1. education
2. special education

Student Safety
n
Safe Environment – Protection of Students
n
Safe Environment – Emergency Procedures
n
Physical Restraint of Students
ÿ Documentation of Physical Restraint (ECP-S31)
ÿ Significant Incident Report (ECP-S32)
n
Use of Protective and Restraint Devices
ÿ Documentation for Use of a Protective Device (ECP-S42)
Durham Public Schools
Programs for Exceptional Children
SAFE ENVIRONMENT – PROTECTION OF STUDENTS
1. Students in Exceptional Children’s Programs are often vulnerable due to physical, emotional and/or
cognitive limitations. Therefore, ECP staff is obligated to provide a safe environment for these
students.
2. Each student has a right to be free from abuse, neglect, and exploitation.
3. Staff shall not abuse a student by intentionally inflicting any emotional or physical harm.
4. Staff shall provide sufficient supervision to avoid the infliction of any emotional or physical harm by
other adults or students.
5. Staff shall not knowingly divulge confidential information about a student, or allow other staff to do
so. Staff shall not borrow or accept money or gifts of substantial value from a student or his/her
family, or allow other staff or students to do so.
6. In emergency situations only the minimum degree of force necessary, and no more, shall be used to
re-establish a safe environment (see physical restraint procedure).
7. A Significant Incident Report shall be used to document any situation in which a student was
subjected to abuse, neglect, exploitation, or potential harm, or was put in a situation of high risk for
such to occur. For situations involving a student put at high risk, the report shall be delivered to the
building administrator by the end of the school day. In situations where abuse, neglect, or
exploitation actually occurred, the report should be delivered to the building administrator as soon as
is practical but no later than the end of the school day. Both the teacher and building administrator
should keep a copy of this report on file. The building administrator should forward a copy of this
report within three days to the Exceptional Children’s office for review by the school’s ECP
Coordinator.
[The DPS district-wide Student Accident Report (RC 28-97) and/or NCIC Form 19 (for employee
injury) must also be filed when otherwise required under Board Policy or Administrative Procedures.]
Related Procedures:
“Safe Environment – Emergency Procedure”
“Physical Restraint of Students”
Related Forms:
Documentation of Physical Restraint (ECP-S31)
Significant Incident Report (ECP-S32)
11-1
Durham Public Schools
Programs for Exceptional Children
SAFE ENVIRONMENT – EMERGENCY PROCEDURES
1. If a student in the Exceptional Children’s Programs becomes violent or aggressive, it is the
responsibility of teachers in these situations to provide for both the safety of the student who is
aggressive as well as the safety of the rest of the students in the classroom.
2. If emergency procedures are included in the student’s Behavior Intervention Plan, these procedures
should be followed to the maximum extent possible under the circumstances.
3. If emergency procedures are not included in the student’s Behavior Intervention Plan, the following
procedures should be followed:
A. The other students in the room should be moved to another location under the supervision of
an adult whenever possible.
B. If the student with the behavioral emergency can be physically restrained safely, the teacher
or assistant should follow the procedure for physical restraint (see “Physical Restraint of
Students”).
C. If the student cannot be physically restrained safely (after the other students have been
moved) an administrator should be summoned for assistance.
D. If necessary to restore a safe environment, the administrator may request assistance from the
School Resource Office (SRO) to remove the student from the setting.
C. In emergency situations only the minimum degree of force necessary, and no more, shall be
used to re-establish a safe environment (see “Physical Restraint of Students”).
D. In any situation where physical restraint was used or the SRO has physically intervened with
a student, the school’s EC Coordinator should be notified by the building administrator and a
Documentation of Physical Restraint form (ECP-S31) should be completed by the staff
members involved in the incident.
Related Procedures:
“Safe Environment – Protection of Students”
“Physical Restraint of Students”
Related Forms:
Documentation of Physical Restraint (ECP-S31)
Significant Incident Report (ECP-S32)
11-2
Durham Public Schools
Programs for Exceptional Children
USE OF PHYSICAL RESTRAINT
1. When a student is in imminent danger of causing injury to him/herself or another person, or when the
student is causing substantial property damage, staff must take immediate action to re-establish a safe
environment.
2. DPS authorized intervention techniques for physical restraint include PIC (Preventive Intervention
Course) and C.P.I (Crisis Prevention Institute - Non-Violent Crisis Intervention).
3. If no trained and currently PIC- or CPI-certified staff members are present, the building administrator
should be notified before any student is physically restrained unless there is an immediate threat of
injury. Non-trained staff members may physically restrain a student only under genuine emergency
circumstances and only until such time as a true emergency no longer exists. They should
immediately defer to and follow the directions of a trained staff member should one arrive to assist.
4. If staff are present who have been trained in PIC or CPI, they may use these techniques to re-establish
a safe environment. Only the minimal amount of physical control and/or the least intrusive technique
that is sufficient to re-establish a safe environment shall be used. Only staff who have been trained
and who have current certification may use PIC or CPI techniques to physically remove a student to
another location.
5. When physical restraint is used two staff people should be present. If only one person is available at
the time of an emergency, another person should be summoned immediately.
6. After the use of any physical intervention technique, a Physical Intervention Report shall be
completed and submitted to the building administrator before the end of the school day. If the
physical intervention lasted more than fifteen minutes, resulted in any injury to the student, or was
conducted by a staff member not trained in physical restraint techniques, the documentation of
physical restraint form (ECP-S31) should be turned in to the building administrator as soon as
possible after the incident, but no later than the end of the school day. (It is not necessary to also
complete the “Significant Incident Report). A copy of this report should be kept on file by both the
teacher and the building administrator. The building administrator should forward a copy within
three days to the Exceptional Children’s office for review by the PIC/CPI trainers.
7. The use of restraint as punishment, the use of restraint in non-emergency situations, and the
intentional infliction of pain are always prohibited under any circumstances, as is the use of corporal
punishment (see DPS Board Policy 4310).
Related Procedures:
“Safe Environment – Emergency Procedures”
“Safe Environment – Protection of Students”
Related Forms:
Documentation of Physical Restraint (ECP-S31)
Significant Incident Report (ECP-S32)
11-3
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Program
DOCUMENTATION OF PHYSICAL RESTRAINT
Student ____________________________________________
Teacher _____________________________________________
Date of incident _________________
Type of classroom _______________
Location of incident ____________________________________________________________________
Time restraint began ________________________
Time restraint ended ______________________
Staff involved in restraint ________________________________________________________________
Staff witnessing restraint ________________________________________________________________
Which staff were trained in PIC? _________________________________________________________
Which staff were trained in CPI? _________________________________________________________
Were authorized techniques used? Yes ______ No _______
If no, describe how the student was physically restrained.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Give a brief description of the circumstances leading up to this incident.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What specific behavior necessitated the use of physical restraint?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Briefly describe the behavior of the student during the restraint.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
ECP-S31
Rev. 8/01
p.1 of 2
Name:
Date:
DOCUMENTATION OF PHYSICAL RESTRAINT (Continued)
Briefly describe the student's behavior after the restraint.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
After the restraint, what interventions or other types of resolutions were used?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
After the restraint, did staff discuss ways to reduce identified behavior? Explain.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature of staff members involved in restraint:
_______________________________________
_______________________________________
_______________________________________
Signature of staff members witnessing restraint:
_______________________________________
_______________________________________
_______________________________________
________________________________________
Signature of building administrator:
________________
Date
Building administrator must forward copy of this form to EC Office at Fuller Building.
Reviewed by PIC or CPI instructor __________________________________________ Date_________
c:
ECP-31
Rev. 8/01
Confidential File
p. 2 of 2
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Program
SIGNIFICANT INCIDENT REPORT
This form should be used to document any event that is out of the ordinary and requires a unique response
by staff to ensure safety and security or to prevent the abuse, neglect, or exploitation of a student, e.g.
runaways, student injury, situations of physical danger, etc.
Name of Student ______________________________________________________________________
Name of Staff ________________________________________________________________________
Date ____________
Time ____________
School ______________________________________
Description of Significant Incident:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Staff Response:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________
Signature of person completing report / Date
_______________________________________
Signature of Building Administrator / Date
Completed form must be forwarded to the EC office within three days of the incident.
____________________________________
Signature of EC Coordinator / Date received
c:
ECP-32
Rev. 8/01
Student confidential folder
Durham Public Schools
Programs for Exceptional Children
USE OF PROTECTIVE AND RESTRAINT DEVICES
Definitions
Protective Device: A protective device is an intervention that is used to promote proper positioning
and safety to assist in providing the student with a free appropriate public education. Protective devices
may consist of physical or occupational therapy equipment or other tools that have been agreed upon by
the IEP Team (including the parent), to be used under specified circumstances.
Restraint: A restraint is any intervention, agreed upon by the IEP Team (including the parent) that is
used to restrict the student’s movement or normal access to his/her own body, to be used under
specified circumstances. A restraint is used to prevent the student from causing injury to self or others, or
to the classroom environment, and may consist of equipment or other tools. Physical restraint techniques
used by school personnel, such as NCI, PIC or CPI, are not addressed here. Refer to the policy entitled
“Use of Physical Restraint” in this section for more information on the use of these techniques.
Use of Protective and Restraint Devices
The use of protective devices should be limited to situations in which the device is needed for positioning
and/or safety. The Physical Therapist and/or Occupational Therapist should be consulted when there
appears to be a need for a protective device. In some cases, rather than a true need for positioning support
or safety, there is very likely a behavioral issue that needs to be addressed in the IEP, or an issue of lack
of classroom support and personnel/supervision. Positioning equipment should not be used to alleviate
behavior problems. Instead, behavior problems should be addressed through the IEP and/or Behavior
Intervention Plan. If the behavior problem is anticipated to require the use of a restraint, the circumstances
under which the restraint may be used should be discussed and documented by the IEP team.
Use of PT and OT Equipment
1.
PT/OT equipment is specially designed to address positioning and/or supportive seating, standing
and mobility issues and, accordingly, is frequently used as a protective device.
2.
PT/OT equipment is NOT designed to restrain students and should NOT be used for that purpose.
3.
Members of the Physical and Occupational Therapy staff are the only individuals who are
qualified to make decisions about the appropriate use of positioning/safety devices. Therefore,
PT/OT equipment may be used only with students who are receiving PT and/or OT services.
4.
Educational staff may NOT make independent decisions about the use of PT/OT equipment.
5.
Seatbelts, whether attached to a chair or added to the chair, may be used as a protective device
ONLY under the supervision of the OT or PT staff with appropriate documentation as described
below.
Documentation of Use of Protective Devices
The use of a protective device must be documented in the IEP, using form ECP-S42, “Documentation for
the Use of a Protective Device.” The Physical or Occupational Therapist must approve the use of the
device. The documentation must include at least the following:
7/02
11-7
Durham Public Schools
Programs for Exceptional Children
1.
Identification of physical issues that affect the student’s ability to independently position self for
classroom activities (e.g., the student is unable to sit or stand independently)
2.
Identification of physical issues that could impact the student’s ability to participate in
classroom activities safely (e.g., poor balance, poor muscle control)
3.
Statement that a protective device is necessary for the student to benefit from his/her program of
special education (i.e., without this device, the student would be unable to participate in
classroom activities appropriately and safely).
4.
Description of the student’s activities that prompt the need for a protective device.
5.
Type of protective device to be used.
6.
Activities for which it will be used.
7.
When, and for how long the protective device will be used during the day.
8.
Timeline for use of the protective device to be reviewed (at least annually, at the IEP review).
9.
Signature of the IEP Team.
10.
If the parent is not present at the meeting, the protective device may not be used until 5 school
days after the parent has been notified (via the DEC-5, “Prior Written Notice”). A copy of the
ECP-S42 should be sent with the DEC-5.
The use of the protective device(s) should be documented on the IEP, DEC 4, p.3 under “Appropriate
supplementary aids, services, and modifications. . .” The IEP may refer to the documentation contained
in the ECP-S42, as described above. For example, the Team may state:
“The protective device identified on the attached form ECP-S42 will be used as described therein.”
The documentation form MUST be attached to the IEP.
Related Procedures:
“Use of Physical Restraint”
“Related Services Referrals”
“Development of the IEP”
“Procedural Safeguards”
Related Forms:
Documentation of Need for a Protective Device (ECP-S42)
Prior Written Notice
7/02
11-8
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
DOCUMENTATION FOR USE OF A PROTECTIVE DEVICE
This form must be completed by the IEP Team and approved by the Physical/Occupational Therapist when a protective device is needed.
The device may not be used until approved by the therapist and notification is given to the parent.
