CCJS - Receipt of Procedural Safeguards

Receipt of Procedural Safeguards
Indicate the date a copy of the Procedural Safeguards was provided to the parent next to the appropriate reason below. Send to Joint Services with the initial referral paperwork or for any of the other reasons listed below.

A copy of the procedural safeguards must be given at least one (1) time per year and for the following reasons:
Student Name

First NameLast Name
When were the procedural safeguards provided?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Teacher of Record
Teacher of Record
Where were the procedural safeguards provided?
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Parent Initials
Should be Empty: