California     710 Community college
05         Fifth Grade                              26       Indonesian                             72 Nonpublic residential school - outside           720 Adult education facility
06         Sixth Grade                              27       Italian                                   California                                       810 Nonpublic day school
07         Seventh Grade                            28       Punjabi                                75 Private day school (not certified by Special     820 Nonpublic residential school –in California
08         Eighth Grade                             29       Russian                                   Education Division)                              830 Nonpublic residential school – outside CA
09         Ninth Grade                              30       Samoan                                 76 Private residential school (not Certified by     840 Private day school (not certified by Special
10         Tenth Grade                              31       Serbian                                   Special education Division)                           Education Division)
11         Eleventh Grade                           32       Thai                                   79 Nonpublic Agency                                 850 Private residential school (not certified by
12         Twelfth Grade                            33       Turkish                                80 Parochial school                                      Special Education Division)
13         12+ grade/Transition                     34       Tongan                                                                                     860 Parochial school
15         Ungraded                                 35       Urdu                                   Code       (8) Services                             890 Service provider location
17         Preschool                                36       Cebuano(Visayan)                       330    Specialized Academic Instruction/RSP         900 Any Other Location or Setting
18         Kindergarten                             37       Sign Language                          330    Specialized Academic Instruction/SDC
                                                    38       Ukrainian                              340    Intensive Individual Services                Code Provider (Mental Health Svcs Only)
Code       (2) Ethnicity                            39       Chaozhou(Chaochow)                     350    Individual and small group instruction       100 District of service
100        Native American                          40       Pashto                                 415    Language and speech                          110 County office of education
201        Chinese                                  41       Polish                                 425    Adapted physical education                   120 SELPA
202        Japanese                                 42       Assyrian                               435    Health and nursing - specialized physical    130 Another district, county, or SELPA
203        Korean                                   43       Gujarati                                      health care services                         200 WorkAbility
204        Vietnamese                               44       Mien                                    436 Health and nursing - other services            210 Transition Partnership Program (TPP)
205        Asian Indian                             45       Rumanian                                445 Assistive technology services                  220 Regional Center
206        Laotian                                  46       Taiwanese                               450 Occupational therapy                           230 Alcohol and drug prevention programs
207        Cambodian                                47       Lahu                                    460 Physical therapy                               240 Child development funded program
299        Other Asian                              48       Marshallese                             510 Individual counseling                          250 Head Start
301        Hawaiian                                 49       Mixteco                                 515 Counseling and guidance                        300 Department of Mental Health
302        Guamanian                                50       Khmu                                    520 Parent counseling                              310 California Children’s Services
303        Samoan                                   51       Kurdish                                 525 Social work services                           320 Department of Social Services
304        Tahitian                                 52       Servo-Croatian                          530 Psychological services                         330 Department of Rehabilitation
399        Other Pacific Islander                   53       Toishanese                              535 Behavior intervention services                 340 Employment Development Department
400        Filipino                                 54       Chaldean                                540 Day treatment services                         400   Nonpublic agency (NPA) under contract
500        Hispanic                                 56       Albanian                                545 Residential treatment services                      with SELPA or district
600        African-American                         57       Tigrinya                                610 Specialized services for low incidence         410 Nonpublic school (NPS) under contract
700        White                                    99       Other-non-English Languages                   disabilities                                      with SELPA or district
                                                                                                     710 Specialized deaf and hard of hearing           500 Other public program
Code       (3) Primary Disability                   Code     (6) District of Residence & District of       services                                     600 Other private program
210     Mental Retardation                                   Service                                 715 Interpreter services
220     Hard of Hearing                             10447 Santa Cruz County Office of Education 720 Audiological services
230     Deafness                                    69732 Bonny Doon Elem                            725 Specialized vision services
240     Speech or Language Impairment               69757 Happy Valley Elem                          730 Orientation and mobility
250     Visual Impairment                           69765 Live Oak Elem                              735 Braille transcription
260     Emotional Disturbance                       69773 Mountain Elem                              740 Specialized orthopedic services
270     Orthopedic Impairment                       69781 Pacific Elem                               745 Reader services
280     Other Health Impairment                     69807 San Lorenzo Valley Unified                 750 Note taking services
281     Established Medical Disability (3-5 only)   69815 Santa Cruz City Elem                       755 Transcription services
290     Specific Learning Disability                69823 Santa Cruz City High                       760 Recreation services, includes therapeutic
300     Deaf-Blindness                              69849 Soquel Union Elem                                recreation
310     Multiple Disability                         75432 Scotts Valley Unified                      820 College awareness/preparation
320     Autism                                       Contact SELPA for other codes or check the      830 Vocational assessment, counseling,
330     Traumatic Brain Injury                       California Public School Directory                    guidance, and career assessment
                                                                                                     840 Career awareness
Code       (4) Residence Status                     Code Federal School Setting Code                 850 Work experience education
10         Parent or Legal Guardian                 400    Regular Classroom/Public day school       855 Job coaching (includes job shadow and
20         Licensed Children’s Institute (LCI)      450    Separate school                                 service learning)
30         Foster Family Home (FFH)                 460    Residential facility                      860 Mentoring
40         Hospital (except state hospital)         470    Homebound/Hospital                        865 Agency linkages (referral and placement)
50         Incarcerated Institution                 480    Correctional facility                     870 Travel training (includes mobility training)
71         State Hospital                           490    Parentally placed in private school       890 Other Transition Service
72         Developmental center                                                                      900 Other special education/related services
90         Other                                    Code (7) School Type                             For definitions of these services see Appendix C
                                                    00     No School (ages 0-5 ONLY)                       in the NSCC SELPA Forms Manuel
Code       (5) Native Language &                    10     Public day school
           Student Language                         11     Public residential school                 Code         Location
00         English                                  15     Special Education Center or facility      210 Home instruction based on IEP Team
01         Spanish                                  19     Other public school or facility (such as        determination (not medical)
02         Vietnamese                                      store front transition program)           220 Hospital
03         Cantonese                                20     Continuation school                       310 Head Start program
04         Korean                                   22     Alternative work education center/work 320 Child development or child care facility
05         Pilipino (Tagalog)
                                                           study program                             330 Public preschool
06         Portuguese
                                                    24     Independent Study                         340 Private preschool
07         Mandarin (Putonghua)
                                                    30     Juvenile court school                     350 Extended day care
08         Japanese
                                                    31     Community school                          360 Residential facility
09         Khme(Cambodian)                          32     Correctional institution or facility      510 Regular classroom/public day school
10         Lao
                                                    40     Home instruction based on IEP team        520 Separate classroom in public integrated
11         Arabic
                                                           determination                                   facility
12         Armenia
                                                    45     Hospital facility                         530 State Special School
13         Burmese
                                                    50     Community college                         540 Separate school or Special Education Center
14         Croatian
                                                    51     Adult education program                         or facility
15         Dutch                                    55     Charter school (operated by an            550 Public residential school
16         Farsi(Persian)
                                                           LEA/district)                             560 Other public school or facility
17         French
                                                    56     Charter school (operated as an            570 Charter school (operated by an LEA/district)
18         German
                                                           LEA/district)                             580 Charter school (operated as an LEA/district)
19         Greek
                                                    61     Head Start program                        610 Continuation school
20         Chamorro (Guamanian)
                                                    62     Child development or child care facility 620 Alternative work education center/work
21         Hebrew
                                                    63     State preschool                                 study facility
22         Hindi
                                                                                                                                                                                                     117
                           NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                                     DATA PAGE (For Ages 0-2Only)
                                                       FOR OFFICE USE ONLY


Student Information
Last Name ___________________________________________ First Name __________________________________

Gender  Female  Male                   Date of Birth _____________________           SSN

Parent/Guardian __________________________________________________              Parent  Guardian  Other

Student Address ____________________________________________ Mailing Address ___________________________________

City State Zip ______________________________________________ City State Zip _____________________________________

Home Phone __________________________ Work Phone ________________________ Cell Phone _________________________


Educational Information
Grade Level _______             District of Residence 44__________      Residence Status           Primary Disability

Ethnicity                                Home Language                ELL  Yes  No         Migrant Ed.    Yes  No

School of Attendance Code                                Infant Setting/Location              Solely Low Incidence

IFSP Dates
                               Month Day Year                                  Month Day Year                           Month Day Year


             Referral Date                                                                            Last IFSP Date
        Original Entry into
         Special Education                                 6 Month Review                             Next IFSP Date

   Last Actual Evaluation                              Next 6 Month Review                            Transition Date


Enrollment Information                                     Copy of IFSP MUST be attached.
 INFANT         AGENCY
                                                                                                ADD/CONTINUE                  EXIT
RELATED        PROVIDING      LOCATION   FREQUENCY    DURATION               TEACHER                             EXIT DATE
                                                                                                    DATE                     REASON
SERVICES        SERVICES




Comments______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Form Completed by _______________________________ Date __________________________
SELPA 30C (3/05)

                                                                                                                                      118
                                                              CODES FOR SELPA 30C (back)
Code   (1) Grade Level                    Code    (6) Native Language (cont.)        Code        (8) Services (cont.)           Code     (11) Frequency (cont.)
16     Infant                             05      Pilipino (Tagalog)                 350 Individual and small group             23 Weekly, three times a week
17     Preschool                          06      Portuguese                              instruction                           24 Weekly, four times a week
18     Kindergarten                       07      Mandarin (Putonghua)               415 Language and speech                    25 Weekly, five times or more a week
                                          08      Japanese                           425 Adapted physical education             31 Monthly, once a month
Code (2) District of Residence            09      Khme(Cambodian)                    435 Health and nursing - specialized       32 Monthly, twice a month
10447 Santa Cruz County Office of         10      Lao                                     physical health care services         33 Monthly, three times a month
         Education                        11      Arabic                             436 Health and nursing - other services    34 Monthly, four times a month
69732 Bonny Doon Elem                     12      Armenia                            445 Assistive technology services          35 Monthly, five times or more a
69757 Happy Valley Elem                   13      Burmese                            450 Occupational therapy                        month
69765 Live Oak Elem                       14      Croatian                           460 Physical therapy                       41 Yearly, once a year
69773 Mountain Elem                       15      Dutch                              510 Individual counseling                  42 Yearly, twice a year
69781 Pacific Elem                        16      Farsi(Persian)                     515 Counseling and guidance                43 Yearly, three times a year
69807 San Lorenzo Valley Unified          17      French                             520 Parent counseling                      44 Yearly, four times a year
69815 Santa Cruz City Elem                18      German                             525 Social work services                   45 Yearly, five times or more a year
69823 Santa Cruz City High                19      Greek                              530 Psychological services                 90 Any other frequency, or as needed
69849 Soquel Union Elem                   20      Chamorro (Guamanian)               535 Behavior intervention services
75432 Scotts Valley Unified               21      Hebrew                             540 Day treatment services                 Code      (12) Duration
Contact SELPA for other codes or check    22      Hindi                              545 Residential treatment services         Number of minutes per session
the California Public School Directory    23      Hmong                              610 Specialized services for low
                                          24      Hungarian                               incidence disabilities                Code(13) Exit Reason
Code   (3) Residence Status               25      Ilocano                            710 Specialized deaf and hard of hearing   70 Returned to regular education or no
10     Parent or Legal Guardian           26      Indonesian                              services                                  longer eligible for special education
20     Licensed Children’s Institute      27      Italian                            715 Interpreter services                       or successful completion of IFSP
       (LCI)                              28      Punjabi                            720 Audiological services                  74 Dropped out, includes attempts to
30     Foster Family Home (FFH)           29      Russian                            725 Specialized vision services                contact unsuccessful
40     Hospital (except state hospital)   30      Samoan                             730 Orientation and mobility               76 Moved and known to be continuing,
50     Incarcerated Institution           31      Serbian                            735 Braille transcription                      includes transfer to another program
71     State Hospital                     32      Thai                               740 Specialized orthopedic services
72     Developmental center               33      Turkish                            760 Recreation services, includes          77   Deceased
90     Other                              34      Tongan                                  therapeutic recreation                78   Parent Withdrawal
                                          35      Urdu                               900 Other special education/related        80   Moved and NOT known to be
Code   (4) Primary Disability             36      Cebuano(Visayan)                        service                                    continuing
010    Mental Retardation (MR)            37      Sign Language                      For definitions of these services see
020    Hard of Hearing (HOH)              38      Ukrainian                               Appendix C in the NSCC SELPA
030    Deafness (DEAF)                    39      Chaozhou(Chaochow)                      Forms Manuel
040    Speech or Language Impairment      40      Pashto
       (SLI)                              41      Polish                             Code         (9) Agency Providing
050    Visual Impairment (VI)             42      Assyrian                                  Service
060    Emotional Disturbance (ED)         43      Gujarati                           10     District of service/enrollment
070    Orthopedic Impairment (OI)         44      Mien                               11     County office of education
080    Other Health Impairment (OHI)      45      Rumanian                           12     SELPA
081    Established Medical Disability     46      Taiwanese                          13     Another district, county or SELPA
       (EMD)(ages 3-5 ONLY)               47      Lahu                               20     Regional center (SARC)
090    Specific Learning Disability       48      Marshallese                        21     Alcohol and drug programs
       (SLD)                              49      Mixteco                            22     Child development funded program
100    Deaf-Blindness (DB)                50      Khmu                               23     Head start
110    Multiple Disability (MD)           51      Kurdish                            30     Department of Mental Health
120    Autism (AUT)                       52      Servo-Croatian                     31     California Children’s Services
130    Traumatic Brain Injury(TBI)        53      Toishanese                                (CCS)
                                          54      Chaldean                           32     Dept. of Social Services
Code   (5) Ethnicity                      56      Albanian                           33     Dept. of Rehabilitation
100    Native American                    57      Tigrinya                           34     Employment Development Dept.
201    Chinese                            99      Other-non-English Languages        40     Nonpublic agency under contract
202    Japanese                                                                             with SELPA or district
203    Korean                             Code    (7) Infant Setting/Location        50     Other public program
204    Vietnamese                         21      Designated Instruction and         60     Other private program
205    Asian Indian                               Services (DIS)
206    Laotian                            22      Resource Specialist Program        Code      (10) Location
207    Cambodian                                  (RSP)                              210 Program designed for children with
299    Other Asian                        23      Special Day Class (SDC)                 developmental delay or disabilities
301    Hawaiian                                                                      220 Program designed for typically
302    Guamanian                          Code       (8) Services                         developing children
303    Samoan                             210 Family training, counseling, and       420 Residential facility
304    Tahitian                                home visits                           430 Home
399    Other Pacific Islander             220 Medical services (for evaluation       440 Hospital (inpatient)
400    Filipino                                only)                                 520 Service provider’s location
500    Hispanic                           230 Nutrition services                     900 Any other location or setting
600    African-American                   240 Service coordination
700    White                              250 Special Instruction                    Code    (11) Frequency
                                          260 Special education aide in regular      11 Daily, once a day
Code   (6) Native Language                     development class child care center   12 Daily, twice a day
00     English                                 or family child care home             13 Daily, three times a day
01     Spanish                            270 Respite Care services                  14 Daily, four times a day
02     Vietnamese                         330 Specialized Academic Instruction       15 Daily five or more times a day
03     Cantonese                          340 Intensive Individual Services          21 Weekly, once a week
04     Korean                                                                        22 Weekly, twice a week
                                                                                                                                                                     119
                         NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                          DATA PAGE (For Suspension/Expulsion Only)
                                                 FOR OFFICE USE ONLY


Student Information
Last Name ___________________________________________ First Name __________________________________

Gender  Female  Male                 Date of Birth _____________________            SSN

Parent/Guardian
Last Name_______________________________ First Name _____________________________                 Parent  Guardian  Other
Student Address ____________________________________________ Mailing Address ___________________________________

City State Zip ______________________________________________ City State Zip _____________________________________

Home Phone __________________________ Work Phone ________________________ Cell Phone _________________________




Educational Information

Grade Level _______          District of Residence 44__________           Primary Disability

Residence Status             District of Attendance

                             School of Attendance Code

Disciplinary Action Information

Date of Disciplinary Action ______________________              Type of Disciplinary Action  Suspension          Expulsion

Date of Incident ____________________________________


Authority who made decision for disciplinary action                       Number of Suspensions this year ___________


Number of Days the disciplinary action is effective _________


Primary Reason for the                 Second Reason for the                 Third Reason for the
disciplinary action                    disciplinary action                   disciplinary action

                                       Status of student as a result of
                                       the disciplinary action


Comments______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Form Completed by _______________________________________________________ Date __________________________

SELPA 30D (3/05)                        Distribution     LEA Office          Student File

                                                                                                                               120
                                                CODES FOR SELPA 30D (back)
Code   (1) Grade Level                       Code (6) Authority who made the                 43 Harassed, threatened, or intimidated a
01     First Grade                                decision                                      pupil who is a witness (EC48900(o))
02     Second Grade                          10   School or district personnel
03     Third Grade                           20   Court order                                Code     (7) Reason (continued)
04     Fourth Grade                          30   Hearing Officer - for likely injury by     44 Unlawfully offered, arranged to sell,
05     Fifth Grade                                the student to himself/herself or to           negotiated to sell, or sold the
06     Sixth Grade                                others                                         prescription drug Soma (EC 48900(p))
07     Seventh Grade                         31   Hearing Officer - for any other            50 Engaged in sexual harassment (EC
08     Eighth Grade                               reasons                                        48900.2)
09     Ninth Grade                                                                           51 Attempted to cause, threatened to cause,
10     Tenth Grade                           Code (7) Reason                                     or participated in an act of hate violence
11     Eleventh Grade                        10 Possessing, selling or furnishing a              (EC 48900.3)
12     Twelfth Grade                             firearm (EC 48915(c)(1))                    52 Engaged in harassment, threats, or
13     12+ grade/Transition                  11 Brandishing a knife at another person            intimidation against a pupil or group of
15     Ungraded                                  (EC 48915(c)(2))                                pupils (EC 48900.4)
17     Preschool                             12 Unlawfully selling a controlled              53 Made terrorist threats against school
18     Kindergarten                              substance (EC 48915 (c)(3))                     officials or school property (EC
                                             13 Committing or attempting to commit a             48900.7)
Code (2) District of Residence                   sexual assault or battery (EC
10447 Santa Cruz County Office of                48915(c)(4) or 48900(n))                    Code     (8) Status of student as result of
       Education                             20 Caused serious physical injury to                disciplinary action
69732 Bonny Doon Elem                            another person (EC 48915 (a)(1))            20 Sent home, without instructional support
69757 Happy Valley Elem                      21 Possession of knife or other dangerous       21 Sent home, with instructional support
69765 Live Oak Elem                              object (EC 48915(a)(2))                     30 Continuation class/school
69773 Mountain Elem                          22 Unlawful possession of any controlled        31 Opportunity class/school
69781 Pacific Elem                               substance (EC 48915(a)(3)                   32 Community day school
69807 San Lorenzo Valley Unified             23 Robbery or extortion (EC 48915 (a)(4)        33 Adult education school
69815 Santa Cruz City Elem                       or 48900(e))                                34 Independent study
69823 Santa Cruz City High                   24 Assault or battery upon any school           40 Juvenile court school
69849 Soquel Union Elem                          employee (EC 48915 (a)(5))                  41 County court school
75432 Scotts Valley Unified                  25 Possession of explosive (EC                  43 Placed in another district
Contact SELPA for other codes or check the       48915(c)(5))                                44 Charter school (operated by a
California Public School Directory           30 Caused, attempted to cause or threatened         LEA/district)
                                                 serious physical injury to another person   45 Charter school (operated as a
Code   (3) Primary Disability                    (EC 48900(a)(1))                                LEA/district)
010    Mental Retardation (MR)               31 Willfully used force or violence on          50 Graduated
020    Hard of Hearing (HOH)                     another person (EC 48900(a)(1))             51 Left district or moved
030    Deafness (DEAF)                       32 Possessed, sold or furnished firearm,        52 Dropped out or placement unknown
040    Speech or Language Impairment             knife, explosive or other dangerous         80 Other alternative education setting
       (SLI)                                     object (EC 48900(b))
050    Visual Impairment (VI)                33 Unlawfully possessed, used, sold,
060    Emotional Disturbance (ED)                furnished, or been under the influence of
070    Orthopedic Impairment (OI)                any controlled substance, alcoholic
080    Other Health Impairment (OHI)             beverage, or intoxicant (EC 48900(c))
081    Established Medical Disability        34 Selling or delivering material
       (EMD)(ages 3-5 ONLY)                      represented to be a controlled substance
090    Specific Learning Disability (SLD)        (EC 48900(d))
100    Deaf-Blindness (DB)                   35 Caused or attempted to cause damage to
110    Multiple Disability (MD)                  school or private property
120    Autism (AUT)                          36 Stole or attempted to steal school
130    Traumatic Brain Injury(TBI)               property or private property (EC
                                                 48900(g))
Code   (4) Residence Status                  37 Possessed or used tobacco or nicotine
10     Parent or Legal Guardian                  products (EC 48900(h))
20     Licensed Children’s Institute (LCI)   38 Committed an obscene act or engaged in
30     Foster Family Home (FFH)                  habitual profanity or vulgarity (EC
40     Hospital (except state hospital)          48900(i))
50     Incarcerated Institution              39 Unlawfully possessed, or unlawfully
71     State Hospital                            offered or arranged to sell, drug
72     Developmental center                      paraphernalia (EC 48900(j))
90     Other                                 40 Disruption of school activities or
                                                 willfully defying the valid authority of
Code (5) District of Attendance                  school personnel (EC 48900(k))
See District codes above (2)                 41 Knowingly received stolen school
                                                 property or private property (EC
                                                 48900(l))
                                             42 Possession of an imitation firearm
                                                 (EC48900(m))

                                                                                                                                        121
                           BEHAVIOR SUPPORT PLAN
                                  SELPA 31
When is this form used?

When a students behavior is impeding the student’s learning or that of his/her peers the IEP
team shall meet and develop a behavior support plan for that student.

Changes from previous versions:
SELPA 31     Revised to follow most current guidelines on writing behavior support plans.
             Added as SELPA form, to include in computerized forms.




                                                                                           122
                      Behavior Support Plan Instructions/Guidelines

1.      The behavior impeding learning is (describe what it looks like):
Describe non-judgmentally in observable terms; if you state a category for the behavior, also
specify exactly what the behavior looks like.

Examples of behavior(s) that may interfere with learning: Description should be observable.
          · Poor attendance - high absenteeism; tardy to class, etc.
          · Disrupts other students student learning as shown by…..e.g. tapping neighbors
              on shoulders; grabbing their materials; argumentative verbal interactions
              during collaborative work groups
          · Outbursts/Rage/Explosive reactions as shown by…e.g. when asked to
              transition to new task, student throws materials; crawls under desk and
              screams
          · Leaves the classroom/school without permission
          · Inappropriate sexual behaviors as shown by…e.g. hands in pants, using words
              related to sexual activity

2.      It impedes learning because:
Less skills learned by student or others? Safety/welfare concerns?

     Examples of how behavior may interfere with learning:
           · Unavailable for instruction
           · Reduced skills learning
           · Reduced productivity
           · Disrupts other students’ opportunity to learn
           · Instructional time is lost for disciplinary proceedings
           · Requires full adult attention

3.      The need for a Behavior Support Plan

Early Stage Intervention
Behavior is not yet significantly impacting learning of student or classroom functioning but
could escalate if not addressed.

Moderate
Behavior is beginning to significantly impact classroom functioning or student learning.

Serious or Extreme
       · If the student has an IEP/504 plan AND the behavior is defined as “serious”
           in California Ed Code: “assaultive, self-injurious or is another pervasive
           maladaptive behavior that significantly impacts the student’s mastery of IEP
           goals and objectives” and/or classroom function, AND if previously a BSP
           was determined by the team to be ineffective STOP. The IEP team must hold
           an IEP/504 plan meeting with designated support staff and a BICM (Behavior
           Intervention Case Manager) present. The IEP/504 plan team, when they conclude
           that the previous BSP was “ineffective”, must request a functional analysis
           assessment to be conducted or supervised by the BICM according to CA Ed.
                                                                                 123
               Behavior Support Plan Instructions/Guidelines (Continued)

         Code. (Note: if this is the first BSP to address serious behavior, bear in mind, if
         ineffective, an FAA must be conducted. Notify a BICM that an FAA may
         become necessary in the future if the plan you are currently designing is
         ineffective)
       · If student does NOT have an IEP/504 plan and the behavior is “serious” or
         “extreme” as defined below, an assessment to determine if student has a
         “suspected disability” may or may not be necessary. Consult with special
         education staff before proceeding.

Serious Designation
Student’s behavior may require a functional analysis assessment if this plan is unsuccessful
due to the severity of impact on the student or others.
        · Assaultive - Physical attacks that are serious and are occurring more than
            infrequently (e.g., more than once in a school year)
        · Self-injurious - Physically harming self (e.g., repeatedly hits self on head;
            continuous skin picking resulting in health issues)
        · Other Pervasive Maladaptive - Serious behaviors that interfere with the quality of
            life, and or IEP mastery occurring in multiple environments (e.g., throws clothing
            off in class and on bus; projectile vomiting in response to requests to perform
            tasks; school refusals or school phobia and/or severe anxiety resulting in more
            than 5 unexcused absences)

Extreme Designation
Student poses a safety issue to others or to self.
Examples:
       · Student has made a substantive threat to harm self or others in the past.
           Appropriate services/interventions/referrals have been arranged. The student has
           been determined to be in an appropriate placement, but requires close follow-up
           monitoring now. This plan is a supplementary aid and support to maintain the
           placement.
       · Student physically harms self, leaving evidence of the attack. Note: Specify
           short duration of BSP plan implementation before reconvening team to request
           FAA if ineffective.
       · Student has physically attacked peers or adults more than one and requires very
           close monitoring to prevent reoccurrence.
       · Student is in danger of a change in placement due to negative impact on others. (if
           BSP is unsuccessful)

4.     Frequency or Intensity or duration of behavior
Specify one: frequency, duration, or intensity. This is to convey to the reader the extent to
which this behavior is significant.




                                                                                   124
               Behavior Support Plan Instructions/Guidelines (Continued)

Environmental Factors Defined
Behaviors always occur within an environmental context and conditions within the
environment may contribute, predict or “trigger” problem behaviors. Any of the following
factors may act as possible triggers:
        · Environmental events
        · Classroom Schedule/Curriculum expectations
        · Physical conditions of the environment
        · Student’s physiological and emotional state

5.       What are the predictors for the behavior?
Situations in which the behavior is likely to occur: people, time, place, object, etc. Those
situations you can predict problems will occur, e.g., difficult task, transition time, when not
working in group, with specific people, when alone, after a request, etc. If this is a behavior
that has occurred only once, state nay known connections between environmental conditions
at the time and the student’s choice of this behavior. If this behavior is a threat of harm to
self or others, consider those situations you predict the student may respond with verbal
statements of concern in the future.

6.      What supports the student using the problem behavior?
(What is missing in the environment/curriculum or what is in the environment/curriculum
that needs changing?) This is always two parts: 1) Changing environmental features so
there is no need to use this behavior; 2) teaching a new way to meet the identified function.
KEY: What has NOT YET been done AT SCHOOL that could change his/her need for this
behavior? What has the student not yet received? If the student has threatened harm to self
or others: Has the student not yet developed a mentor relationship with a supportive adult at
school? Not yet received interventions and services to address long term psychosocial
stressors? Relate your statement to the function of the verbal statements made and the plan
you have to address identified difficulties.

7.      What Environmental changes, structure and supports are needed to remove the
student’s need to use this behavior? (Changes in time/materials/interactions to remove
likelihood of behavior) Who will establish? Who will monitor?
KEY CONCEPT: any intervention specified in this section must be logically related to the
analysis just completed on (5) the predictors of behavior and (8) what supports the student
using problem behavior.
KEY WRITING GUIDE: Remember that you will need to add more details to each idea
below so that implementers can be accountable for using these supports. Details of how
implementers will do these changes are site-specific and require extended discussion. Write
enough detail so that everyone remembers the specifics and materials selected to do these
changes.




                                                                                   125
               Behavior Support Plan Instructions/Guidelines (Continued)

Functional Factors Defined
All behavior, whether desirable or undesirable, serves one of two functions for the
individual: 1) Get something desired: e.g., an object; attention from peers or adults; fulfill a
basic human need. 2) Avoid, escape or protest something undesired: e.g. to avoid work that
the student knows he is unable to do, escape an environment where the student feels inferior
or not valued.
THE BSP TEAMS TASK: Identify the function, teach a functionally equivalent, acceptable
behavior and reinforce the student’s switching to this replacement behavior when she/he
needs his/her needs met. A behavior support plan will not be effective unless it addresses
development of a functionally-equivalent behavior. Otherwise, the problem behavior will
continue to occur.

8.      Team believes the behavior occurs because:
(Function of behavior in terms of getting, protesting or avoiding something. What student is
getting (e.g., social status, attention, $, etc.) or protest/escape/avoiding (e.g. difficult work,
past action of peers, interaction style of an adult with this behavior.

9.      What the team believes the student should do instead of problem behavior?
(How should the student escape/protest/avoid or get his/her way in an acceptable manner?)
In the future, how will he/she get needs met that this behavior fulfilled, e.g., something
desired or something protested or escaped when necessary?

10.     What teaching strategies/necessary curriculum/materials are needed (to teach the
replacement behavior, successive teaching reinforcing steps to learn the alternative behavior)
Examples: better communication skills, anger management, picture exchange system for
nonverbal student with cognitive disabilities, self-management systems, following schedules
and routines, learning new social skills, learning how to negotiate, learning structured
choice, learning new scripts, learning notebook organization, etc. Any general or specific
skill deficit you hope to correct to change the behavior.

11.      What are reinforcement procedures to use for establishing, maintaining and
generalizing the new behavior?
Consider a range of non-intrusive ones: A simple praise statement the student enjoys;
privately given specific praise; notes home; contingent access to favorite classroom
activities. What motivates the student and enhances quality of life right now. Who will give,
how frequently? Will reinforcement happen in school and at home, or by outside school or
community personnel?
KEY CONCEPT: A reinforcer is something proven to increase the behavior. Consider:
What does the student seek? What does the student visibly enjoy and change his or her
behavior to gain more of? What does the student say s/he wants to work for?




                                                                                      126
               Behavior Support Plan Instructions/Guidelines (Continued)

Reactive Strategies Defined
The team will need to develop a strategy to use in case the misbehavior occurs again. This
strategy should include how to handle the student when she/he is in crisis, who will interact
with the student at that time, and when should other agencies be involved. The reactive
strategy should also address how to debrief the student as well as provide the staff a
mechanism to evaluate the effectiveness of the plan.

12.     What strategies will be employed if the behavior occurs again? (prompt student to
switch to the replacement behavior, positive discussion with student after behavior ends any
necessary classroom or school consequences. Consider early intervention to debriefing
strategies to consequences.)
What works to calm the student? How can you best prevent escalation? Will structured
choice help? Offering “Time Away” to cool off non-emotionally? What series of behaviors
should adults employ to return the student to rule-following behavior? Who will
therapeutically debrief the student after control is achieved? Will consequences such as
expulsion/suspensions be necessary? Exactly under what conditions?

Behavioral Goals Defined
Behavioral goals are the “bottom line” of the Behavior Support Plan. In this section the BSP
Team clearly defines the anticipated outcome of the plan. Behavior goals may focus on the
following: 1) Reducing the frequency of the problem behavior, 2) Increasing the use of an
alternative behavior, 3) Developing new general skills that remove the student’s need to use
the interfering behavior. Be sure there is at least one goal on what you want the student to do
as a replacement behavior that meets the same need as the problem behavior. As with all
good goals, they should be measurable so the team can track progress and determine
effectiveness.

13.    Behavioral Goals:
The behavior goals(s) are brief statement referencing the IEP or 504 team’s discussion:
What new skills will the student achieve through this plan, not just what will the student not
do anymore. The goals are designed to achieve one or more of the following: reduce the
frequency of the problem behavior; increase the use of the replacement behavior; develop
new general skills that remove the student’s need to use the problem behavior.
Example behavior goals: Specify behavior and criterion level. See Appendix B for matrix
on developing behavioral goals.
       · By 1/07, XXX will demonstrate acceptance of changes in routine by proceeding
           to next activity with no resistance as observed by the teacher or aide on 90% of
           trials recorded over a three week period.
       · By 6/08, XXX will privately ask for assistance when work is too hard on 95% of
           “too hard” assignments as observed by the teacher in a four week period.
       · By 4/08, XXX will reduce self-stimulating behaviors to less than 10% of leisure
           time periods as observed by the teacher in a three month period.




                                                                                   127
               Behavior Support Plan Instructions/Guidelines (Continued)

Communication Provisions Defined
Document what system of communication will be used between the team members to report
the student’s progress. Communications should report new skills and learning rates not just
infractions. The plan should include how often and in what manner the participants will
communicate. Be sensitive to the fact that different agencies will require different timelines
(i.e. although IEP behavioral goals are reported at least quarterly, Departments of Probation,
Social Services, or outside therapists may require more frequent progress reports.) Take into
account any physical handicap of any of the team members (deaf, blind, etc.) and other
situations (no telephone, non-English speaking, illiterate) that may influence the
communication provisions to be used. Remember that some information on student behavior
may be sensitive and confidential in nature. Whenever information is shared with outside
agencies, an informed consent from the parent(s) and a formal Release of Records must be
obtained.

14.    Manner of communication/frequency/participants
What system? Phone calls by whom to whom? Informal notes? Daily report cards? Weekly
logs? Consider family, administrators, IEP team, SST team, counselors, probation officer or
other agencies. Report new skills learning rates, not just infractions. Remember, behavioral
goals and objectives are reported at least quarterly if the student has an IEP.




                                                                                  128
                                          NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                                                  BEHAVIOR SUPPORT PLAN
                                          For Behavior Interfering with Student’s Learning or the Learning of His/Her Peers
                               Note: Numbers correspond with the scoring system on the BSP quality Evaluation Guide

                       The BSP attaches to:        IEP date: ________        504 plan date: ________        Team meeting date: ________

  Student Name ______________________________ Today’s Date _________ Next Review Date                        _________
  1. The behavior impeding learning is (describe what it looks like)         _________________________________________
  2. It impedes learning because            ________________________________________________________________
  3. The need for a Behavior Support Plan: early stage intervention            moderate    serious  extreme
  4. Frequency or intensity or duration of behavior             ___________________________________________________
     reported by __________________________ and/or               observed by          ________________________________

  PREVENTION PART I:                                ENVIRONMENTAL FACTORS AND NECESSARY CHANGES
                  5. What are the predictors for the behavior? (Situations in which the behavior is likely to occur: people, time,
Observation &




                  place, subject, etc.)
  Analysis




                  ____________________________________________________________________________________
                  6. What supports the student using the problem behavior? (What is missing in the environment/curriculum or
                  what is in the environment curriculum that needs changing?)
                  ______________________________________________________________________________________

                                              Remove student’s need to use the problem behavior
   Intervention




                  7. What environmental changes, structure and supports are needed to remove the student’s need to use this behavior?
                       (Changes in time/Space/Materials/Interactions to remove likelihood of behavior.)
                       _____________________________________
                  Who will establish? _________________ Who will monitor? ___________________ Frequency __________

  ALTERNATIVES PART II:                             FUNCTIONAL FACTORS & NEW BEHAVIORS TO TEACH & SUPPORT
                  8. Team believes the behavior occurs because: (Function of behavior in terms of getting, protest, or avoid something)
                  ____________________________________________________________________________________________
Observation &




                     ___________________________________________________________________________________________
  Analysis




                                                            Accept an alternative behavior that meets same need
                  9.  What team believes the student should do INSTEAD of the problem behavior? (How should the student
                      escape/protest/avoid or get his/her need met in an acceptable way?)
                  ______________________________________________________________________________________________
                  ______________________________________________________________________________________________
                  10. What teaching Strategies/Necessary Curriculum/Materials are needed? (To teach the replacement behavior, successive
                      teaching/reinforcing steps to learn the alternative behavior.)                                                            __
   Intervention




                       Who will establish? _________________ Who will monitor? ___________________ Frequency______________

                  11. What are reinforcement procedures to use for establishing, maintaining, and generalizing the new behavior(s)?


                       Selection of reinforcer based on:
                          reinforcer for using replacement behavior        reinforcer for general increase in positive behaviors
                           By Whom? __                                                       Frequency?         __________________


  Diana Browning Wright, Behavior/Discipline Trainings 2004
  SELPA 31 (3/05)



                                                                                                                                          129
EFFECTIVE REACTION PART III:                         REACTIVE STRATEGIES


12. What strategies will be employed if the problem behavior occurs again? (Prompt student to switch to the replacement
    behavior, positive discussion with student after behavior ends any necessary classroom or school consequences)



      Personnel?


OUTCOME PART IV:                                     BEHAVIORAL GOALS
13. Behavioral Goal(s)




      The above behavioral goal(s) are to:  Increase use of replacement behavior and may also include:
       Reduce frequency of problem behavior      Develop new general skills that remove student’s need to use the problem behavior

Observation and Analysis Conclusion:

   Are curriculum accommodations or modifications also necessary? Where described: _________________________________   Yes   No
   Are environmental supports/changes necessary?      …………………………………………………………………………….                                   Yes   No
   Is reinforcement of alternative behavior alone enough (no new teaching is necessary)?      ………………………………             Yes   No
   Are both teaching of new alternative behavior AND reinforcement needed?         …………………………………………….                  Yes   No
   This BSP to be coordinated with other agency’s service plans?     ……………………………………………………………                           Yes   No
   Person responsible for contact between agencies
COMMUNICATION PART V:                                COMMUNICATION PROVISIONS
14. Manner and frequency of communication

      Between?                                                       Frequency?

PARTICIPATION PART VI:                               PARTICIPANTS TO PLAN DEVELOPMENT



     Student                                                                 Parent


     Educator and Title                                                      Educator and Title


     Educator and Title                                                      Educator and Title


     Administrator                                                           Administrator


     Other and Position                                                      Other and Position



Diana Browning Wright, Behavior/Discipline Trainings 2004
SELPA 31 (3/05)




                                                                                                                       130
          SPECIAL EDUCATION BEHAVIOR EMERGENCY REPORT
                          SELPA 32A


Who fills out this form?
When a serious behavior occurs in the classroom, the staff present are required to fill out a
behavior emergency report and follow the guidelines for notification of parent, special
education administrator. At that time a determination will be made by the special education
administrator and IEP team, whether the behavior requires a Positive Behavior Intervention
Plan for that student. The check list must be completed to insure that all appropriate actions
and follow-through have been completed.

Each school site has established an individual who has been trained to write a Positive
Behavior Intervention Plan for those students whose behavior is defined as serious according
to the California Education Code’s definition. Serious behavior as defined in California
Education Code is assaultive, self-injurious, causes serious property damage, or other
pervasive maladaptive behavior. Contact your district to determine who is the designated
BICM (Behavior Intervention Case Manager) for you district.

This is only to be used for students who have an active IEP.

Changes from previous versions:
SELPA 32A Form revised to meet current state recommendations and local training for
             behavior emergency reports.




                                                                                           131
                INSTRUCTIONS FOR USE OF THE SPECIAL EDUCATION
                        BEHAVIOR EMERGENCY REPORT


1.    This report is to be used only for students who have an active IEP.

2.    A Behavioral Emergency is the demonstration of a serious behavior problem: (1)which has not previously
      been observed and for which a Behavioral Intervention Plan has not been developed or (2) for which a
      previously designed behavioral intervention is not effective. CCR T5, §3001(c)

3.    Serious behavior problems are defined as the individual's behaviors which are self-injurious, assaultive or
      causing property damage which could lead to suspension or expulsion pursuant to Education Code Section
      48900(f). CCR T5, §3001 (y)

4.    Emergency Interventions shall not be used as a substitute for the systematic Behavioral Intervention Plan
      that is designed to change, replace, modify, or eliminate a targeted behavior. CCR T5, §3052 (i)(l)

5.    Emergency Interventions may only be used to control unpredictable spontaneous behavior which poses
      clear and present danger of serious physical harm to the individual or others or serious property damage
      which cannot be immediately prevented by a response less restrictive than the temporary application of a
      technique used to contain behavior. CCR T5, §3052 (i)

6.    Whenever a behavioral emergency occurs, only Behavioral Emergency Interventions approved by the
      Special Education Local Planning Area may be used. CCR T5, §3052 (i)(2)

7.    No Emergency Intervention shall be employed for longer than is necessary to contain the behavior. Any
      situation which requires prolonged use of an emergency intervention shall require staff to seek assistance
      of the school site administrator or law enforcement agency as applicable to the situation. CCR T5, §3052
      (i)(3)

8.    Parent or residential care provider shall be noticed within one (1) school day whenever an emergency
      intervention is used. CCR T5, §3052 (i)(5)

9.    The Behavioral Emergency Report shall immediately be completed and maintained in the individual's file.
      CCR T5, §3052 (i)(5)

10.   Any time a Behavioral Emergency Report is written regarding an individual who does not have a
      behavioral intervention plan, the designated responsible administrator shall, within 2 days, schedule a
      functional analysis assessment of that emergency behavior for the purpose of conducting an IEP review
      and schedule a meeting to develop an interim behavioral intervention plan with the parent/care provider.
      CCR T5, §3052 (i)(7)

11.   Any time a Behavioral Emergency Report is written regarding an individual who has a Behavioral
      Intervention Plan, any incident involving a previously unseen behavior problem or where a previously
      designed intervention is not effective should be referred to the IEP team to review and determine if the
      incident constitutes a need to modify the plan. CCR T5, §3052 (i)(8)




                                                                                                  132
                        BEHAVIORAL EMERGENCY REPORTS


Whenever an emergency intervention is used or serious property damage occurs, a
Behavioral Emergency Report shall immediately be completed and maintained in the
individual's file. Anytime a behavioral emergency occurs the parent and/or residential care
provider and administrator shall be notified within one school day. The Behavioral
Emergency Report shall include all of the following:

1. The name and age of the individual;
2. The setting and location of the incident;
3. The name of the staff member or other persons involved;
4. A description of the incident and the emergency intervention used, and whether the
   individual is currently engaged in any systematic behavioral intervention plan;
5. Details of any injuries sustained by the individual or others, including staff, as a result of
   the incident.

Within two days, the responsible administrator will schedule a date for an IEP Team
Meeting. At the meeting the IEP Team will:

1. Review the Behavioral Emergency Report
2. Complete the Determination of Need for a Functional Analysis Assessment:

     a. Determine the need for a functional analysis assessment, and document reasons for
        not proceeding, if a functional analysis assessment will not be conducted.
     b. If a functional analysis is needed, determine the need for an Interim Behavior
        Intervention Plan.

Anytime a Behavioral Emergency Report is written regarding an individual who has a
Behavioral Intervention Plan, the individual should be referred to the IEP team to review and
determine if the incident constitutes a need to modify the plan.




                                                                                    133
                           NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                  BEHAVIOR EMERGENCY REPORT
Name of Student ______________________________________________ DOB _______________________
                    Last                              First
Date of Incident: _____________ Time _________ Location/Setting ________________________________
Person Preparing Report _____________________________ Title __________________________________
Others Involved______________________________________________________________________________
________________________________________________________________________________________
Behavior Addressed in IEP?      Yes      No Name of BICM:             __________________________

CHECK TYPE OF INCIDENT:                                                          CHECK IF:
   Injury to other student                  Injury to self                          Physical containment
   Injury to staff                          Property Damage                         Site Security involvement
   Runaway                                  Throwing Objects                        Law Enforcement involvement

Description of the Incident:_________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Intervention(s) Used and Result: ____________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Details of Injuries Sustained and Treatment Given (if any):               ___________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Parent/Care Provider Notified:_________________________________________________________________
                                  Last Name, First Name                          Date        Time   Method


Principal/Designee Notified:____________________________________________________________________
                                  Last Name, First Name                          Date        Time   Method

Follow-up Needed:__________________________________________________________________________
________________________________________________________________________________________

REVIEWED BY: ______________________________________________                                           ___________
                   Special Education Administrator Signature                                           Date

ACTION TAKEN: ________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

RECEIVED BY: ___________________________________                          ___________
                   SELPA Representative Signature                         Date

SELPA 32A(3/05)                 DISTRIBUTION:             Original-District   Copy 1-SELPA


                                                                                                                    134
                            BEHAVIOR EMERGENCY REPORT CHECKLIST


                                                                          Date & Initials of
                                                                         Person Responsible

1. The parent and/or residential care provider, if appropriate, will
   be notified within one school day when the emergency
   intervention is used.                                               ___/___/___, _______

2. The Behavior Emergency Report (EV-75) will immediately be
   completed and a copy maintained in the student’s file.              ___/___/___, _______

3. The Behavior Emergency Report will immediately be
   forwarded to, and reviewed by, the designated responsible
   administrator.                                                      ___/___/___, _______

4. If the Behavior Emergency Report was written regarding a
   student who does not have a Behavior Intervention Plan, the
   designated responsible administrator will, within two days,
   schedule an IEP team meeting to review the emergency report
   and determine whether a functional assessment and/or interim
   plan is indicated.                                                  ___/___/___, _______

5. If the Behavior Emergency Report was written regarding a
   student who has a Behavior Intervention Plan, any incident
   involving a previously unseen serious behavior problem, or
   where a previously designed intervention is not effective,
   should be referred to the IEP team to review and determine
   if the incident constitutes a need to modify the plan.              ___/___/___, _______

6. Responsible administrator will forward copy of this form to
   the district office.                                                ___/___/___, _______




                                                                                               135
                   POSITIVE BEHAVIOR INTERVENTION
                        REFERRAL INFORMATION
                              SELPA 32B


When is this form used?

When serious behavior occurs in the classroom, and it is determined that a Positive Behavior
Intervention Plan may be necessary, this form can be used to make a referral to the local
Behavior Intervention Case Manager (BICM).


Changes from previous versions:
SELPA 32B Revised to follow most current guidelines and training on behavior support
             and intervention.
             Added as SELPA form, to include in computerized forms.




                                                                                         136
                         NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                 POSITIVE BEHAVIOR INTERVENTION REFERRAL INFORMATION

Student: ______________________ B/D: ___________ Age: _____ Grade: ______ Date:            _____________
School:          _________________ Disability:__________ Program:________________ ID#:   ______________
Referred by: ______________________ Position: _________________ Phone:             _____________________

Define the Problem:

What are the behaviors of concern? For each, describe the ecology, frequency, duration and intensity:
          _____________________________________________________________________________
          _____________________________________________________________________________
                 _____________________________________________________________________________
                 _____________________________________________________________________________
                 _____________________________________________________________________________
                 _____________________________________________________________________________


Interventions attempted and student's response:
           _____________________________________________________________________________
           _____________________________________________________________________________
           _____________________________________________________________________________
           _____________________________________________________________________________
                 _____________________________________________________________________________
                 _____________________________________________________________________________
                 _____________________________________________________________________________
                 _____________________________________________________________________________
                 _____________________________________________________________________________


Describe one behavior incident and include the following information: How is the behavior performed? How
often does it occur per day, week, or month? How long does it last? What is the magnitude of the behavior?
(high, medium, low)
                 ______________________________________________________________________________
                 ______________________________________________________________________________
                 ______________________________________________________________________________
                 ______________________________________________________________________________
                 ______________________________________________________________________________
                 ______________________________________________________________________________
                 ______________________________________________________________________________
                 ______________________________________________________________________________
SELPA32B(3/05)


                                                                                                           137
                  POSITIVE BEHAVIOR INTERVENTION REFERRAL INFORMATION (Continued)

Please complete the following checklist:                                                     (Circle One)

Is this behavior life-threatening?                                                            YES    NO
Does this behavior provide a health risk to the student?                                      YES    NO
Does this behavior interfere with learning?                                                   YES    NO
Is this behavior likely to become serious in the near future if not modified?                 YES    NO
Is this behavior dangerous to others?                                                         YES    NO
Is this behavior getting worse or not improving?                                              YES    NO
Is this behavior of great concern to caregivers?                                              YES    NO
Has this been a problem for some time?                                                        YES    NO
Does this behavior damage materials?                                                          YES    NO
Does this behavior interfere with community acceptance?                                       YES    NO
Would other behaviors improve if this behavior improved?                                      YES    NO

Briefly describe communication with family/caregivers regarding behavior concerns:
                 _______________________________________________________________________________
                 _______________________________________________________________________________
                 _______________________________________________________________________________
                 _______________________________________________________________________________
                 _______________________________________________________________________________
                 _______________________________________________________________________________
                 _______________________________________________________________________________

Please attach the following items to this form:
      • Copy of current IEP
      • Pertinent medical information including medication being taken
      • Current documentation/data of any special interventions implemented
      • Copy of the student's schedule, including LSH, APE, etc.




_______________________________________________                        Date:    ________________________
Person(s) completing form




Page 2 of 2
SELPA32B(3/05)


                                                                                                       138
                INTERIM BEHAVIOR INTERVENTION PLAN
                            SELPA 32C

When is this form used?

When serious behavior occurs in the classroom, and it is determined that a Positive Behavior
Intervention Plan may be necessary, this form can be used in the interim while a complete
Functional Assessment is being completed, and a Positive Behavior Intervention Plan is
developed.


Changes from previous versions:
SELPA 32C No changes.




                                                                                         139
                            NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA

                                                                                                      Date: _____________
                                      INDIVIDUALIZED EDUCATION PLAN
                                       INTERIM BEHAVIOR INTERVENTION PLAN

                  Student                           Birthdate                            Staff Behavior

                  Teacher                             School          6) Once severe problem behaviors have occurred:


Behavior Intervention Case Manager                     Date



It is recommended that these boxes be completed in numerical order.


                    Student Behavior
1) Severe Problem Behaviors:                                          7) Avoiding escalation-creating events:




2) Escalation behaviors:                                              8) Once escalation-creating events have occurred:




3) Escalation-creating events:                                        9) Once escalation behaviors have occurred:




4) De-escalation behaviors:                                           10) Once de-escalation behaviors have begun:




5) Post-incident behaviors:                                           11) Once post-incident behaviors have begun:




Approval for this plan was given:

By: ___________________________________ to _______________________________ on ___________
         Parent/Guardian                                              Staff Member                           Date

SELPA 32A(3/05)            DISTRIBUTION:        Copy 1-LEA Office      Copy 2 - Teacher File   Copy 3 - Parent
                                                                                                                            140
                      FUNCTIONAL ASSESSMENT FORMS
                             SELPA 33 A B & C



About Functional Assessments
A functional assessment examines antecedents to the problem behavior and the consequences
that occur following the behavior. A hypothesis is then formed about what outcome the
student gains by using this problem behavior.
The outcome, from the student's perspective, is in terms of either:
       1. Getting something desired (This behavior is working, or has worked in the
       past, to gain something. In other words, the behavior maintains because it is
       "positively reinforced."),
       or
       2. Protesting, Escaping or Avoiding something undesired (This behavior is
       working, or has worked in the past, to remove, partially remove, or
       communicate displeasure about something undesired by the student. In other
       words, the behavior maintains because it is "negatively reinforced.")

Importance of Functional Assessments
It is imperative that the team designing a behavior plan carefully develop the hypothesis
about the function of behavior. The plan will both teach a replacement behavior that meets
the same function and will specify environmental alterations that remove the need for the
student to use this problem behavior to get his/her needs met. For example, if the hypothesis
of the behavior is "revenge," a plan would teach the child how to get revenge in a better way,
which is not a viable option. However, if the hypothesis of the behavior is "a protest about
the past action of peers," the plan would teach the student a more appropriate protest form
that would meet his/her needs, which is a viable option.

SELPA 33A Functional Assessment Tracking Form

When is this form used?

The functional assessment tracking form is to be used as a tool when a functional assessment
is being done by the team, in order to track who is doing what and when it will be completed.

SELPA 33B Observation Form

This form is to be used when tracking observations for a functional assessment.




                                                                                            141
                          FUNCTIONAL ASSESSMENT FORMS
                              SELPA 33ABC (continued)


     Who fills out this form?
     People who will be using the Functional Assessment Observation form should be trained
     before using the form independently, or discuss with their local BICM (Behavior intervention
     Case Manager) how the form should be properly filled out.

Identification/Dates   Show who is being observed and the dates on which the data are being
                       collected. Note that a single page can be used across multiple days.

Time Intervals         This section is separated into blocks that can be used to designate specific
                       intervals (1 hour, half hour, 15 minutes). List here the periods and
                       setting/activities in which observation is taking place. Depending on each
                       student’s typical pattern of behavior or schedule, you may want to use
                       unequal interval periods within the blocks. If targeted behaviors are very
                       frequent during a particular time period or activity, multiple blocks can be
                       used to record for that period.

Behaviors              List the individual behaviors you have identified for monitoring during the
                       observations. You may also decide to list positive behaviors. The form
                       allows for flexibility in monitoring behaviors. If a particular behavior
                       occurs in both low-intensity and high-intensity forms, you can list each
                       form as a separate behavior to identify differences or similarities in their
                       patterns of occurrence. When several behaviors occur regularly in
                       combinations, you may monitor them all within a single behavior notation
                       (dropping to the floor, kicking, screaming, can all be recorded under
                       tantrum). However, be cautious about grouping behavior together for
                       coding. Once of the more useful pieces of information obtained through
                       the FAO is the individual behaviors that tend to occur together and those
                       that do not.

Predictors             List important events of stimuli identified in your interviews as potential
                       predictors for the occurrence of problem behaviors. The FAO form already
                       lists several potential predictors that have often been found in research.
                       Additional empty slots are provided for you to list potential predictors
                       specific to the student being observed. You might also label a column
                       “Other/Don’t Know” when the person recording data cannot identify the
                       particular set of events or antecedents to the occurrence of the problem
                       behavior.




                                                                                      142
                           FUNCTIONAL ASSESSMENT FORMS
                               SELPA 33ABC (continued)
Perceived Functions     Make your “best guess” regarding what you perceive as the apparent
                        function of behaviors that occur during the incident (why you think he/she
                        did what he/she did). This section has two major areas: obtaining desired
                        things and escaping/avoiding undesired things. The specific things that
                        would be designated on the form would depend on information gathered
                        during the interview process. The form lists several common outcomes
                        that individuals may be attempting to obtain or escape/avoid, along with
                        blank columns to fill in based on interviews. A column for “Don’t Know”
                        is included for situations in which observers are unsure of possible
                        functions of the behavior observed.

Actual Consequences     You record data on the actual consequences that follow problem-behaviors,
                        for example, the student was told “no”, was ignored, was redirected. This
                        information gives you some idea of the consistency with which certain
                        consequences are being provided. It also provides clues to the potential
                        functions of problem behaviors.

Comments                Observers can write brief comments here regarding behaviors that occurred
                        during the corresponding block of time. Observers also use this space to
                        write their initials for a block of time in which no target behaviors were
                        observed. This verifies that observation was occurring and that not
                        problem behaviors were observed. Knowing when and under what
                        circumstances problem behaviors do not occur can be very informative.

Event and Data Record   The row of numbers at the bottom are designed to help the observer keep
                        track of the number of problem behavior events that have occurred and the
                        days across which these events were observed. The numbers are sued to
                        show each event with one or more problem behaviors.

     Computer Information for SELPA 33B
     The form will automatically compute totals at the bottom of the form. Change the number in
     a box each time an occurrence happens in the time period (A behavior that has already
     occurred once, occurs again - change the number from 1 to 2). Also can be used at end of
     tracking period by transferring numbers to computer version from paper version, the form
     will provide totals.

     SELPA 33C

     When is this form used?

     To be used when completing a functional assessment to record antecedents, behaviors and
     consequences.

     Changes from previous versions:
     SELPA 33A B & C            New forms.
                                                                                     143
                   FUNCTIONAL ASSESSMENT TRACKING FORM

Student: _________________________________________ DOB:     ___________________

BICM: _____________________________________ Meeting Date:   ___________________

Description of behavior(s) of concern:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Observation/Assessments

Procedure/instrument                Assigned to              Due Date
 _________________________                 __________              ________
 _________________________                 __________              ________
 _________________________                 __________              ________
 _________________________                 __________              ________


Interviews

Interviewee                                Assigned to             Due Date
 _________________________                 __________              ________
 _________________________                 __________              ________
 _________________________                 __________              ________
 _________________________                 __________              ________


Record Review

Information Requested                      Assigned to             Due Date
 _________________________                 __________              ________
 _________________________                 __________              ________
 _________________________                 __________              ________
 _________________________                 __________              ________




SELPA 33A (3/05)




                                                                              144
                                                                              NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA
                                                                          FUNCTIONAL ASSESSMENT OBSERVATION FORM
Student: ______________________________________________ Birthdate: _____________ Starting Date: ______________ Ending Date: ____________

BICM: _______________________________________________
                                                                                                                                                  Perceived Functions
                    Behaviors                                                                           Predictors                                             Get/Obtain                                                           Escape/Avoid                                    Actual Conseq




                                                                                                                                                                                                                                                                                                    COMMENTS: If nothing
                                                                                                                                                                   Desired Item/Activity




                                                                                                                                                                                                                                                                                                    happened in period –
                                                                                                Alone (no attention)




                                                                                                                                                                                                                                                                 Other/Don’t Know
                                                                                                                                                                                                                                      )
                                    Demand/Request




                                                                                                                                                                                                                   Demand/Request
                                                                                                                                                                                           Self-Stimulation
                                                         Difficult Task




                                                                                                                                                                                                                                                                                                    write initials
                                                                              Transitions




                                                                                                                                                                                                                                      Activity (
                                                                                                                                                  Attention




                                                                                                                                                                                                                                                   Person
Time




Total

            Events: 1       2   3                    4                    5                 6                          7   8   9   10   11   12               13            14                 15             16         17                  18       19    20               21     22    23   24   25
            Date:
SELPA 33B (3/05)

                                                                                                                                                                                                                                                                                                                     145
                                       NORTH SANTA CRUZ COUNTY
                                   SPECIAL EDUCATION LOCAL PLAN AREA
                                      FUNCTIONAL ASSESSMENT
Student:          __________________________________________ Birthdate: ________________
BICM: ____________________________________________ Meeting Date: _____________

            ANTECEDENT                       BEHAVIOR                 CONSEQUENCES
                  (Before)                   (During)                     (After)

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________

      __________________                __________________          __________________
SELPA 33C(3/05)




                                                                                           146
                BEHAVIOR INTERVENTION PLAN FORMS
                         SELPA 34A B C & D



Who fills out these forms?

Each district has established an individual who has been trained to write a behavior
intervention plan for those students whose behavior is impeding his/her learning or the
learning of others. This individual needs to be certified by the SELPA office as a BICM
(Behavior Intervention Case Manager), and have been trained on how to properly fill out
these forms.

Changes from previous versions:
SELPA 34A, B, C, D Forms revised to meet current state guidelines and local training for
                    Positive Behavior Intervention Plans.




                                                                                     147
                                                NORTH SANTA CRUZ COUNTY
                                            SPECIAL EDUCATION LOCAL PLAN AREA
                               COVERSHEET FOR FAA & PBIP DEVELOPMENT - SECTION 1 OF 4

Student: __________________________________ Date of Birth: __________________________________
Current Teacher: ___________________________ Current School: _________________________________
THE POSITIVE BEHAVIORAL INTERVENTION PLAN PROCESS AND CONTENT
        Step One:
If a student with an IEP has behavior that meets the California Education Code’s definition of “serious behavior,” that the
team will expand to include a Behavior Intervention Case Manager’s (BICM) designated by the SELPA as having
sufficient training in positive behavioral interventions.
The BICM assists the team in developing a positive behavioral intervention plan.
Serious behavior as defined in California Education Code is: (check one and define)
 Assaultive _____________________________________________________________________________
      Self-injurious __________________________________________________________________________
      Serious property damage _________________________________________________________________
      Other pervasive maladaptive behavior ______________________________________________________

Step One Results: IEP team date when BICM services were determined to be required
__________________________________________________________________________________________
Behavior Intervention Case Manager appointed: __________________________________________________

       Step Two:
The BICM, at the request of the IEP Team, will conduct or supervise the conducting of a Functional Analysis assessment
(FAA) and report back to the team. An FAA consists of documenting methods of data collection (Section 2) combined
with observation and analysis summaries shown on sections of the BSP (Section 3).
Step Two Results: FAA was conducted: date(s) ___________________________________________________
      Step Three:
The IEP team, including the BICM, reconvenes to determine if a positive behavioral intervention plan is required. The
BICM presents the FAA Data Collection during FAA (Section 2) and the Observation & Analysis section of the Core
Behavior Plan (portions of Section 3). If a plan is to be developed, the team then develops the interventions portion of
PBIP Core Plan (Section 3) and the data collection that shall occur during the plans implementation (Section 4).
Step Three Results: IEP team met to consider developing a positive behavioral intervention plan date(s)
_________________________________________________________________________________________
If PBIP was developed, next IEP team review PBIP date ___________________________________________
For additional review dates if plan is ineffective, see PBIP Data Collection Form (Section 4).
Summary: At the conclusion of these steps, a decision about developing a behavior plan will have been made. If the IEP team
concludes the student does NOT have a serious behavior, but does have “behavior interfering with learning,” a Behavior Support
Plan (BSP) may be suggested by any member of the IEP team to specify positive behavioral interventions and supports. This BSP
does not require the addition of the BICM nor the use of the supplementary forms. If the IEP team determines the behavior is
serious and requires a Positive Behavioral Intervention Plan, four sections are required for a complete PBIP.
Diana Browning Wright, Behavior/Discipline Trainings, 2004
SELPA 34A (3/05)                                                                                             PBIP1 Coversheet.doc




                                                                                                                                148
                                        NORTH SANTA CRUZ COUNTY
                                   SPECIAL EDUCATION LOCAL PLAN AREA
         Data Collection During Function Analysis for “Serious Behavior,” CA Ed. Code- Section 2 of 4
                                 FUNCTIONAL ANALYSIS ASSESSMENT REPORT
                                                 Positive Behavioral Intervention Plan Development
This report has been prepared for the IEP team to comply with Title 5, CCR, 3001, 3052. This student’s behavior requires functional analysis assessment for
consideration of a positive behavioral intervention plan. The FAA report consists of: a) Coversheet-Section 1, b) this Data Collection during Function Analysis for
“Serious Behavior,”-Section 2 and c) all data analysis summary portions contained in the main body of the behavior plan-Section 3. If the IEP team develops a PBIP,
all four sections are required. For additional guidance, see: California Education Code (http://www.leginfo.ca.gov/calaw.html) and Positive Intervention for Serious
Behavior Problems, CDE Publications (916) 445-1260.