Student’s Name: ___________________________ Exceptionality: _______ Circle Related Services: PT OT
1. Describe any physical issue which affects the student’s ability to be independent when positioning him/herself
for classroom activities. (e.g., unable to sit or stand independently)
2. Describe any physical concerns that could impact on the student’s ability to participate safely in classroom
activities. (e.g., poor balance, poor muscle control)
3. Does the IEP team agree that a protective device is the most appropriate way for this student to benefit from
his/her education (without this device, the student would be unable to participate in classroom activities
appropriately and safely)?
Yes
No
Explain: (What is happening that prompts the need for a protective device?)
4. Specify the type of protective device to be used:
5. State the particular activities which require this student to use a protective device:
6. Length of time or time periods during the day when the device is to be used:
7. How often will the use of this protective device be reviewed?
Signatures of IEP Team:
Name
Title
Date
Parent
LEA Rep
EC Teacher
Reg. Ed Teacher
Therapist
* If the parent is not present at the meeting, the protective device may not be used until 5 school days after the parent has been notified
(via the DEC-5, “Prior Written Notice”). A copy of this form should be sent with the DEC-5.
Approval of the Physical/Occupational Therapist
I agree that use of the specified protective device in the manner described above is appropriate for this student.
_____________________________________ __________________
Signature of PT / OT (circle one)
Date
Copy to parent ____/____/____
ECP-S42
7/02
Durham Public Schools
Programs for Exceptional Children
BEHAVIORAL SUPPORT ASSISTANTS
The Office of Exceptional Children’s Programs offers the services of a limited number of Behavioral Support
Assistants to help students experiencing a sudden, unexpected behavioral crisis. The Behavioral Support Assistants
work under the direction of the Behavior Support Liaison and are provided as a short-term intervention designed to
allow personnel within the school to develop a long-term plan to address the student’s needs. As a condition of this
service, it is expected that school personnel will meet regularly with the Behavioral Support Assistant, Behavior
Support Liaison, and/or other members of the ECP administrative team during the period of service. School
personnel will be expected to follow through with the recommendations of ECP personnel working with the
student.
The following procedure applies to the assignment of a Behavioral Support Assistant to assist a school.
1.
If the teacher has problems with a student, the (BST) Behavior Support Team at the school will assess the
situation and recommend strategies to address the problem.
2.
If strategies recommended by the BST are not working, the teacher should contact the SAP team if the
student is a regular education student. If the student is an exceptional education student, a FBA (Functional
Behavioral Assessment) and a BIP (Behavioral Intervention Plan) must be developed by the IEP team.
3.
If the student is still having problems following the SAP interventions or FBA/BIP, an administrator at the
school should assess the situation to determine if all required procedures have been followed and new ideas
explored.
4.
Administrator should contact EC Coordinator to request a Behavioral Support Assistant. Form ECP-F10,
“Behavior Support Assistant Request Form,” should be complete by the school team and given to the
Coordinator.
5.
The EC Coordinator should review the request form for the following, as applicable:
Referral form
Cumulative Folder Data
Grades
EOG/EOC
Retention History
Attendance
Discipline History
List of outside agencies involved
SAP History
ECP Folder
FBA
BIP
Before and After School Data
List of school staff involved
Other relevant information
6.
An EC Coordinator will assess the above information and do a classroom observation.
7.
EC Coordinator will ask the BST to try other strategies and/or meet with Behavioral Support Liaison to
determine if a Behavior Support Assistant is needed.
8.
EC Coordinator and the Behavior Support Liaison will meet with the principal to discuss and plan meeting
of Behavioral Support Team at the school.
9.
Behavioral Support Assistants are subject to immediate reassignment to intervene with a student in
imminent danger of hurting self or others.
Related Forms: Behavior Support Assistant Request Form (ECP-F10)
7/02
11-10
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
BEHAVIOR SUPPORT ASSISTANT REQUEST FORM
Student’s Name ______________________________________________ Date of Birth __________________
Grade _____________________________ Race __________________________ Sex _____________________
School _________________________________________ Primary Disability __________________________
Teacher's Name ____________________________________________________________________________
Please give reasons why the above student is being referred. Please describe specific behaviors.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please include the following information with this form:
____
____
____
____
Referral Form
EOG/EOC
Discipline History
FBA
____ Cumulative Folder Data
____ Before/After School Data
____ SAP History
____ BIP
_____
_____
_____
_____
Grades
Attendance
ECP Folder
Retention History
List of school staff involved: ____________________________________________________________________
List of outside agencies involved: ________________________________________________________________
Other relevant information: _____________________________________________________________________
Do not write below this line
Behavioral Support Team reviewed and tried other strategies. Yes_____ No _____ If yes, what strategies were
tried?________________________________________________________________________________________________
______________________________________________________________________________
EC Coordinator reviewed and suggested other strategies. Yes_____ No _____ If yes, what strategies were
suggested?____________________________________________________________________________________________
____________________________________________________________________________________________
Received Date _________________________________ Referred By__________________________________
Accepted Date ___________ Rejected Date ____________ Behavior Assistant __________________________
********************************************************************************************
Comments: __________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________________
ECP-F10
7/02
Occupational Course
of Study
n
n
Student Enrollment
Parent and Student Notification Letter
(ECP-S33)
ÿ
Student Enrollment Form (ECP-S34)
Durham Public Schools
Programs for Exceptional Children
THE OCCUPATIONAL COURSE OF STUDY -- STUDENT ENROLLMENT
Overview
The Occupational Course of Study, available only for students with an IEP, is a program that focuses on
the acquisition of functional academic and work readiness skills. It is not a separate diploma, but one
of four courses of study leading to a regular diploma. Successful completion of the OCS requirements,
which include school and community-based training as well as competitive employment, results in
graduation with a North Carolina Diploma.
According to the North Carolina Department of Public Instruction, students meeting the following
guidelines should be considered for the Occupational Course of Study: (1) students who are being served
in the Exceptional Children’s Program, (2) who have a post-school outcome goal for employment (not
college) after graduation, (3) whose post-school needs are not being met by the NC Standard Course of
Study and (4) who wish to pursue a course of study that provides functional academics and hands-on
vocational training.
The Occupational Course of Study is not: (1) an appropriate curriculum for all students who cannot obtain
a high school diploma through one of the other courses of study; (2) a program designed to remove
certain students from the accountability standards; or (3) a “classroom-textbook” driven course of study.
The IEP Team must consider enrollment of students into the Occupational Course of Study on a case by
case basis. Students should not be recommended based solely on their disability classification. However,
all members of the IEP Team should recognize that the curriculum objectives were designed for students
functioning intellectually, academically, and socially in the mild mentally handicapped range.
In most cases the decision to enroll a student into the Occupational Course of Study will be made when
the student is in the 8th grade. Students who enroll during their 9th or 10th grade year may have to spend
an extra year in high school in order to complete all the requirements.
Procedure for Enrolling a Student in the Occupational Course of Study
If an EC teacher or IEP Team believes that this program is appropriate for a student they should follow
these steps:
q Contact the parent to discuss enrollment. Send them the DPS parent letter that describes the OCS
(Occupational Course of Study Parent & Student Notification, ECP-S33), along with an Invitation to
Conference.
q
Hold an IEP meeting to discuss enrollment and other high school options (for example, the Career
Prep. Course of Study). This may occur at the same time as the annual IEP meeting. Review the
requirements as listed on the parent letter and notification. The team should include at least one of
the student’s EC teachers, one of his/her regular education teachers, an LEA representative, a
guidance counselor, the parent, and the student.
q
If the IEP Team, including the parent and student, agree that this pathway is appropriate, the team
should sign the OCS Student Enrollment Form (ECP-S34). Give a copy to the parent and keep the
original in the front of the confidential folder.
Rev. 7/02
12-1
Durham Public Schools
Programs for Exceptional Children
q
Review the student’s IEP and transition plan. The student’s EC placement should be marked as
“Separate” and the goals aligned with the OCS curriculum objectives. For example, math goals might
include, “The learner will demonstrate an understanding of financial management skills necessary for
independent living and employment.” If the student does not have a transition plan, this is a good
time to write one.
q
Check the “Separate Setting” database. If the student is not listed on it, (possibly because the student
has been in a resource setting) or the address is incorrect, send a SIMS Update Form (ECP-S40) to the
Elementary/Secondary EC Administrator at the Central Office. Indicate on the form that the student
is OCS and the date that the student will begin the separate setting.
q
Enlist the counselor’s assistance in registering the student for the correct OCS classes for the next
school year.
q
Keep a list of students who are being enrolled. You will be asked to send this to the central office
and/or to the appropriate high school.
Note: If, after “reasonable” IEP meeting notification, the parent does not respond or attend the meeting,
the IEP Team may sign the enrollment form. In these cases it is particularly important that the student
understands this Course of Study, agrees to participate, and signs the enrollment form.
Related Forms:
Rev. 7/02
OCS Parent and Student Notification (ECP-S33)
OCS Student Enrollment Form (ECP-S34)
12-2
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
OCCUPATIONAL COURSE OF STUDY
PARENT AND STUDENT NOTIFICATION
Date:
Dear Parent/Guardian and Student:
The Occupational Course of Study is a new high school program approved by the North Carolina State
Board of Education for certain students who receive services from the Exceptional Children’s Program. It
is one of four courses of study leading to a regular diploma. This program focuses on the acquisition of
functional academic and work readiness skills and prepares students to enter competitive employment.
Successful completion of the Occupational Course of Study requirements results in graduation with a
North Carolina Diploma.
Course requirements include:
• 4 courses in Occupational English
• 3 courses in Occupational Mathematics
• 2 courses in Occupational Science
• 2 courses in Occupational Social Studies
• 4 courses in Occupational Preparation which include 300 hours of school-based training, 240 hours of
community-based training, and 360 hours of paid employment.
• 1 course in Health/Physical Education
• 4 courses in Career/Technical
Courses in this program cannot be substituted for courses in other programs of study (for example,
Occupational English I cannot be substituted for English I) and occupational courses will not be accepted
for credit by most colleges.
Parents of students enrolled in the Occupational Course of Study will be expected to do the following:
• Provide copies of the student’s birth certificate, social security card, and medical insurance
information
• Sign and return all forms as needed
• Sign referral forms to Vocational Rehabilitation when their child reaches the age of 16
• Participate in IEP meetings and transition planning for their child.
We would like to discuss enrolling your child in this course of study at the date and time noted on the
enclosed Invitation to Conference. If you have any questions, please call me at 560-_______ .
Sincerely,
EC Facilitator
c:
confidential folder
ECP-S33
Rev. 8/01
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
OCCUPATIONAL COURSE OF STUDY
STUDENT ENROLLMENT FORM
Student: _____________________________________________________________________________
Name of Parent or Guardian: _____________________________________________________________
Address: _____________________________________________________________________________
Current School: _______________________________________________________________________
Student’s area of exceptionality: ___________________________________
School: _______________________________________________________
Date of Meeting: _______________________________________________
The IEP Team recommends that the above named student be enrolled in the Occupational Course of
Study to begin on ________________________________ (date).
Participants in meeting:
Name
Position
________________________________________
Parent
________________________________________
Student
________________________________________
LEA Representative
________________________________________
ECP Teacher
________________________________________
________________________________
________________________________________
________________________________
Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Distribution: Place the original of this form in the EC file, give a copy to the parent, and mail a copy to the Transition Specialist.
ECP-S34
Rev. 7/02
Closing the School Year
n
Promotion and Retention
n
End of Year IEP Procedures
n
End of Year Folder Exchange
Durham Public Schools
Programs for Exceptional Children
PROMOTION AND RETENTION
The school principal makes promotion and retention decisions in accordance with State regulations
and school board policy 3225.6
3225.6 Promotion/Retention of Students with Exceptional Learning Needs
The decision regarding the retention/promotion of exceptional children will be determined by the
IEP Team in consultation with the principal.
Factors to consider if a student fails to meet promotion standards:
The IEP Team should reconvene immediately with the principal to consider the following:
• Is the current IEP appropriate?
• Is the manner of assessment appropriate and does it include any accommodations and/or
modifications identified in the IEP?
• Were all the services required by the student to make progress in the general education curriculum
appropriately identified in the student’s IEP?
• Did the student receive all the services identified in the IEP?
• If ESL, were the linguistic needs of the student appropriately identified?
Minutes are to be kept of the discussion and the decision. Minutes should reflect that all of the above
questions were discussed. Place minutes in the confidential folder and give parents their copy.
13-1
Durham Public Schools
Programs for Exceptional Children
END OF YEAR IEP PROCEDURES
Exit of seniors who are graduating with a diploma:
1. Send parents a Handbook on Parents’ Rights and Invitation to Conference letter marked “change of
placement” and “exit from the program”.
2. Review the student’s goals and progress and be sure the parents understand the student is graduating
from Exceptional Children’s services.
3. IEP Team signs Prior Written Notice form, exiting student from Exceptional Children’s services.
4. All other seniors should have an IEP that continues into the next year, as they are eligible to receive
Exceptional Children’s services until the age of 21 or upon graduating with a diploma.
5th/8th graders moving to middle and high school:
1. IEPs should be reviewed for any changes needed at the receiving school.
2. The IEP Team must amend any changes in time/meeting dates.
3. If the student’s needs in the receiving school result in a change of placement on the IEP, the following
must be done:
• Send Invitation to Conference and Handbook on Parents’ Rights.
• Amend the IEP to reflect the change of placement.
• Complete the Prior Written Notice form.
• Complete SIMS/4 GL Data update.
4. IEPs that expire prior to September 15th should be rewritten before the end of the school year.
13-2
Durham Public Schools
Programs for Exceptional Children
END OF YEAR FOLDER EXCHANGE
The confidential folders of rising K, 6th and 9th grade students must be transferred to the students' new
schools at the end of the school year. Folder exchange usually takes place sometime during or near the
last week of school and is announced in advance.
The Case Manager is responsible for ensuring that his/her folders are prepared for transfer at any time,
i.e., they should be kept current and complete throughout the year. In the spring, the Case Manager must
carefully review each transferring folder to confirm that all required components of the folder are present
and in proper order. Not later than 5 school days before the end of the school year for students, the Case
Manager should attach the final progress report of the year to the IEP.
Folders to be transferred must be in correct folder order. (See "Guidelines for Uniform Folder Order -EC Active Folder (Green Dot).") In addition to the folder order, the following components of the folders
will be checked at the time of folder exchange:
1.
2.
3.
4.
IEP – must be current
3 yr. reevaluation – must be current
Progress Reports – must be present for entire year
SIMS sheet – must be present
Folders brought to the folder exchange that are not in folder order or that are missing required
components will be returned to the Case Manager for immediate correction.
Graduating Seniors:
Folders of graduating seniors must be forwarded to the DPS Records Center, using the form “Records
Transfer For Graduating Seniors” (ECP-F7).
Related Forms:
Records Transfer For Graduating Seniors (ECP-F7).
13-3
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
RECORDS TRANSFER FOR GRADUATING SENIORS
At graduation time each spring, every EC Facilitator or designee in the senior high schools should
indicate on this form in alphabetical order those exceptional education students who will graduate.
Please make three (3) copies of this form and send to the following by June 1:
(1) Records Center; (2) ECP Central Office, Fuller Building; and (3) School File.
Signature of Person Completing Form:
____________________________________________________
High School:
____________________________________________________
Last Name, First Name MI
Date Completed
ECP-F7
Rev. 8/01
Date of Birth
Last Name, First Name MI
___________________________________
Date of Birth
Job Descriptions
n
Case Manager
ß Facilitator
ß Coordinator
ß Specialist
ß Teaching Assistant
Durham Public Schools
Programs for Exceptional Children
JOB DESCRIPTION – CASE MANAGER
The Case Manager is usually the teacher of the student with a disability or a suspected disability. In the
event the student has speech as the primary category; the speech pathologist is the Case Manager. If the
student is served by a specialist, i.e. autistic, blind visually impaired, etc. on a consultative basis, the
special teacher in the school to which the student is assigned is the Case Manager. The Exceptional
Children’s Facilitator (EC Facilitator) or the principal is responsible for assigning students to the Case
Manager.
Responsibilities of the Case Manager (This is not an exhaustive list.)
Compliance: The Case Manager is responsible for compliance of the special education folder of a
student with a disability. This includes:
- Organizing and keeping the confidential folder in proper folder order;
- Ensuring that IEPs are kept current;
- Ensuring that 3-year reevaluations are kept current;
- Working with EC Facilitator to correct problems in the folder; and
- Ensure compliance with students’ designated methods of participating in State Testing Program.*
* For students participating through the Alternate Academic Assessment Inventory or the
Alternate Assessment Portfolio, baseline data must be collected during the first 3 weeks of the
school year and regularly thereafter.
Communication:
- Advise students’ regular education teacher(s) about students’ IEP, modifications, and
accommodations;
- Communicate student progress via regular progress reports to parents;
- Advise EC Facilitator of students’ testing modifications as required;* and
- Collect data as required by the Central Office.
*For third-grade students, this information must be communicated within the first 3 weeks of the
school year so that modifications will be provided for the EOG Pre-Test.
Referral: After receiving assignment as Case Manager or receiving referral from EC Facilitator:
- Serve on SAP Team when requested to do so by school administrator;
- Begin special folder for student, organizing the order according to DPS directions;
- Notify staff members who must be present at pre-evaluation meeting;
- Schedule pre-evaluation meeting;
- Send Invitation to Conference to parents (all blanks must be filled) and Handbook on Parent’s
Rights. Request parent bring any information, i.e. privately obtained evaluations, parental
concerns, etc., to the meeting; and
- Send 2nd and (when appropriate) 3rd notice to parent when there is no response.
Pre-evaluation Meeting:
- Gather information that will be needed at the pre-evaluation meeting, i.e., information from SAP;
- Chair the meeting;
- Arrange for someone at the meeting to take minutes;
- Notify EC Facilitator of need for an interpreter for a parent with limited English proficiency or
who is deaf or hard of hearing; and
- Obtain written consent for evaluation and provide copy of consent for parent.
14-1
Durham Public Schools
Programs for Exceptional Children
Following the Pre-evaluation meeting:
- Notify EC Facilitator of need for psychological testing;
- Complete educational testing;
- Notify EC Facilitator of need for other required testing: e.g., occupational therapy, physical
therapy, medical evaluations including vision and hearing, adapted physical education, adaptive
behavior, assistive technology, social history, behavioral assessment, etc.; and
- Provide psychologist with completed test information along with copy of permission to test.
Eligibility Meeting:
- Schedule meeting;
- Notify persons who must be in attendance;
- Send Invitation to Conference with adequate notice to allow parents to attend. Send 2nd and 3rd
notices if no response is received from parent;
- Ensure that all evaluation material required by pre-evaluation meeting participants is completed
and available for the meeting;
- Notify EC Facilitator if any interpreters are needed;
- Arrange for someone at the meeting to take minutes; and
- Ensure the Summary of Evaluations has been completed.
Eligibility Meeting That Includes IEP Development and Placement Decision:
- Chair the meeting unless the EC Facilitator has been assigned to do so;
- Following the determination of eligibility ensure that the eligibility statement on the Summary of
Evaluations is completed;
- Facilitate the IEP development process; (See DPS procedures on IEPs)
- See that appropriate signatures are obtained on the IEP signature page;
- Ensure that parent receives copy of completed IEP along with minutes as appropriate;
- Obtain written parent permission to place;
- Ensure that any teacher or other staff who has responsibility for any part of the IEP receives a
copy of the IEP or a copy of the parts for which he/she is responsible; and
- Give parent the Handbook on Parents’ Rights
Separate IEP Meeting From Eligibility Meeting:
- Same as above except the meeting focuses only on IEP development and placement.
Annual Review and Reevaluation:
- Same responsibilities and process as above except for annual review, which is the review and
development of the IEP on an annual basis.
- Refer to section of DPS procedures on reevaluation.
14-2
Durham Public Schools
Programs for Exceptional Children
JOB DESCRIPTION – EXCEPTIONAL CHILDREN’S FACILITATOR
The Exceptional Children’s Facilitator (EC Facilitator) is a teacher who is assigned responsibilities at a
designated school to:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Chair IEP Team meetings as appropriate.
Ensure that all mandated timelines are adhered to in processing student referrals and service delivery
(i.e., annual reviews and reevaluations).
Ensure that EC folders are complete, accurate, and compliant, including all required documentation in
folder order.
Serve as liaison between school and administrative staff for Exceptional Children’s Programs.
Address parent concerns and ensure that parents are informed of parental rights and are given
maximum opportunity to participate in all educational decisions.
Assist with training and orienting new Exceptional Children’s teachers.
Audit records to ensure compliance.
Receive and transfer confidential records.
Arrange for data input.
Assign and assist Case Managers as needed with initial eligibility, reevaluation and annual review
meetings.
Help provide training and support for regular and special education staff.
Consult with principal regarding exceptional children’s needs and assist with the evaluation of
building level programs.
Monitor statewide testing program for students with disabilities.
Obtain accurate teacher schedules and class loads and monitor EC teachers’ caseloads for State
compliance.
Assist with behavioral issues, i.e., manifestation meetings, suspension records, etc.
Coordinate psychological and other required assessments.
Serve on the Oversight Committee when appropriate.
14-3
Durham Public Schools
Programs for Exceptional Children
JOB DESCRIPTION – EXCEPTIONAL CHILDREN’S COORDINATOR
The Exceptional Children’s Coordinator is a Central Services special education staff person who provides
leadership to personnel in the schools, assists the Assistant Superintendent for Exceptional Children’s
Programs and responds to parents. Duties and responsibilities of this position are varied and complex.
Persons in this position must possess a high level of knowledge and expertise in the area of education of
students with disabilities, as well as possess excellent communication and interpersonal skills. A list of
the types of activities in which the coordinator is involved follows:
• Plans staff development;
• Assists with personnel allotments for the schools;
• Plans and assists with programming at the building based sites;
• Acts as liaison between teacher and principal;
• Acts as liaison between principal and central office staff;
• Assists with personnel interviews;
• Assists with recruitment of teachers, assistants, and related service personnel;
• Assists with teacher observations and evaluation of school level personnel;
• Approves final assignment to self-contained classes;
• Makes decisions about program locations at particular schools;
• Works to maintain compliance at the school level with State, federal and local procedures;
• Attends manifestation meetings as requested;
• Responds to emergencies;
• Works with court counselors as appropriate;
• Attends court as required (due process hearings, etc.);
• Gives depositions as required;
• Orchestrates response to parent complaints;
• Develops and works with corrective action plans responding to parent complaints;
• Responds to requests for and schedules independent educational evaluations;
• Coordinates the scheduling of related services and transportation;
• Works with the transfer of folders within the school system;
• Assists with the tracking of students;
• Works with budgets; and
• Assists with headcount.
14-4
Durham Public Schools
Programs for Exceptional Children
JOB DESCRIPTION – EXCEPTIONAL CHILDREN'S SPECIALIST
The specialist is a teacher who is assigned responsibilities in a particular category of disability or a
particular area of expertise. The specialist may have direct teaching responsibilities, but usually serves
students on a consultative or outreach basis. The specialist is available to regular and special education
teachers who may require assistance in working with a particular child. The assistance may include direct
instruction of the student in order to provide models for the regularly assigned teacher. It may include
observation of the student and the regularly assigned teacher, followed by recommendations that will
improve instruction and services to the student. It may include providing information on different types
of techniques or methodologies that might be more appropriate for the student. It may include the
specialist meeting with the parent. It may include assisting with determining the requirement of assistive
technology and instruction for the teacher, as well as the student, in how to use it.
There are specialists in the following areas:
- Blind and visually impaired
- Autism
- Assistive technology
- Speech-language
- Physical therapy
- Occupational therapy
- Audiology
- Transition
Note: Teachers who are employed in specialist positions do not act as Case Managers.
14-5
Durham Public Schools
Programs for Exceptional Children
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
JOB DESCRIPTION – EC TEACHING ASSISTANT
The EC Teacher Assistant works under the supervision of the classroom teacher and/or principal. A wide
variety of tasks to support the teacher and students may fall within the scope of the job. The specific
tasks that are required will vary according to the particular needs of the EC students in the class. The EC
Teacher Assistant may be asked to perform any of the following duties:
Supervision of Students and Behavior Monitoring:
• Meet the buses in the morning and escort students to the classroom daily*
• Accompany students from separate to regular education inclusion classes or other classes,
activities, or events during the school day*
• Assist in transition times: bus lot, cafeteria, etc.*
• Supervise students during breakfast and lunch and on the playground*
• Assist in dismissal and supervise students during departure, including escorting students to the
bus as needed*
• Discipline misbehavior through approved methods, at the direction of the teacher
• Report discipline problems to teacher or other supervisory personnel*
• Report to teacher or other supervisory personnel significant change or lack of change in student
behavior*
• Model appropriate social skills and respect for others*
Academic Assistance:
• While in the class, assist students with understanding directions, beginning and completing
assignments, or as otherwise directed by the teacher*
• Provide follow-up from class instruction*
• Work with small groups of student under the direction of the classroom teacher*
• Occasionally cover classroom while teacher attends EC or other meetings (lead teacher plans and
leaves assignments and activities)*
Student Support
• Assist with personal/physical care of student based on child’s needs, including, but not limited to
any of the following:*
- tube feedings
- catheterization
- assisting with transfers of physically impaired students from wheelchair to toilet, desk, etc. and
back
- changing soiled clothing
- changing diapers
- assisting with toileting
• Assist with implementation of modifications and accommodations on student IEPs*
7/02
14-6
Durham Public Schools
Programs for Exceptional Children
Communication and Record Keeping
•
•
•
•
•
•
Maintain confidentiality of student records, performance and medical/disability-related
information*
Communicate observations, information, etc., regarding students, classroom activities, etc. to the
classroom teacher and/or parents as directed by the teacher*
Participate in data collection for student IEPs as directed by the teacher*
Participate in IEP meetings, discussions, etc. upon request of teacher/principal*
Assists in data collection for behavioral intervention plans, contracts, reward systems, etc.*
Take attendance, prepare materials,* and file student work
Other
• Other duties as assigned by supervisory personnel
• Participate in available training for the duties listed above*
*Denotes essential function of the job
Knowledge, Skills and Abilities Required
•
•
•
•
•
•
•
•
•
•
7/02
Working knowledge of the core subjects at the grade level to which employment assignment is
made
Ability to read, speak and write the English language sufficiently to be clearly understood by
school personnel and parents
Ability to lift and/or transfer students or materials weighing up to 50 pounds without assistance
and up to 100 pounds with assistance
Ability to establish and maintain positive relationships with students, staff and parents.
Ability to record data accurately
Ability to maintain safe environment for students during activities and mealtime
Ability to follow minimally detailed written and oral instructions without constant supervision
Ability to independently solve minor problems
Ability to maintain confidentiality of student information
Ability to follow prescribed procedures to maintain sanitary environment
14-7
Additional Local Forms
Durham Public Schools
Programs for Exceptional Children
ADDITIONAL LOCAL FORMS
1.
IEP Team Meeting Minutes Form (ECP-S35)
Used to record minutes of all IEP meetings.
2.
Exceptional Student Information Sheet (ECP-S36)
Completed by Case Managers. The form serves to share class schedules and modifications with
regular teachers.
3.
Acknowledgement of Receipt of EC Information (ECP-S37)
Completed by regular education teachers to verify that they have received a copy of their
students' IEPs and/or modifications and accommodations.
4.
Confidential Social Developmental History (ECP-S38)
Usually completed during the SAP process.
5.
Confidential Social Developmental History Update (ECP-S38A)
Used to update the social developmental history for a reevaluation.
6.
Surrogate Referral (ECP-S39)
Completed by Facilitator and sent to EC Central Office personnel in charge of assigning
Surrogate Parents.
7.
Special Education Class Enrollment Form (Class Schedule) (ECP-DPI1)
Completed by each EC teacher at the request of EC Central Office to indicate daily schedule of
the number of students served by category each period of the day. Directions included.
8.
Separate Data Base Codes and Explanations
Used to manually update the EC Central Office database of EC separate students.
9.
SIMS Update Form (ECP-S40)
Used to record information necessary for updating the Student Information Management System
(SIMS) database.
10.
Health Screening Report (ECP-S41)
Used in evaluation/reevaluation and eligibility determinations for disabilities that require a
health screening. Requires review and signature of school nurse.
11.
Modified Textbook Order Form (ECP-F9)
Used to record requests for modified textbooks that are necessary to meet IEP requirements.
12.
Records Center Transfer Form for Confidential Records
To be affixed to boxes of confidential records transferred to the Records Center
Rev. 7/02
15-1
p. ___ of ___
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
IEP TEAM MEETING MINUTES
Name of Student:_____________________________________ Meeting Date: ____/_____/____
DOB:____________________________ School: ________________________________________
Present for meeting: ______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Purpose of meeting: ______________________________________________________________
________________________________________________________________________________
Parent received copy of Parents’ Rights Handbook prior to meeting: Yes q
No q
If no, explain____________________________________________________________________
Presentation: ____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_________________
Decision/Recommendation: ______________________________________________________
_______________________________________________________________________________
Follow-up: _____________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Report Submitted By: _________________
ECP-S35
Rev. 8/01
Copy Given to Parent____________
p. ___ of ___
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
IEP TEAM MEETING MINUTES (Continued)
Student Name _________________________________ Meeting Date:_____/_____/____
DOB:____________________________School:________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
ECP-S35
Rev. 8/01
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
EXCEPTIONAL STUDENT INFORMATION SHEET
For School Year 200__ – 200__
Student's Name
Date of Birth
School
Grade
Parents' Names
Home Phone
Work Phone
IEP Review Date
Re-Eval Date
Case Manager
ECP Teacher(s)
Exceptionality
Areas
Related Services
Behavior Intervention Plan ?
Notes:
Student's Schedule*
FIRST SEMESTER
CLASSES
SECOND SEMESTER
TEACHERS
CLASSES
TEACHERS
HR
1
2
3
4
5
6
7
*Optional for elementary students
p. 1 of 2
ECP-S36
Rev. 8/01
DURHAM PUBLIC SCHOOLS
Exceptional Children's Programs
EXCEPTIONAL STUDENT INFORMATION SHEET
For School Year 200__ – 200__
Student's Name
Case Manager
Classroom services: (indicate none, consult (con), inclusion (inc), or resource (res) )
LA or
English
Social
Studies
Math
Science
Copy of IEP goals and objectives attached: Yes ____ No____
Student has a behavior intervention plan: No ____ Yes____ Copy attached _____
Standardized Testing Modifications (check all that apply)
Separate setting
Extended time
Read aloud
Scribe
Mark in book
Multiple sessions
1 Test item per page
Other:
Classroom Modifications (Check all that apply)
Instructional
Presentation
Instructional
Materials
Assignments
Testing
Physical
Environment
Interpreter
Audio
Tapes
Alternate
Read Aloud
Seated near
Teacher
Teacher
Notes
Demo
Teaching
Student
Notes
Tape
Recorder
Large Print
Simplified
Larger Desktop
Models
Oral
Extended
Time
Separate
Setting
Sequential
Modified
Large Print
Captioned
Films
Regraded
Dictation
Adapted Text
Completion
Timeline
Self-paced
Projects
Cooperative
Group Proj.
Multiple
Choice
Short
Answer
Highlight
Text
Graphic
Organizer
Course
Outline
Study Guide
Review
Materials
Portfolio
Demonstration
Nonglare
Lights
Away from
Windows
Classes on 1st
Floor
Supplemental
Aides
Braille/
Braillewriter
CrammerAbacus
Magnification
Devices
Computer/
Word Proc.
p. 2 of 2
ECP-S36
Rev. 8/01
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
ACKNOWLEDGMENT OF RECEIPT OF EC INFORMATION
TO:
All Teachers of EC Students
FROM:
RE:
Verification of receipt of modification sheets and/or IEP for the following students:
1. ______________________________________
2. ______________________________________
3. ______________________________________
4. ______________________________________
5. ______________________________________
6. ______________________________________
Please initial students' names and sign below indicating you have received these items. Return memo in this
folder/envelope to ______________________________________. Thank you.
