ELD Services Request Form
Email of Requester
*
example@example.com
Student's Name
*
Student First Name
Last Name
PA Secure ID (if unknown type none)
*
Date of Birth
*
/
Month
/
Day
Year
Date
Grade
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Gender
*
Please Select
Male
Female
Unsure
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District of Residence
*
Please Select
Adams County Technical Institute
Bermudian Springs
Central York
Chambersburg Area
Crispus Attucks
Conewago Valley
Dallastown Area
Dover Area
Eastern York
Fairfield Area
Fannett-Metal
Franklin County Career & Technology Center
Gettysburg Area
Gettysburg Montessori Charter School
Greencastle-Antrim
Hanover Public
Juniata County School District
Lincoln Charter
Littlestown Area
Northeastern
Pennwood Cyber Charter School
Red Lion Area
School District of York City
South Eastern
South Western
Southern York
Spring Grove Area
Tuscarora
Upper Adams
Waynesboro Area
West York Area
York Area Regional Charter School
York County School of Technology
York Suburban
Other
ELD PIMS Information
Please complete as much of this section as you can with the information you have about the student.
Student's Home Language (PIMS Field 123)
*
Please Select
Arabic 0190
Haitian Creole 1760
Swahili 4310
Spanish 4260
Vietnamese 4800
Portuguese 3670
Persian/Farsi 3610
Tagalog 4350
Other
EL Status (PIMS Field 41)
*
Please Select
01 - Current EL
03 - Former EL, 1st yr. monitor
04 - Former EL, 2nd yr. monitor
05 - Former EL, Exited and No Longer Monitored
06 - Current EL, LIFE
07 - Former EL, exited, 3rd yr.
08 - Former EL, exited, 4th yr.
99 - Never EL
Unsure
EL Program Start Date (PIMS Field 68)
/
Month
/
Day
Year
Date
Title III Eligible (PIMS Field 95)
*
Please Select
Yes
No
Unsure
Is this student a migrant? (PIMS Field 112)
*
Please Select
Yes
No
Unsure
Which ACCESS Test format does the student take? (PIMS Field 221)
*
Please Select
E= ACCESS
A= Alternate ACCESS
O= Other LEA requesting precode
Is this student eligible for potential reclassification?
*
Please Select
Yes
No
Unsure
Is the student an immigrant?
*
Please Select
Yes
No
Unsure
Does the student have an IEP/504?
*
Please Select
Yes
No
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Immigrant Information
Please complete as much of this section as you can with the information you have about the student.
Country of Birth
*
Date First Enrolled in US School(PIMS Field 110)
*
/
Month
/
Day
Year
Date
Years in US Schools (PIMS Field 125)
*
Please Select
0-1
1-2
2 or more
Is this student exempt from the ELA Assessment due to being in the country for less than 1 year? (PIMS Field 222)
*
Please Select
Yes
No
Unsure
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IEP Information
Please complete as much of this section as you can with the information you have about the student.
Please select the primary disability
*
Please Select
504
Autism/Autistic (AS)
Deaf-blindness
Hearing Impairment, including Deafness (HI)
Intellectual Disability (ID)
Multiple Disabilities (MD)
Orthopedic Impairment
Emotional Disturbance (ED)
Specific Learning Disability (SLD)
Speech or Language Impairment (SLI)
Traumatic brain injury
Visual Impairment including Blindness (VI)
Other Health Impairment (OHI)
Please select the secondary disability
*
Please Select
N/A
Autism/Autistic (AS)
Deaf-blindness
Hearing Impairment, including Deafness (HI)
Intellectual Disability (ID)
Multiple Disabilities (MD)
Orthopedic Impairment
Emotional Disturbance (ED)
Specific Learning Disability (SLD)
Speech or Language Impairment (SLI)
Traumatic brain injury
Visual Impairment including Blindness (VI)
Other Health Impairment (OHI)
Which standardized test does student participate in?
*
Please Select
None
PSSA
PASA
Keystones
Unsure
Please upload the most current IEP
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Parent Guardian Contact Information
Please complete as much of this section as you can with the information you have about the student.
Parent/Guardian Name (Primary Contact)
*
Relationship to Student
*
Please Select
Mother
Father
Guardian
Grandparent
Foster Parent
Other
Parent/Guardian Phone Number
*
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Does the contact need an interpreter or translated materials?
*
Please Select
Yes
No
Unsure
What language do materials need to be translated in?
Please Select
Arabic
Haitian Creole
Swahili
Spanish
Vietnamese
Portuguese
Persian/Farsi
Tagalog
Nepali
Other
Is there a secondary contact?
*
Please Select
Yes
No
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Secondary Parent/ Guardian Contact Information
Please complete as much of this section as you can with the information you have about the student.
Parent/Guardian Name (Secondary Contact)
*
Relationship to Student
*
Please Select
Mother
Father
Guardian
Grandparent
Foster Parent
Other
Parent/Guardian Phone Number
Format: (000) 000-0000.
Parent/ Guardian Email Address
example@example.com
Does the contact need an interpreter or translated materials?
Please Select
What language do materials need to be translated in?
*
Please Select
Arabic
Haitian Creole
Swahili
Spanish
Vietnamese
Portuguese
Persian/Farsi
Tagalog
Nepali
Other
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Next
ELD Services Requested
What type of ELD service is being requested?
*
Please Select
In-person
Virtual
Monitor (reclassified students only)
Consult
Student's Current Placement
*
Is this placement temporary?
Please Select
Yes
No
When do you expect it to end?
-
Month
-
Day
Year
Date
Total Number of Minutes being requested
*
Date services are to begin
*
/
Month
/
Day
Year
Date
Please upload all pertinent documents (home language form, screener, identification form, WIDA ACCESS scores)
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