Student: __________________________________ Date of Birth: __________________________________
IEP Team Documentation: All four conditions have been met prior to assessment
     Student has an IEP
     IEP team has determined instructional/behavioral approaches in IEP are ineffective
     Behavior is “serious” by Ca. Ed. Code definition
          Self-injurious               Assaultive              Serious property damage                         Other pervasive, maladaptive
     Parent has signed assessment plan for this functional analysis assessment.
Date: _________________________________
Behavior Intervention Case Manager Assigned by IEP Team
(This analysis may only be conducted by or supervised by a BICM that has been specifically authorized to perform this function by
the SELPA.)
BICM completing this report:             ___________________________________________________
Documentation: All three required data collection methods were conducted or supervised by the BICM
· Interview(s) with:     __________________________________
                         __________________________________
                         __________________________________
· Direct observation(s) to determine relationship of behavior to antecedents and consequences conducted on Date(s)
   ______________________________________________________________________________
     Location(s) ___________________________________________________________________________
· Review of data (check all that apply):
          Previous assessments
          Discipline records
          Classroom behavioral data
          Reports from other settings: ____________________________________________________________
Additional Baseline Data Analysis (all areas below are required)
     Method of systematically gathering data on antecedents/consequences (BICM must specify):
                      Using Functional Observation Form (see attached) ___________________________________________
                      Using other data collection form (see attached) _____________________________________________
                      Other (describe) _____________________________________________________________________
                      Frequency, Intensity, duration of targeted behavior was determined across all required components:
                      Activities (specify): _______________________________________________________________
                      Settings (specify): ________________________________________________________________
                      People present (specify): ___________________________________________________________
                      Times of day (specify): ____________________________________________________________
                      Summary:
                       Frequency: _______________               Intensity: _______________             Duration: _______________
Diana Browning Wright, Behavior/Discipline Trainings, 2004                                                                          PBIP2 FAA Data Colleciton.doc
           SELPA 34B (3/05)



                                                                                                                                                   149
                                       NORTH SANTA CRUZ COUNTY
                                  SPECIAL EDUCATION LOCAL PLAN AREA
        Data Collection During Function Analysis for “Serious Behavior,” CA Ed. Code- Section 2 of 4
                                                FUNCTIONAL ANALYSIS ASSESSMENT REPORT
         Rate of occurrence of targeted (problem) behavior: ____________________________________________________
          Associated antecedents and consequences: ______________________________________________________________
          _________________________________________________________________________________________________
             Rate of occurrence of alternative behavior:
          ___________________________________________________________
          Associated antecedents and consequences: ______________________________________________________________
          _________________________________________________________________________________________________
             All settings in which problem behavior occurs:
          ___________________________________________________________
          __________________________________________________________________________________________________
Additional Requirement: Analysis of history of behavior and effectiveness of previous interventions (gathered through review
record, verbal reports):
         INEFFECTIVE previous interventions include: _____________________________________________
         EFFECTIVE previous interventions include: _______________________________________________
Additional Requirement: Review of records for health and medical factors which may influence behavior
(Consider medication effects, sleep difficulties, health, diet, behavioral correlates of specific disabilities, etc.) Findings to consider:
________________________________________________________________________
Conclusion: Positive Behavioral Intervention Plan Necessity (Both criteria must be met)
                   Student exhibits a serious behavior problem
                      This behavior problem significantly interferes with the implementation of the goals and objectives of the
          student’s IEP.
Conclusion: BICM recommendations for IEP team consideration
Choose one finding:
    Develop a positive behavioral intervention plan based on the Functional Analysis Assessment (The complete positive
        behavior intervention plan includes 4 sections: 1) coversheet that establishes the need for PBIP; 2) this form which
        documents data collection procedures and BICM and subsequent IEP team recommendations; 3) the core behavior plan
        developed by the IEP team; 4) additional requirements during implementation of plan. A PBIP must include all four
        sections.)
         No PBIP required, Develop BSP
         No plan required
          Rationale for recommendation: __________________________________________________________________________
          ____________________________________________________________________________________________________




Diana Browning Wright, Behavior/Discipline Trainings, 2004                                                       PBIP2 FAA Data Colleciton.doc
          SELPA 34B (3/05)


                                                                                                                              150
                           Note: Numbers correspond with the scoring system on the BSP Quality Evaluation Guide
                                                          NORTH SANTA CRUZ COUNTY
                                                    SPECIAL EDUCATION LOCAL PLAN AREA
                                                  Not For Display - For Teacher/Staff Use Only
                                               Positive Behavior Intervention Plan- Section 3 of 4
                                    For Behavior Defined as “Serious” in California Ed Code; Requires all four sections

Student Name: __________________________ Today’s Date: _________________Next Review Date:_____________________

1.                The behavior impeding learning is (describe what it looks like) _____________________________________________________
2.                It impedes learning because__________________________________________________________________________________
3.                History of PBIPs             First PBIP         Revision of first PBIP       Number of previous PBIPs ______________
4.                Frequency or intensity or duration of behavior ____________________
                 Reported by _______________________________________ and/or  observed by ____________________________________

PREVENTION PART 1:              ENVIRONMENTAL FACTORS AND NECESSARY CHANGES
    What are the predictors for the behavior? (Situations in which the behavior is likely to occur: people, time, place, subject,
    etc.)
Observation &




    5.___________________________________________________________________________________________
  Analysis




                    ____________________________________________________________________________________________
                    What supports the student using the problem behavior? (What is missing in the environment/curriculum or what is in the
                    environment curriculum that needs changing?) 6.
                    ________________________________________________________

                                                      Remove student’s need to use the problem behavior
                    What environmental changes, structure and supports are needed to remove the student’s need to use this behavior?
Intervention




                    (Changes in Time/Space/Materials/Interactions to remove likelihood of behavior) 7.
                    ____________________________________
                    ____________________________________________________________________________________________
                    ____________________________________________________________________________________________
                    Who will establish _________________ Who will monitor? __________________ Frequency __________________


ALTERNATIVES PART II:           FUNCTIONAL FACTORS AND NEW BEHAVIORS TO TEACH AND SUPPORT
    Team believes the behavior occurs because: (Function of behavior in terms of getting, protest, or avoiding something)
   Observation &




    8. ___________________________________________________________________________________________
     Analysis




                                         Accept a replacement behavior that meets same need
    What team believes the student should do INSTEAD of the problem behavior? (How should the student
    escape/protest/avoid or get his/her need met in an acceptable way?) 9. _________________________________________
                    _____________________________________________________________________________________________
                    _____________________________________________________________________________________________
                    What teaching Strategies/Necessary Curriculum/Materials are needed? (List successive teaching steps for student to learn
                    replacement behaviors) 10. ________________________________________________________________________
                    ____________________________________________________________________________________________
                    ____________________________________________________________________________________________
   Intervention




                    Who will establish _________________ Who will monitor? __________________ Frequency __________________

                    What are reinforcement procedures to use for establishing, maintaining, and generalizing the replacement behavior(s)?
                    11. _________________________________________________________________________________________
                    ____________________________________________________________________________________________
                    Selection of reinforcer based on: ____________________________________________________________________
                     reinforcer for using replacement behavior  reinforcer for general increase in positive behaviors
                    By Whom? ______________________________________ Frequency? __________________________________

Diana Browning Wright, Behavior/Discipline Trainings, 2004                                                                  PBIP3 Core Plan.doc
SELPA 34C (3/05)
                                   Distribution: Copy 1 - LEA Office   Copy 2 - Teacher/Specialist   Copy 3 - Parent           151
                  Note: Numbers correspond with the scoring system on the BSP Quality Evaluation Guide
                                                           NORTH SANTA CRUZ COUNTY
                                                        SPECIAL EDUCATION LOCAL PLAN AREA
     EFFECTIVE REACTION PART III:                                           REACTIVE STRATEGIES

     What Strategies will be employed if the problem behavior occurs again? (1. Prompt student to switch to the replacement
     behavior, 2. Describe how staff should handle the problem behavior if it occurs again, 3. Positive discussion with student after
     behavior ends, 4. Any necessary further classroom or school consequences) 12. __________________________________
     _____________________________________________________________________________________________
     _____________________________________________________________________________________________
     Personnel? ____________________________________________________________________________________

     OUTCOME PART IV:                           BEHAVIORAL GOALS
     Behavioral Goal(s) 13. __________________________________________________________________________
     _____________________________________________________________________________________________
     _____________________________________________________________________________________________
     The above behavioral goal(s) are to:  Increase use of replacement behavior and may also include:
      Reduce frequency of problem behavior  Develop new general skills that remove student’s need to use the problem behavior


     Observation and analysis conclusion:
     Are curriculum accommodations or modifications also necessary? Where described: _____________________ yes                                                   no
     Are environmental supports/changes necessary? ...................................................................................................... yes    no
     Is reinforcement of replacement behavior alone enough (no new teaching is necessary)? ....................................... yes                           no
     Are both teaching of new replacement behavior AND reinforcement needed? ........................................................ yes                        no
     This PBIP to be coordinated with other agency’s service plans? ............................................................................. yes            no
     Person responsible for contact between agencies _________________________________

     COMMUNICATION PART V:                               COMMUNICATION PROVISIONS
     Manner and content of communication 14. ____________________________________________________________
     ______________________________________________________________________________________________
     Between? _____________________________ Frequency? _____________________________________________

            PARTICIPATION PART VI:                                                      PARTICIPANTS IN PLAN DEVELOPMENT



       Student                                                                              Parent


       BICM                                                                                 Educator and Title


       Educator and Title                                                                   Educator and Title


       Administrator                                                                        Administrator


       Other and Position                                                                   Other and Position



Diana Browning Wright, Behavior/Discipline Trainings, 2004                                                                                           PBIP3 Core Plan.doc
          SELPA 34C (3/05)
                             Distribution: Copy 1 - LEA Office           Copy 2 - Teacher/Specialist         Copy 3 - Parent
                                                                                                                                                          152
                                                NORTH SANTA CRUZ COUNTY
                                            SPECIAL EDUCATION LOCAL PLAN AREA
                   Data Collection during PBIP for “Serious Behavior”, CA Ed. Code -Section 4 of 4
                                POSITIVE BEHAVIOR INTERVENTION PLAN ADDITIONAL
                                 REQUIREMENTS DURING IMPLEMENTATION OF PLAN
For a complete PBIP document for “serious behavior,” include coversheet (Section 1), data collection during functional
assessment(Section 2), the core behavior plan(Section 3), and this form (Section 4)


Additional Requirement: Specified data collection during behavior intervention plan implementation
(All components must be specified)
 Schedules for recording the frequency of the use of the interventions
                  How often: ___________________________________________________________
                  By Whom: ___________________________________________________________
                  Method of recording: ___________________________________________________
 Schedules for recording frequency of targeted (problem) behavior
                  How often: ___________________________________________________________
                  By Whom: ___________________________________________________________
                  Method of recording: ___________________________________________________
 Schedules for recording frequency of replacement behaviors
                  How often: ___________________________________________________________
                  By Whom: ___________________________________________________________
                  Method of recording: ___________________________________________________
 Criteria for discontinuing the use of the interventions:
                  If ineffective, discontinuation criteria and next steps:
      If ____________________________________________ (condition)
      Then _________________________________________ (next steps).
                  If alternative interventions required, discontinuation criteria and next steps:
      If ____________________________________________ (condition)
      Then _________________________________________ (next steps).

Additional Requirements: Evaluation of program effectiveness-personnel, frequency, method, data to
evaluate
Designated Frequency of scheduled intervals to evaluate the behavior plan determined by IEP team:
       Daily: ____________________________________________________________________________
       Weekly: __________________________________________________________________________
       Monthly: _________________________________________________________________________
       Report card periods: ________________________________________________________________
       Other: ___________________________________________________________________________




Diana Browning Wright, Behavior/Discipline Trainings, 2004                                                   PBIP4 PBIP Data Colleciton.doc
SELPA 34D (3/05)
                        Distribution: Copy 1 - LEA Office    Copy 2 - Teacher/Specialist   Copy 3 - Parent


                                                                                                                          153
                                                NORTH SANTA CRUZ COUNTY
                                            SPECIAL EDUCATION LOCAL PLAN AREA
                   Data Collection during PBIP for “Serious Behavior”, CA Ed. Code -Section 4 of 4
                                POSITIVE BEHAVIOR INTERVENTION PLAN ADDITIONAL
                                 REQUIREMENTS DURING IMPLEMENTATION OF PLAN

Program Effectiveness Conducted between/by: (teacher, BICM, parent(s), other(s):
      (Specify) _________________________________________________________________________

Designated Method of conducting program effectiveness review:
       Meetings at (location/times): __________________________________________________________
       Telephone conferences (times): ________________________________________________________
       Email (time sent): ___________________________________________________________________
       Other: ____________________________________________________________________________

Data to Evaluate: measures of frequency, duration and intensity of targeted behavior to be evaluated by comparison with
baseline _________________________________________________________________________________

Modifications without IEP Team meeting

Minor modifications may be made by BICM or qualified designee if parent is notified of the need and reviews evaluation
data prior to changes
 Parent notified of right to question any modification through IEP procedures
 Anticipated changes include increasing and decreasing (Check all that apply)
                Frequency of reinforcement
                Prompting of alternative behavior
                Frequency of teaching of new behavior
                Environmental structure

Other settings receiving copies of this plan

           Notification only. Setting(s): _____________________________________________________________
           Implement across setting(s): ______________________________________________________________
            Personnel responsible for implementing in other sites include: ________________________________
            ___________________________________________________________________________________




Diana Browning Wright, Behavior/Discipline Trainings, 2004                                                   PBIP4 PBIP Data Colleciton.doc
SELPA 34D (3/05)

                        Distribution: Copy 1 - LEA Office    Copy 2 - Teacher/Specialist   Copy 3 - Parent
                                                                                                                          154
                       NOTICE OF CONFIDENTIAL FILE
                                 SELPA 35


Who fills out this form?

The case manager fills this form out to put in the student's cumulative file to alert teachers
that the child has been referred for special education services. The form should be completed
even if the child did not qualify but has been assessed.

Changes from previous versions:
SELPA 35        No changes.




                                                                                           155
                                 NORTH SANTA CRUZ COUNTY
                             SPECIAL EDUCATION LOCAL PLAN AREA


                           NOTICE OF CONFIDENTIAL FILE



Name: __________________________________________           Birthdate _____________________________

School: _________________________________________          LEA _________________________________




CONFIDENTIAL INFORMATION CONCERNING THIS PUPIL IS AVAILABLE FROM :

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________


A COPY OF THIS INFORMATION WILL BE RELEASED TO YOU UPON REQUEST, ACCORDING TO EXISTING STATE
AND FEDERAL LAWS GOVERNING PRIVACY AND DISCLOSURE OF PUPIL RECORDS.




                                                      DISTRICT/COUNTY OFFICE OF EDUCATION


                               ADDRESS




                               TELEPHONE




                                (To be placed in the Cumulative Folder)
SELPA 35 (3/05)


                                                                                                 156
                   MONITORING FOR STUDENTS PLACED
                    OUTSIDE DISTRICT-OF-RESIDENCE
                               SELPA 36


Who fills out this form?

The district of residence will maintain files for special education students placed out of
district. These central files will be generated by the beginning of the second semester of the
school year and will be updated continuously.

This form is usually maintained by the district administration.

When an IEP is scheduled for any student who is placed outside the district of residence, the
case coordinator for the service provider (agency or district) will notify: 1) the administrator
from the district of residence, 2) the site administrator for the campus on which the student’s
class or program is located, 3) the student’s parents, 4) any other pertinent staff or individuals
as needed. The case coordinator is responsible for ensuring that notice is provided in a timely
manner.

Changes from previous versions:
SELPA 36     No changes.




