Western Wayne Schools: Special Education Data Sheet
Email
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Teacher of Record Name
*
Student's Full Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
STN Number
*
Case Conference Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Meeting Purpose (check all that apply)
Move In
Annual Case Review
Revise IEP
Revise IEP without a Meeting
Initial Evaluation
Reevaluation Review
Manifestation Determination
Exit Secondary Education
Initial Service Plan
Annual Service Plan
Revise Service Plan
Revise Service Plan without a Meeting
Other
School
*
Western Wayne Elementary
Lincoln Middle/High School
Other
Grade
*
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
12+
Eligibility
*
Student qualifies for initial placement in special education
Student does NOT qualify
Student continues to qualify for special education services under the same eligibility category
Student's area of eligibility has changed due to a recent reevaluation
Student is enrolled for a Special Education Service Plan ONLY
Student's special education services have been terminated. Complete a Special Education Exit Form.
Student's LRE has changed.
Other
Primary Area of Special Education Eligibility
(01) Multiple Disabilities
(02) Orthopedic Impairment
(03) Blind or Low Vision
(04) Deaf or Hard of Hearing
(05) Emotional Disability (Full Time)
(06) Emotional Disability (Other)
(07) Specific Learning Disability
(08) Developmental Delay
(09) Language or Speech Impairment
(10) Mild Cognitive Disability
(11) Moderate Cognitive Disability
(12) Severe Cognitive Disability
(14) Deaf-Blind
(15) Autism Spectrum Disorder
(16) Traumatic Brain Injury
(17) Other Health Impairment
Secondary Area of Special Education Eligibility
(01) Multiple Disabilities
(02) Orthopedic Impairment
(03) Blind or Low Vision
(04) Deaf or Hard of Hearing
(05) Emotional Disability (Full Time)
(06) Emotional Disability (Other)
(07) Specific Learning Disability
(08) Developmental Delay
(09) Language or Speech Impairment
(10) Mild Cognitive Disability
(11) Moderate Cognitive Disability
(12) Severe Cognitive Disability
(14) Deaf-Blind
(15) Autism Spectrum Disorder
(16) Traumatic Brain Injury
(17) Other Health Impairment
(99) No Secondary Area of Eligibility
Tertiary, Etc. Areas of Disability, if Applicable
Related Services
(21) Occupational Therapy
(22) Physical Therapy
(35) Special Transportation
No Related Services
Other
Least Restrictive Environment
Preschool Age (3 through 5)
School Age (6 through 21)
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Preschool Student
Preschool LRE
(26) Regular Early Childhood Setting for >= 10 hours per week
(27) Other Location for >= 10 hours per week
(28) Regular Early Childhood Setting for < 10 hours per week
(29) Other Location for < 10 hours per week
(33) Separate Class
(34) Separate School
(35) Residential Facility
(36) Service Provider Location
(37) Home
(38) Child Parentally Placed in a Private Preschool
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School Age Student
School Age LRE
(50) Regular Classroom (80% or more)
(51) Resource Room (40-79%)
(52) Separate Class (<40%)
(53) Separate Day School Facility (+50%)
(54) Residential Facility (+50%)
(55) Correctional Facility
(56) Parentally Placed in a Private School
(57) Homebound/Hospital
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Special Education Location/Facility Type
Special Education Location/Facility Type
(01) Community Based Preschool
(02) Medicare/Behavioral Health Placement
(03) Homeschooled
(04) Court Ordered Placement
(05) Residential Placement
(06) Out of State Placement
(07) Public Preschool Program in a Separate Building
(08) Head Start
(09) Private Vendor Placement
(10) Non-Accredited (Grades K-13)
(99) Not Applicable, State Assigned School Number Provided
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