                                                                                               157
                                                    NORTH SANTA CRUZ COUNTY SELPA
                                                    Monitoring for Out-Of-District Placements

                                                 District of Residence:


         Student        Case          Service              IEP            Attend         Follow-Up          Dates of     Comments or
                   Coordinator/Site   Provider            Notice          (Y) or       Communications      Visitations   Observations
                                                                           (N)        (Parent or Service
                                                                                          Provider)




Reviewed by:

Administrator                                                                 Date:
SELPA 36 (3/05)

                                                                                                                                        158
                     PRIVATE SCHOOL SERVICE PLAN or
                      INDIVIDUAL SERVICE PLAN (ISP)
                                SELPA 37


When a student qualifies for special education services, and the parents state their intention
to place their child in a private school or continue their enrollment in a private school an IEP
should be held to determine the services offered based on assessment results. The parent
may then decline the IEP and the special education services offered. Pursuant to 20 USC
1412(a)(10), (IDEA 97) and the North Santa Cruz County Special Education Local Plan, the
district may provide speech services for the student enrolled in private school, although these
services may not be the equivalent amount offered in the IEP. By law, the amount of funding
for speech services offered for private school students may not exceed the proportionate
share of federal special education funds. This proportionate share is calculated annually by
the SELPA office.

When is this form to be used?

This form should be used when the parent states that they intend to decline the services
offered in the IEP. If speech services are to be provided the goals and objectives to be
addressed, service, personnel responsible, frequency/duration and location should be
specified. Often these services are provided for a limited number of sessions, if so this
should also be noted on the agreement. If no services are to be provided the appropriate box
should be checked.

Be sure to include the date of the IEP held offering services in the public school setting.

See Private Schools policy and procedures for further information.

Changes from previous versions:
SELPA 37 New SELPA form.




                                                                                              159
       NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA (SELPA)
                          INDIVIDUAL SERVICE PLAN (ISP)

Student’s Name: _______________________________________ DOB: ______________________ Grade: __________________

Parents: _____________________________________________              Address: _____________________________________________

Home Phone: ________________________________________                Work Phone: __________________________________________

Local Educational Agency (District where private school is located/LEA):____________________________________________

District of Residence/DOR: __________________________________                     Home School:______________________________

Private School: _______________________________________             Private School Phone:___________________________________

Check one of the following two boxes:

The above-named student is eligible for special education services. The student’s parents have expressed an interest in enrolling
 the student in public school. Accordingly, the DOR has offered a free appropriate public education, (FAPE), available to the
 student by developing an individualized educational program, (IEP), on _________________(insert date here) By their signatures
 below, the student’s parents acknowledge and agree that:
 (1) the DOR has offered a FAPE available to the student; and
 (2) the IEP developed on ________________ (insert date here) constitutes a FAPE.

OR

 above-named student is eligible for special education services. The student’s parents have clearly stated to the DOR that they
 The
 will enroll or will continue to enroll the student in a private school without the consent of, referral by, or payment by the DOR.
 The student's parents have made it clear that they are not interested in the development of an IEP. Accordingly, the DOR has
 offered to develop an IEP if and when the student’s parents express an interest in enrolling the student in public school. By their
 signatures below, the student’s parents decline the development of an IEP at this time and state that they are enrolling or are
 continuing to enroll the student at the following private school:


Pursuant to the Individuals with Disabilities Education Improvement Act, (IDEIA), the LEA must provide services to parentally
placed private school children with disabilities consistent with their number and location in the State using a proportionate share of
federal funding. This obligation is set forth in the IDEIA-2004, 20 USC 1412(a)(10)(A), and the NORTH SANTA CRUZ COUNTY
SELPA’s Policy for Serving Children with Disabilities Enrolled by Their Parents in Private School. This policy has been presented
and explained to the student’s parents. By their signatures below, the student’s parents acknowledge receipt of a copy of this policy.


After appropriate consultation with representatives of private school children with disabilities, the LEA has decided to provide
_________________________________ services to parentally placed private school children with disabilities.

The LEA hereby offers the following service(s) to the student:


               Special Education Service(s)                         Frequency, Duration &               Anticipated Start Date
                                                                     Location of Service(s)            & End Date of Service(s)




                                                                                                                                    160
       NORTH SANTA CRUZ COUNTY SPECIAL EDUCATION LOCAL PLAN AREA (SELPA)
                                SERVICES PLAN

Check one of the following boxes:

It is not appropriate to develop goal(s) and objectives for the above-specified service(s).
It is appropriate to develop goal(s) and objectives for the above-specified service(s). See attached North Santa Cruz County
  SELPA Goals & Objectives Form (SELPA 12).
Refer to IEP developed on ______ for goals and objectives in the area of service(s) on this Individual Services Plan.

Personnel Responsible for Implementation of Service(s):

___________________________________________________________________________________________________________

Parents check one of the following two boxes if student is enrolling or continuing to enroll in private school:

 I consent to the above-specified service(s) to my child.
 I decline the above-specified service(s) to my child at this time.

Parent: _______________________________________________________ Date: __________________

Parent: _______________________________________________________ Date: __________________

Administrator/Designee: ____________________________ Title: ______________________ Date: ______________________

Service Provider: __________________________________            Title: ______________________ Date: ______________________

Other: ___________________________________________ Title: ______________________ Date: ______________________

Other: ___________________________________________ Title: ______________________ Date: ______________________

Other: ___________________________________________ Title: ______________________ Date: ______________________

Other: ___________________________________________ Title: ______________________ Date: ______________________

Private School Representative: _______________________ Title: ______________________ Date: ______________________

Private School Representative: _______________________ Title: ______________________ Date: ______________________


Note to Parents/Guardians: You will receive an annual letter requesting information regarding whether you:
    1) intend to continue the student’s unilateral placement at the private school for the following school year and continue to
        receive an ISP;
    2) intend to continue the student’s unilateral placement at the private school for the following school year and discontinue
        receiving an ISP;
    3) are requesting that the DOR convene an IEP team meeting because you are interested in enrolling the student in public
        school; and/or
    4) consent to a triennial evaluation (if applicable).


Annual Review Date: ___________________________________                  Triennial Review Date: _______________________________




                                                                                                                       161
                                                                                      APPENDIX A

Sample Goals for Individual Transition Plan (SELPA 13G)

These are sample goals and should be modified to meet the needs of each individual student.
The code in parentheses is to be used on computerized to insert goals into appropriate field.
In addition, new goals can be added in any of these areas to keep in your bank of goals on
your computer (SELPA 13G Transition Goals), or typed directly into SELPA 13G as
needed.

INSTRUCTION
     · Complete a career interest inventory (IN1)
     · Investigate 3 careers of their choice (IN2)
     · Be able to identify at least 3 strengths and weaknesses (IN3)
     · Fill out a job application with no errors (IN4)
     · Demonstrate proper job interview behavior by role playing (IN5)
     · Demonstrate work maturity skills by receiving an average score or better on the
       job readiness evaluation form (IN6)
     · Complete a resume with no errors (IN7)
     · Complete a portfolio and receive a passing score (IN8)
     · Be able to make change up to $1 (IN9)
     · Fulfill the graduation requirement to receive a high school diploma (IN10)
     · Other

COMMUNITY EXPERIENCES
    · Complete a job shadowing experience in their interest area and receive a
      satisfactory behavior (CO1)
    · Volunteer at a public or private non-profit site and receive a satisfactory
      evaluation (CO2)
    · Interview someone who has a job in their area of career interest (CO3)
    · Participate in a field trip to Cabrillo College (CO4)
    · Obtain a driver’s license (CO5)
    · Explore options for post-secondary education or training program requirements
      (CO6)
    · Acquire the necessary skills to use public transportation (CO7)
    · Other

EMPLOYMENT
    · Obtain a part-time job in his/her interest area (EM1)
    · Enroll in a post-secondary vocational training program (EM2)
    · Enroll in the work Experience Education (WEE) Class and earn 5 credits (EM3)
    · Receive a satisfactory evaluation at their job (EM4)
    · Enroll in job corps (EM5)
    · Enlist in the armed forces (EM6)
    · Enroll in the CCC (EM7)
    · Acquire knowledge on how to maintain a job or change you life (EM8)
    · Identify 3 resources that will assist in finding a job (EM9)
    · Participate in supported employment (EM10)
    · Other


                                                                                           162
POST ADULT LIVING
     · Enroll in Cabrillo College and major in ____________ (PA1)
     · Learn how to ask for assistance and clarification when needed (PA2)
     · Learn and practice appropriate interpersonal communication and social skills for
       different settings (PA3)
     · Identify necessary accommodations at postsecondary and work environments
       (PA4)
     · Acquire an identification card and the ability to communicate personal
       information (PA5)
     · Acquire independent living skills (budgeting, shopping, cooking, housekeeping,
       etc.) (PA6)
     · Identify interests and options for the future (PA7)
     · Other




                                                                             163
                                                                                                                             APPENDIX B
                       GOAL WRITING FOR GENERAL POSITIVE BEHAVIOR INCREASE
                         OR PROBLEM BEHAVIOR REDUCTION OR ELIMINATION
                                                 Diana Browning Wright

                                                                                                                            6. Measured By Whom
                                                                             4. Under What          5. At What Level of
      1. By When                 2. Who          3. Will Do X                                                                   & Measurement
                                                                               Conditions               Proficiency
                                                                                                                              Method & Materials

By when will criteria        The student   Specify what the              Under what               At what level of          Who will measure
be reached (This is the                    student will do that is       conditions (What         proficiency,              mastery?
final date to determine if                 observable and                variables are present?   (Examples: number of      Specify specifically who
the goal/objective has                     measurable. To be             Examples: in what        times, % of               will observe and record.
been met)                                  observable &                  location, during what    observations, number
                                           measurable, the               activity, with what      of specific behaviors     How will s/he measure
                                                                         staff)                   in a behavior chain
                                           description should                                     shown)                    the goal attainment?
                                           clearly state what the                                                           Specify an objective
                                           behavior looks like with                               What level of             measurement system
                                           no ambiguity as to what                                competence are you        that would not likely
                                           is to be measured.                                     striving for?             vary between
                                           Describe as though you                                                           observers.
                                           were taking a picture of
                                           the behavior.                                                                    What materials are
                                                                                                                            necessary?
                                           (Do not describe how                                                             Specify all materials
                                           the student feels or                                                             necessary
                                           thinks; this is not readily
                                           measurable.)

By 6/03                           Billy    Will request a break     During reading and            With 100% accuracy        As observed and
                                           using the technique      math seatwork                 on 3 out 5 days in a 2-   rated by math and
                                           taught in speech                                       week period               reading teachers
                                           therapy and practiced in                                                         Using the “4 Key
                                           class                                                                            Behaviors Record
                                                                                                                            Sheet” developed by
                                                                                                                            the Speech Pathologist




                                                                                                                                          164
                                                                                                       APPENDIX B


                               GOAL ACTIVITY - INCREASE POSITIVE, DECREASE NEGATIVE

                                                                                                  6. Measured By
                                                           4. Under What   5. At What Level of        Whom &
                      1. By When   2. Who   3. Will Do X
                                                             Conditions        Proficiency         Measurement
                                                                                                 Method & Materials
     Complete
       Work
+
– Stop
           hitting
           schedule
+ Follow
           swearing
– Stop




                                                                                                          165
                                                                                                                                                                      APPENDIX B


                                       GOAL WRITING FOR REPLACEMENT BEHAVIOR

                                                                                                                                                                        9. Measured
                    2. Instead 3. To achieve                                                         6. To achieve                                  8. At What          By Whom &
                                                                             5. Will Do Z                           7. Under What
 1. By When             of X   what (purpose                  4. Who                                 what (purpose                                   Level of           Measurement
                                                                              behavior                                Conditions
                    behavior or function Y)                                                          or function Y)                                 Proficiency          Method &
                                                                                                                                                                          Materials

By when will        Describe the     State the function     The student   Specify what the           Repeat the             Under what            At what level of     Who will
criteria be         problem          of the behavior in                   student will do that       function of the        conditions (What      proficiency,         measure
reached (This is    behavior in      terms of:                            is observable and          behavior again.        variables are         (Examples:           mastery?
the final date to   measurable       PULL IN                              measurable. To be                                 present?              number of times,     Specify specifically
determine if the    and              1) what student                      observable &                                      Examples: in what     % of observations,   who will observe
                                                                                                                            location, during      number of specific
goal/ objective     observable       gets by the                          measurable, the                                                                              and record.
                                                                                                                            what activity, with   behaviors in a
has been met)       terms,           problem behavior                     description should                                what staff)           behavior chain
                                     (e.g., attention,                    clearly state what                                                      shown)               How will s/he
                                     social status,                       the behavior looks                                                                           measure the goal
                                     money, etc.) or                      like with no                                                            What level of        attainment?
                                     PUSH AWAY                            ambiguity as to what                                                    competence are       Specify an objective
                                     2) what student is                   is to be measured.                                                      you striving for?    measurement
                                     protesting (e.g.,                    Describe as though                                                                           system that would
                                     past actions of a                    you were taking a                                                                            not likely vary
                                     peer, difficult                      picture of the                                                                               between observers.
                                     work, etc.) or                       behavior.
                                     escaping (difficult                                                                                                               What materials are
                                     work, undesired                      (Do not describe                                                                             necessary?
                                     interactions, etc.)                  how the student                                                                              Specify all
                                                                          feels or thinks; this is                                                                     materials
                                                                          not readily                                                                                  necessary
                                                                          measurable.)

By 6/03             Instead of       To escape a            Billy         Will request a break       To escape a            During reading        With 100%            As observed and
                    running out of   lengthy or difficult                 using the technique        lengthy or difficult   and math              accuracy on 3 out    rated by math and
                    the room         assignment                           taught in speech           assignment             seatwork              5 days in a 2-       reading teachers
                                                                          therapy and                                                             week period          Using the “4 Key
                                                                          practiced in class                                                                           Behaviors Record
                                                                                                                                                                       Sheet” developed
                                                                                                                                                                       by the Speech
                                                                                                                                                                       Pathologist




                                                                                                                                                                       166
                                                                                                       APPENDIX B


                   WRITING BEHAVIORAL GOALS REPLACEMENT BEHAVIORS

                                                                                                                9. Measured By
                         3. To achieve                           6. To achieve                  8. At What          Whom &
1. By   2. Instead of X                           5. Will Do Z                  7. Under What
                        what (purpose    4. Who                  what (purpose                   Level of        Measurement
When        behavior                               behavior                       Conditions
                        or function Y)                           or function Y)                 Proficiency        Method &
                                                                                                                   Materials


                              To                                       To
                           escape                                   escape
                        difficult work                           difficult work



                        To get social                            To get social
                           attention                                attention
                         from peers                               from peers



                        To initiate a                             To initiate a
                           social                                    social
                        interaction                               interaction



                         To protest                               To protest
                        past actions                             past actions
                         of a peer                                of a peer




                                                                                                          167
                                                                                            APPENDIX B

                            CALIFORNIA DEPARTMENT OF EDUCATION

     CALIFORNIA SPECIAL EDUCATION MANAGEMENT INFORMATION SYSTEM
                               (CASEMIS)


                                 DEFINITION OF SELECTED CODES

 SCHOOL TYPES CODES
CODE Selected School Types
10    Public day school: Day schools operated or administered by a public agency to provide instruction
          in general education. This includes schools listed in the California Public Schools Directory
          published by the California Department of Education. This category does not include residential
          school, or other types of schools listed under this field.

11        Public residential school: Schools operated or administered by a public agency to provide
          instruction in general education, where students reside at the same location. This category does not
          include any other types of schools listed under this field.

15        Special education center or facility: A separate school operated by an LEA for students with
          disabilities. (USC 1412(a) (5) (A)

19        Other public school or facility: Any other setting where an LEA may provide special education
          services, including community facilities, off-campus classrooms, etc. (EC 56361(g): (USC
          1401(29)(A)

20        Continuation school: Continuation schools primarily serve students 16 through 18 years old by
          providing individualized instruction and flexible scheduling to meet their individual graduation
          needs, while allowing them to comply with the compulsory part-time attendance laws. It, also, is
          mandated to provide guidance, placement, and follow-up services to students. (EC 48400-48454,
          CAC Title 5 Sec 11000-11010).

22        Alternative work education center: An alternative program to teach basic academic skills, with
          emphasis on the improvement of student motivation for achievement in order to obtain employment
          or to return to regular high school. Center will operate on a clinical, client-centered basis; and
          provide classroom instruction, on-the-job training, career counseling and placement services. (EC
          52900). The center may also provide appropriate educational services to school dropouts through
          recruitment or referral. These services may include: instruction in basic academic skills, motivation,
          employment or re-entry orientation. The goal is transition to public school, diploma equivalency
          program, vocational program, military or other service program, or post-secondary education. In
          addition a program administered by the Student Aid Commission to provide an opportunity for
          college students to earn money while gaining experience in educationally beneficial or career-related
          employment. (EC 69951).

24        Independent study: An alternative to classroom instruction consistent with a school district's course
          of study. This is an instructional strategy (not a categorical program) that responds to an individual's
          needs and styles of learning. (EC 46300(3), 51745-51749.5, CCR Title 5 Sec 11700-11703).




                                                                                               168
                                                                                        APPENDIX B

30   Juvenile court school: An alternative program that serves the educational needs of students who are
     under the protection or authority of the Juvenile Court or local school district. The County Office of
     Education provides for the education programs in juvenile ranches, camps and schools, as well as
     juvenile halls. Students are placed in juvenile court schools when referred by the juvenile court or a
     deputy probation officer. These programs seek to transition the students back to an appropriate
     educational, training, and/or employment setting upon release or after the court terminates
     jurisdiction. (W&IC Sec 202 et seq., EC Sec 1980 et seq.).

31   Community school: An alternative program that serves the educational needs of students. The
     County Office of Education provides for the education programs in community schools. Students are
     placed in community schools when expelled from school, or referred by a School Attendance Review
     Board (SARB). These programs seek to transition the students back to an appropriate educational,
     training, and/or employment setting. This also includes district operated community schools.

32   Correctional institution or incarcerated facility: It is an institution run by the California
     Department of Corrections, California Youth Authority or any other public agency where an
     individual is detained for infraction with the law and where educational classes provide instruction in
     civic, vocational, literacy, health, homemaking, technical, and general education.

40   Home instruction: An alternative to classroom instruction. An IEP team decision states and certifies
     that the student's diagnosed condition prevents him/her from attending a school setting. Instruction
     may be delivered individually, in small groups or by teleclass. (Title V, Section 3051.4).

45   Hospital facility: The educational needs of students who are placed or who reside in a public
     hospital, state licensed children's hospital, psychiatric hospital, proprietary hospital, or a health
     facility for medical purposes are the responsibility of and provided by the district or county office in
     which the hospital or facility is located. (EC 56167-56168).

50   Community college: This includes specialized services and educational programs offered by the
     post-secondary community colleges for students over high school age in academics, reading and
     mathematics labs, and vocational, career, and community development skills.

51   Adult education program: This includes programs, such as, parenting, basic education, high school
     diploma, English as a second language, citizenship, short-term vocational programs, older adults,
     adults with disabilities, home economics education, and health and safety in order to provide or
     improve the skills of adults.

55   Charter school (operated BY a LEA/district): Charter schools that are deemed to be a public
     school within the District/SELPA participate in either the same manner as other schools within the
     District or as described in a memorandum of understanding.

56   Charter school (operated AS an LEA/district): Charter schools that are deemed a local education
     agency for the purpose of special education must participate in an approved special education local
     plan (SELPA) as an LEA. (EC 56195.1 sections (a), (b), or (c) (20 USC 1400 et seq., EC 47641 (a),
     AB 1115, Chapter 78, Statutes of 1999).




                                                                                           169
                                                                                          APPENDIX B

61      Head Start program: A part-day comprehensive child development program for children 3-5 years
        of age from low-income families. Services are provided in this program through four components:
        education, social services, parent involvement and health. Head Start is mandated to make a
        minimum of 10% of its enrollment opportunities available for preschool age children with
        disabilities.

62      Child development or child care facility: Any residence or building, or part thereof, in which child
        care and development services are provided. The facility must be licensed by the State Department of
        Social Services.

63      State preschool program: Part-day comprehensive developmental programs for children 3-5 years
        of age from low-income families. The programs include educational development, health services,
        parent education and participation, program evaluation, and staff development.

64      Private preschool: A preschool program operated by a private agency, that provides basic
        supervision, age appropriate activities, nutrition, and parent education for preschool children ages 3-
        5.

65      Extended day care: An extended school day program that provides educational activities that are
        appropriate to the ages of the students and that capture the students' interests and needs. (EC 58752).

70      Nonpublic day school: A nonpublic, nonsectarian day school (under the field SCH_TYPE) that
        enrolls individuals with exceptional needs pursuant to an individualized education program, employs
        at least one special educator, and is certified by the department (EC 56034).

71/72   Nonpublic residential school: A nonpublic, nonsectarian school that enrolls individuals with
        exceptional needs pursuant to an individualized education program, employs at least one special
        educator, and is certified by the department. This school provides an educational program at the same
        location where the student resides (often a licensed children's institution). (EC 56034).

75      Private day school (not certified by special education): A school, sectarian or nonsectarian, which
        is not administered by a public agency and does not provide special education services. Students
        attending this school do not reside at the school premises. Services are provided through an ISP, in
        accordance with district policy for serving students in private schools.

76      Private residential school (not certified by special education): A school, sectarian or nonsectarian,
        which is not administered by a public agency, and does not provide special education and services.
        The student resides at this school, although private residential school may provide a combination of
        residential and day programs. The status of a student (whether day or residential) will depend on
        where the student resides. Services are provided through an ISP, in accordance with district policy for
        serving students in private schools.

80      Parochial School: A school that is affiliated with or run by a religious organization.




                                                                                             170
                                                                                           APPENDIX B


 RESIDENTIAL STATUS
CODE Residential Status
10      Parent or legal guardian: This includes natural or adoptive parents and surrogate parents or other
        persons or relatives who have legal custody of children.

20      Licensed children's institution (LCI): Licensed Children's Institution is a residential facility which
        is licensed by the state, or other public agency which has delegated authority by contract with the
        state to license, to provide nonmedical care to children, including, but not limited to, individuals with
        exceptional needs. "Licensed Children's Institution", in addition, includes a group home as defined by
        subdivision (a) of Section 80001 of Title 22 of the California Code of Regulations. See Education
        Code Section 56155.5(a) for exclusions.

30      Foster Family Home (FFH): Foster Family Home is a family residence which is licensed by the
        state, or other public agency which has delegated authority by contract with the state to license), to
        provide 24-hour nonmedical care and supervision for not more than six foster children, including, but
        not limited to, individuals with exceptional needs. "Foster family home", in addition, includes a small
        family home as defined in paragraph (6) of subdivision (a) of Section 1502 of the Health and Safety
        Code (E.C. 56155.5(b)).

40      Hospital: A public hospital, state-licensed children's hospital, psychiatric hospital, proprietary
        hospital, or a health facility for medical purposes. (E.C. 56167(a)). It does not include state hospital
        (see below).

50      Residential facility: A Residential facility is a nonsectarian school where a student with exceptional
        needs resides on a 24-hour basis and receives special education and related services at the school.
        This includes both public and private facilities. Does not include LCIs.

60      Incarcerated institution: Individuals with exceptional needs who have been adjudicated by the
        juvenile court, for placement in a juvenile hall or juvenile home, day center, ranch, or camp, or for
        individuals with exceptional needs placed in a county community school (E.C. 56150); includes
        placement in California Youth Authority and other public correctional institutions.

71      State hospital: A state hospital is a residential facility operated by the California Department of
        Developmental Services (DDS).

72      Developmental center: A Developmental Center is a residential facility operated by the California
        Department of Developmental Services (DDS).



 DISABILITY
CODE Disability Categories
110     Mental retardation (MR): Mental Retardation means significantly subaverage general intellectual
        functioning, existing concurrently with deficits in adaptive behavior, and manifested during the
        developmental period, that adversely affects a child's educational performance. (34 CFR Sec.
        300.7(c)(6)).




                                                                                               171
                                                                                         APPENDIX B

120   Hard of hearing (HH): Hard of Hearing means hearing, impairment, whether permanent or
      fluctuating, that adversely affects a child's educational performance, but that is not included under the
      definition of "deaf in this section.

      Hearing impairment (HI): Hearing Impairment is a federal category of disability, which includes
      both hard of hearing and deaf individuals as defined above.

130   Deafness (DEAF): Deafness means a hearing impairment that is so severe that the child is impaired
      in processing linguistic information through learning, with or without amplification, which adversely
      affects educational performance. (34 CFR Sec. 300.7(c)(3))

140   Speech or language impairment (SLI): Speech or Language Impairment means a communication
      disorder such as stuttering, impaired articulation, language impairment, or a voice impairment, that
      adversely affects a child's educational performance. (34 CFR Sec. 300.7(c)(11))

150   Visual impairment (VI): Visually Impaired, including blindness means an impairment in vision
      that, even with correction, adversely affects a child's educational performance. The term includes
      both partially seeing and blind children. (34 CFR Sec. 300.7(c)(13)).

160   Emotional disturbance (ED): Emotional Disturbance means a condition exhibiting one or more of
      the following characteristics, over a long period of time and to a marked degree, that adversely
      affects educational performance:

      A. An inability to learn which cannot be explained by intellectual, sensory, or health factors;
      B. An inability to build or maintain satisfactory interpersonal relationships with peers and teachers;
      C. Inappropriate types of behavior or feeling under normal circumstances;
      D. A general pervasive mood of unhappiness or depression; or
      E. A tendency to develop physical symptoms or fears associated with personal or school problems.

      The term (ED) includes schizophrenia. The term does not apply to children who are socially
      maladjusted, unless it is determined that they have an emotional disturbance. (34 CF Sec.
      300.7(c)(4)).

170   Orthopedic impairment (OI): Orthopedic Impairment means a severe orthopedic impairment that
      adversely affects a child's educational performance. The term includes impairments caused by
      congenital anomaly (e.g., clubfoot, absence of some member, etc.), impairments caused by disease
      (e.g., poliomyelitis, bone tuberculosis, etc.), and impairments from other causes (e.g., cerebral palsy,
      amputations, and fractures or burns which cause contractures). (34 CFR Sec. 300.7(b)(6 Sec.
      300.7(c)(8))

180   Other health impairment (OHI): Other Health Impairment means having limited strength, vitality
      or alertness, due to chronic or acute health problems such as a heart condition, tuberculosis,
      rheumatic fever, nephritis, asthma, sickle cell anemia, hemophilia, epilepsy, lead poisoning,
      leukemia, or diabetes, which adversely affects a child's educational performance. (34 CFR Part 300.7
      (c) (9)).




                                                                                            172
                                                                                       APPENDIX B

181   Established medical disability (EMD): A disabling medical condition or congenital syndrome that
      the individualized education program (IEP) team determines has a high predictability of requiring
      special education and services. (CA Ed Code, Section 56441.11(d)) [Note: This eligibility category is
      only applicable for children ages 3-5]

190   Specific learning disability (SLD): Specific Learning Disability means a disorder in one or more of
      the basic psychological processes involved in understanding or using language, spoken or written,
      that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or to do
      mathematical calculations, including such conditions as perceptual disabilities, brain injury, minimal
      brain dysfunction, dyslexia, and developmental aphasia. The term does not include learning problems
      that are primarily the result of visual, hearing, or motor handicaps, of mental retardation, of
      emotional disturbance or of environmental, cultural, or economic disadvantage. (34 CFR Sec.
      300.7(c)(10)).

200   Deaf-blindness (DB): Deaf-Blindness means concomitant hearing and visual impairments, the
      combination of which causes such severe communication and other developmental and educational
      needs that they cannot be accommodated in special education programs solely for children with
      deafness or children with blindness. (34 CFR Sec. 300.7(c)(2)).

210   Multiple disabilities (MD): Multiple Disabilities means concomitant impairments (such as mental
      retardation-blindness, mental retardation-orthopedic impairment, etc.,) the combination of which
      causes such severe educational needs that they cannot be accommodated in special education
      programs solely for one of the impairments. The term does not include deaf-blind children. (34 CFR
      Sec. 300.7(c)(7)).

220   Autism (AUT): Autism means a developmental disability significantly affecting verbal and non-
      verbal communication and social interaction, generally evident before age three, which adversely
      affects educational performance. Other characteristics often associated with autism include,
      engagement in repetitive activities and stereotyped movements, resistance to environmental change
      or change in daily routines, and unusual responses to sensory experiences. The term does not does
      not apply if a child’s educational performance is adversely affected primarily because the child has
      an emotional disturbance. A child who manifests characteristics of "autism" after age three, that child
      could be diagnosed as having "autism" if the criteria in the above paragraph are satisfied. (34 CFR
      Sec. 300.7(c)(1)).

230   Traumatic brain injury (TBI): Traumatic Brain Injury means an acquired injury to the brain caused
      by an external physical force, resulting in total or partial functional disability or psychosocial
      impairment, which adversely affects educational performance. The term applies to both open or
      closed head injuries resulting in impairments in one or more areas, such as cognition; language;
      memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual and
      motor abilities; psychosocial behavior; physical functions; information processing; and speech. The
      term does not include brain injuries that are congenital or degenerative, nor brain injuries induced by
      birth trauma. (34 CFR Sec. 300.7(c)(12))




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                                                                                         APPENDIX B


 FEDERAL PRESCHOOL SETTING CODES
CODE Preschool Setting Categories
400   Regular early childhood program or kindergarten: A program setting that includes at least 50
      percent nondisabled children. Early childhood programs include, but are not limited to:
      • Head Start;
      • kindergarten
      • reverse mainstream classrooms;
      • private preschools;
      • preschool classes offered to an eligible pre-kindergarten population by the public school system;
      and
      • group childcare.

440   Separate class: In this setting the student attends a special education program in a class with less
      than 50% nondisabled children.

450   Separate school: This is a placement setting where children receive all of their special education
      program in public or private day schools designed specifically for children with disabilities.

460   Residential facility: This is where children receive all of their special education and related services
      in publicly or privately operated residential schools or residential medical facilities on an inpatient
      basis.

470   Home: This is the setting when children receive all of their special education and related services in
      the principal residence of the child's family or caregivers.

475   Service provider location: This is the setting when children receive all of their special education and
      related services from a service provider, and who did not attend an early childhood program or
      special education program provided in a separate class, separate school, or residential facility. For
      example, speech instruction provided in:
      • private clinician’s office;
      • clinician’s offices located in school buildings,
      • hospital facilities on an outpatient basis, and
      • libraries and other public locations.


 FEDERAL SCHOOL SETTING (AGES 6-22)
400   Regular classroom/public day school: A program setting that includes at least 50 percent
      nondisabled children

450   Separate school: This is a setting where children receive all of their special education and related
      services in educational programs in public or private day schools specifically for children with
      disabilities.

460   Residential facility: Public and private residential facilities where students reside during the school
      week and receive special education and related services for greater than 50 percent of the school day.
      Do NOT include children who receive special education programs at the facility but do not live there.




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                                                                                           APPENDIX B

470     Homebound/Hospital: This setting is where students receive special education programs and related
        services in homebound/hospital environment
        Do NOT include children with disabilities whose parents have opted to home-school them and who
        receive special education at the public expense.

480     Correctional facility: This setting includes students who received special education programs in
        correctional facilities. These data are intended to be a count of all children receiving special
        education in:
        • short-term detention facilities (community-based or residential), or
        • correctional facilities

490     Parentally placed in private school: This setting is where students have been enrolled by their
        parents or guardians in regular parochial or other private schools and whose basic education is paid
        through private resources and who receive special education and related services at public expense
        from a local education agency or intermediate educational unit under a service plan. Include children
        whose parents chose to home-school them, but who receive special education and related services the
        public expense. Do NOT include children who placed in private schools by the LEA


 TRANSITION GOALS
200     Training: Systematic instruction, workplace learning and experience to gain skill and effectiveness
        in a specific discipline or subject area to improve performance and promote competence on the job.
        (Reference: Education Code Section 56462(b)1

300     Education: A general diffusion and acquisition of knowledge and intelligence including the
        promotion of intellectual, scientific, moral and agricultural improvement gained through instruction.
        (Reference: California Constitution Article 9 section 1

400     Employment: Employment means service, including service in interstate commerce, performed by
        an employee for wages or under any contract of hire, written or oral, express or implied.
        Reference: (California Unemployment Insurance Code Section 601

500     Independent living skills: Abilities, proficiency, facility, or dexterity that is acquired or developed
        through training and experience that enables persons with disabilities to become self-sufficient and
        enjoy a living arrangement in the community that maximizes the individual’s life choices and self
        determination without the direct control or supervision of another person.
        California Welfare and Institutions Code Sections 5670-5676


 SERVICES
CODE Special Education Service Categories
210     Family training, counseling, and home visits(ages 0-2 only): This service includes: services
        provided by social workers, psychologists, or other qualified personnel to assist the family in
        understanding the special needs of the child and enhancing the child’s development.
        Note: Services provided by specialists (such as medical services, nursing services, occupational
        therapy, and physical therapy) for a specific function should be coded under the appropriate service
        category, even if the services were delivered in the home.




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                                                                                        APPENDIX B

220   Medical services (for evaluation only) (ages 0-2 only): Services provided by a licensed physician
      to determine a child’s developmental status and need for early intervention services.

230   Nutrition services (ages 0-2 only): These services include conducting assessments in: nutritional
      history and dietary intake; anthropometric, biochemical, and clinical variables; feeding skills and
      feeding problems; and food habits and food preferences.

240   Service coordination (ages 0-2 only):

250   Special instruction (ages 0-2 only): Special instruction includes: the design of learning
      environments and activities that promote the child’s acquisition of skills in a variety of
      developmental areas, including cognitive processes and social interaction; curriculum planning,
      including the planned interaction of personnel, materials, and time and space, that leads to achieving
      the outcomes in the child’s IFSP, providing families with information, skills, and support related to
      enhancing the skill development of the child; and working with the child to enhance the child’s
      development.

260   Special education aide in regular development class, childcare center or family childcare home
      (ages 0-2 only):

270   Respite care services (ages 0-2 only): Through the IFSP process, short-term care given in-home or
      out-of-home, which temporarily relieves families of the ongoing responsibility for specialized care
      for child with a disability (Note: only for infants and toddlers from birth through 2, but under
      3.)

330   Specialized academic instruction: Adapting, as appropriate to the needs of the child with a
      disability the content, methodology, or delivery of instruction to ensure access of the child to the
      general curriculum, so that he or she can meet the educational standards within the jurisdiction of the
      public agency that apply to all children. (34 CFR 300.26(b)(3))

340   Intensive individual instruction: IEP Team determination that student requires additional support
      for all or part of the day to meet his or her IEP goals.

350   Individual and small group instruction: Instruction delivered one-to-one or in a small group as
      specified in an IEP enabling the individual(s) to participate effectively in the total school program (30
      EC 56441.2, 5 CCR 305.1)

410   Language and speech: Language and speech services provide remedial intervention for eligible
      individuals with difficulty understanding or using spoken language. The difficulty may result from
      problems with articulation (excluding abnormal swallowing patterns, if that is the sole assessed
      disability); abnormal voice quality, pitch, or loudness; fluency; hearing loss; or the acquisition,
      comprehension, expression of spoken language. Language deficits or speech patterns resulting from
      unfamiliarity with the English language and from environmental, economic or cultural factors are not
      included.
      Services include; specialized instruction and services; monitoring, reviewing, and consultation. They
      may be direct or indirect including the use of a speech consultant.




                                                                                            176
                                                                                        APPENDIX B

420   Adapted physical education: Direct physical education services provided by an adapted physical
      education specialist to pupils who have needs that cannot be adequately satisfied in other physical
      education programs as indicated by assessment and evaluation of motor skills performance and other
      areas of need. It may include individually designed developmental activities, games, sports and
      rhythms, for strength development and fitness, suited to the capabilities, limitations, and interests of
      individual students with disabilities who may not safely, successfully or meaningfully engage in
      unrestricted participation in the vigorous activities of the general or modified physical education
      program. (CCR Title 5 Sec. 3051.5).

430   Health and nursing – specialized physical health care services: Specialized physical health care
      services means those health services prescribed by the child’s licensed physician and surgeon,
      requiring medically related training of the individual who performs the services and which are
      necessary during the school day to enable the child to attend school (CCR Section 3051.12(b)(1)(A)).
      Specialized physical health care services include but are not limited to suctioning, oxygen
      administration, catheterization, nebulizer treatments, insulin administration and glucose testing (CEC
      49423.5 (d))

435   Health and nursing – other services: This includes services that are provided to individuals with
      exceptional needs by a qualified individual pursuant to an IEP when a student has health problems
      which require nursing intervention beyond basic school health services. Services include managing
      the health problem, consulting with staff, group and individual counseling, making appropriate
      referrals and maintaining communication with agencies and health care providers. These services do
      not include any physician-supervised or specialized health care service.
      IEP-required health and nursing services are expected to supplement the regular health services
      program. 34 CFR 300.306; CCR Title 5 Sec 3051.12).

440   Assistive technology services: Any specialized training or technical support for the incorporation of
      assistive devices, adapted computer technology or specialized media with the educational programs
      to improve access for students. The term includes a functional analysis of the student's needs for
      assistive technology; selecting, designing, fitting, customizing, or repairing appropriate devices;
      coordinating services with assistive technology devices; training or technical assistance for students
      with a disability, the student's family, individuals providing education or rehabilitation services, and
      employers. (34 CFR Part 300.6).

450   Occupational therapy: Occupational Therapy (OT) includes services to improve student's
      educational performance, postural stability, self-help abilities, sensory processing and organization,
      environmental adaptation and use of assistive devices, motor planning and coordination, visual
      perception and integration, social and play abilities, and fine motor abilities.
      Both direct and indirect services may be provided within the classroom, other educational settings or
      the home; in a group or on an individual basis; and may include therapeutic techniques to develop
      abilities; adaptations to the student's environment or curriculum; and consultation and collaboration
      with other staff and parents. Services are provided, pursuant to an IEP, by a qualified occupational
      therapist registered with the American Occupational Therapy Certification Board. (CCR Title 5 Sec.
      3051.6, E.C. Part 30 Sec. 56363).




                                                                                            177
                                                                                        APPENDIX B

460   Physical therapy: These services are provided, pursuant to an IEP, by a registered physical therapist,
      or physical therapist assistant, when assessment shows a discrepancy between gross motor
      performance and other educational skills. Physical therapy includes, but is not limited to, motor
      control and coordination, posture and balance, self-help, functional mobility, accessibility and use of
      assistive devices. Services may be provided within the classroom, other educational settings or in the
      home; and may occur in groups or individually. These services may include adaptations to the
      student's environment and curriculum, selected therapeutic techniques and activities, and consultation
      and collaborative interventions with staff and parents. (B&PC Ch. 5.7, CCR Title 5 Sec. 3051.6, EC
      Part 30 Sec. 56363, GC-Interagency Agreements Ch. 26.5 Sec. 7575(a)(2)).

510   Individual counseling: One-to-one counseling, provided by a qualified individual pursuant to an
      IEP. Counseling may focus on aspects, such as educational, career, personal; or be with parents or
      staff members on learning problems or guidance programs for students. Individual counseling is
      expected to supplement the regular guidance and counseling program. (34 CFR Sec. 300.24(b)(2),
      (CCR Title 5 Sec. 3051.9).

515   Counseling and guidance: Counseling in a group setting, provided by a qualified individual
      pursuant to an IEP. Group counseling is typically social skills development, but may focus on
      aspects, such as educational, career, personal; or be with parents or staff members on learning
      problems or guidance programs for students. IEP-required group counseling is expected to
      supplement the regular guidance and counseling program. (34 CFR Sec. 300.24.(b)(2)); CCR Title 5
      Sec. 3051.9) Guidance services include interpersonal, intrapersonal or family interventions,
      performed in an individual or group setting by a qualified individual pursuant to an IEP. Specific
      programs include social skills development, self-esteem building, parent training, and assistance to
      special education students supervised by staff credentialed to serve special education students. These
      services are expected to supplement the regular guidance and counseling program. (34 CFR 300.306;
      CCR Title 5 Sec 3051.9).

520   Parent counseling: Individual or group counseling provided by a qualified individual pursuant to an
      IEP to assist the parent(s) of special education students in better understanding and meeting their
      child's needs; may include parenting skills or other pertinent issues. IEP-required parent counseling is
      expected to supplement the regular guidance and counseling program. (34 CFR Sec. 300.24(b)(7);
      CCR Title 5 Sec 3051.11).

525   Social work services: Social Work services, provided pursuant to an IEP by a qualified individual,
      includes, but are not limited to, preparing a social or developmental history of a child with a
      disability; group and individual counseling with the child and family; working with those problems in
      a child's living situation (home, school, and community) that affect the child's adjustment in school;
      and mobilizing school and community resources to enable the child to learn as effectively as possible
      in his or her educational program. Social work services are expected to supplement the regular
      guidance and counseling program. (34 CFR Sec. 300.24(b)(13); CCR Title 5 Sec 3051.13).




                                                                                           178
                                                                                         APPENDIX B

530   Psychological services: These services, provided by a credentialed or licensed psychologist pursuant
      to an IEP, include interpreting assessment results to parents and staff in implementing the IEP;
      obtaining and interpreting information about child behavior and conditions related to learning;
      planning programs of individual and group counseling and guidance services for children and
      parents.
      These services may include consulting with other staff in planning school programs to meet the
      special needs of children as indicated in the IEP. (CFR Part 300 Sec. 300.24).
      IEP-required psychological services are expected to supplement the regular guidance and counseling
      program. (34 CFR Sec. 300.24); CCR Title 5 Sec 3051.10).

535   Behavior intervention services: A systematic implementation of procedures designed to promote
      lasting, positive changes in the student's behavior resulting in greater access to a variety of
      community settings, social contacts, public events, and placement in the least restrictive environment.
      (Title 5 Section 3001(d)).

540   Day treatment services: Structured education, training and support services to address the student’s
      mental health needs (Health & Safety Code, Div.2, Chap.3, Article 1, 1502(a)(3))

545   Residential treatment services: A 24-hour out-of-home placement that provides intensive
      therapeutic services to support the educational program (Welfare and Institutions Code, Part 2,
      Chapter 2.5, Art. 1, Section 5671))

610   Specialized services for low incidence disabilities: Low incidence services are defined as those
      provided to the student population of orthopedically impaired (OI), visually impaired (VI), deaf, hard
      of hearing (HH), or deaf-blind (DB). Typically, services are provided in education settings by an
      itinerant teacher or the itinerant teacher/specialist. Consultation is provided to the teacher, staff and
      parents as needed. These services must be clearly written in the student's IEP, including frequency
      and duration of the services to the student. (CCR Title 5 Sec. 3051.16 & 3051.18).

710   Specialized deaf and hard of hearing services: These services include speech therapy, speech
      reading, auditory training and/or instruction in the student's mode of communication. Rehabilitative
      and educational services; adapting curricula, methods, and the learning environment; and special
      consultation to students, parents, teachers, and other school personnel may also be included. (Title 5
      Sections 3051.16 and 3051.18).

715   Interpreter services: Sign language interpretation of spoken language to individuals, whose
      communication is normally sign language, by a qualified sign language interpreter.
      This includes conveying information through the sign system of the student or consumer and tutoring
      students regarding class content through the sign system of the student. (CCR Title 5, Sec. 3051.16)

720   Audiological services: These services include measurements of acuity, monitoring amplification,
      and Frequency Modulation system use. Consultation services with teachers, parents or speech
      pathologists must be identified in the IEP as to reason, frequency and duration of contact; infrequent
      contact is considered assistance and would not be included. (CCR Title 5 Sec. 3051.2)




                                                                                            179
                                                                                          APPENDIX B

725   Specialized vision services: This is a broad category of services provided to students with visual
      impairments. It includes assessment of functional vision; curriculum modifications necessary to meet
      the student's educational needs -- including Braille, large type, aural media; instruction in areas of
      need; concept development and academic skills; communication skills (including alternative modes
      of reading and writing); social, emotional, career, vocational, and independent living skills.
      It may include coordination of other personnel providing services to the students (such as
      transcribers, readers, counselors, orientation & mobility specialists, career/vocational staff, and
      others) and collaboration with the student's classroom teacher. (CAC Title 5 Sec. 3030(d), EC
      56364.1).

730   Orientation and mobility: Students with identified visual impairments are trained in body
      awareness and to understand how to move. Students are trained to develop skills to enable them to
      travel safely and independently around the school and in the community. It may include consultation
      services to parents regarding their children requiring such services according to an IEP.

735   Braille transcription: Any transcription services to convert materials from print to Braille. It may
      include textbooks, tests, worksheets, or anything necessary for instruction. The transcriber should be
      qualified in English Braille as well as Nemeth Code (mathematics) and be certified by appropriate
      agency.

740   Specialized orthopedic services: Specially designed instruction related to the unique needs of
      students with orthopedic disabilities, including specialized materials and equipment (CAC Title 5,
      Sec. 3030(e) & 3051.16)

750   Note taking services: Any specialized assistance given to the student for the purpose of taking notes
      when the student is unable to do so independently. This may include, but is not limited to, copies of
      notes taken by another student, transcription of tape-recorded information from a class, or aide
      designated to take notes. This does not include instruction in the process of learning how to take
      notes.

755   Transcription services:

760   Recreation services, includes therapeutic recreation: therapeutic recreation and specialized
      instructional programs designed to assist pupils to become as independent as possible in leisure
      activities, and when possible and appropriate, facilitate the pupil's integration into general recreation
      programs; (CAC Title 5, Sec. 3051.15; 20 USC 1401(26(A)(1)) (34 CFR 300.24)

820   College awareness:

830   Vocational assessment, counseling, guidance, and career assessment: Organized educational
      programs that are directly related to the preparation of individuals for paid or unpaid employment and
      may include provision for work experience, job coaching, development and/or placement, and
      situational assessment. This includes career counseling to assist student in assessing his/her aptitudes,
      abilities, and interests in order to make realistic career decisions. (Title 5 Section 3051.14).

840   Career awareness: Transition services include a provision for in paragraph (1)(c)(vi), self-advocacy,
      career planning, and career guidance. This comment also emphasized the need for coordination
      between this provision and the Perkins Act to ensure that students with disabilities in middle schools
      will be able to access vocational education funds. 34CFR-SEC.300.29




                                                                                             180
                                                                                         APPENDIX B



850   Work experience education: Work experience education means organized educational programs
                    that are directly related to the preparation of individuals for paid or unpaid
                    employment, or for additional preparation for a career requiring other than a
                    baccalaureate or advanced degree.
      (34 CFR 300.26)

860   Mentoring:

865   Agency linkages (referral and placement): Service coordination and case management that
      facilitates the linkage of individualized education programs under this part and individualized family
      service plans under part C with individualized service plans under multiple Federal and State
      programs, such as title I of the Rehabilitation Act of 1973 (vocational rehabilitation), title XIX of the
      Social Security Act (Medicaid), and title XVI of the Social Security Act (supplemental security
      income). 34 CFR SEC.613

870                               Travel Training (includes mobility training):

890   Other transition services: These services may include program coordination, case management and
      meetings, and crafting linkages between schools and between schools and post-secondary agencies.

900   Other special education/related services – Any other specialized service required for a student with
      a disability to receive educational benefit




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