Signature _________________________________________ Date _______________________
ECP-S37
Rev. 8/01
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
CONFIDENTIAL SOCIAL DEVELOPMENTAL HISTORY
Completed by __________________________________
Date ______________________
Relationship to Student _____________________________
I.
Student Information
Name ____________________________________________________ School ___________________
Age ___________
Date of Birth ____/____/____ Gender ______
Grade ______________
Address _______________________________________________
Telephone _________________
II.
Parent Information (If relevant, also provide information for stepparent or guardian.)
Mother ________________________________
Father _________________________________
Age _____ Education ____________________
Age _____ Education ____________________
Place of Birth ___________________________
Place of Birth __________________________
Marital Status: Married ______
Separated ______
When __________________
Divorced ______
When __________________
Custody arrangements __________________________________________________________________
_____________________________________________________________________________________
Remarried?
Mother _____ When ________
Father _____ When ________
Deceased?
Mother _____ When ________
Father _____ When ________
III.
Employment Information (circle parents with whom the child lives)
Mother / Step-Mother / Guardian
Father / Step-Father / Guardian
Employer ______________________________
Length of Employment ___________________
Work Telephone ________________________
Employer ______________________________
Length of Employment ___________________
Work Telephone _________________________
IV.
Family Composition
List brothers and sisters and/or members of stepfamilies:
Name
Relationship
____________________________
___________
____________________________
___________
____________________________
___________
____________________________
___________
____________________________
___________
Gender
______
______
______
______
______
ECP-S38
Rev. 8/01
Age
_____
_____
_____
_____
_____
Lives in the Home
yes ____
no ____
yes ____
no ____
yes ____
no ____
yes ____
no ____
yes ____
no ____
p. 1 of 4
Name:
Date:
CONFIDENTIAL SOCIAL DEVELOPMENTAL HISTORY (Continued)
V.
Medical History
Pregnancy:
Mother’s age at delivery ______________
Father's age ______________________
Complications: Premature_____ Number of weeks early _______ Number of week's late____________
Urinary Infection ______
Toxemia ____
High Blood Pressure _________
Other _________________________________________________________________
Illnesses ________________________________________
Medications ______________________
Smoking _______ How Much? ___________________________________________________________
Alcohol ________ How Much? ___________________________________________________________
Any unusual stress during the pregnancy which has not been addressed :___________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
VI.
Neonatal Period
Birthplace _______________________________________
Birthweight ______________________
Breech ____
Cesarean ____ Why? _____________________________________________________
VII.
Early Development
When did the child:
Sit _________
Crawl _________
Stand _________
Walk __________
Say single words __________
Use sentences __________
Feed self ________________
Complete Toilet training ___________
Did she/he eat well? _________________________
Sleep well? ______________________
Describe his/her disposition (e.g., active, passive, loud, quiet, happy, etc.) _________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
VIII. Diseases/Illnesses (indicate age when contracted)
Measles _________________ Mumps _________________ Pneumonia _________________
Spinal Meningitis ___________________ Scarlet Fever ______________________________
Rheumatic Fever ___________________ Anemia __________________________________
Heart Problems _________________________ Kidney Problems ______________________
High fevers ________________ Describe _________________________________________
Serious injuries __________ Describe ____________________________________________
Allergies ___________________________________________________________________
History of seizure activity _____________________________________________________
Vision ________________ Hearing ________________ Ear Infections _________________
IX.
Hospitalization (include age, length of stay, reason, etc.)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
ECP-S38
Rev. 8/01
p. 2 of 4
Name:
Date:
CONFIDENTIAL SOCIAL DEVELOPMENTAL HISTORY (Continued)
X.
Current Health
Present health condition is: ____ Excellent
_____ Good
_____Satisfactory
______Poor
Child has problems with: ____ Speech
____ Hearing
____ Vision
____Asthma
____ Headaches
____ Stomach Aches ____ Diabetes
____ Hyperactivity
____ Bed Wetting
____ Tubes in Ears ____ Ear Aches/Infections
Other ________________________________________________________________________________
Does the child have good eating habits? ____________________________________________________
Child’s weight:
____ Underweight
____ Normal
____ Overweight
Is the child on medication?
_____ Yes
____ No
Condition being treated: __________________________________________________________
Name of medication:_____________________________________________________________
Dosage: _______________________________________________________________________
XI.
Family History (Include relationship to child.)
Epilepsy _________________ Seizure _________________ Convulsions _________________________
Diabetes ______________________________ Mental Handicap _______________________________
Cerebral Palsy _________________________ Physical Disabilities ____________________________
Mental Illness __________________________ Behavior Difficulties ____________________________
Learning Difficulties ____________________ Other ________________________________________
XII.
Behavioral/Emotional Information
Parent’s perspective concerning child’s problem(s) __________________________________________
___________________________________________________________________________________
Parent/Child Relationship:
Mother (Stepmother) __________________________________________________________________
___________________________________________________________________________________
Father (Stepfather) ___________________________________________________________________
___________________________________________________________________________________
Sibling relationships __________________________________________________________________
___________________________________________________________________________________
Relationship with peers _______________________________________________________________
___________________________________________________________________________________
Behavior(s) of most concern to parents __________________________________________________
___________________________________________________________________________________
Discipline Techniques/Results __________________________________________________________
___________________________________________________________________________________
Family moves _______________________________________________________________________
Deaths or losses _____________________________________________________________________
Family problems _____________________________________________________________________
___________________________________________________________________________________
Specific behaviors observed in the home (include ages and any comments)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Do the parents feel the child is under any peer pressure? _____________________________________
___________________________________________________________________________________
ECP-S38
Rev. 8/01
p. 3 of 4
Name:
Date:
CONFIDENTIAL SOCIAL DEVELOPMENTAL HISTORY (Continued)
XIII. Preschool/School Experiences
Child’s primary care person ______________________________________________________________
Have there been others? (grandparent, babysitter, daycare, preschool, etc.) Please list who and for how long:
________________________________________________________________________________
_____________________________________________________________________________________
What is your child’s attitude toward school? _________________________________________________
_____________________________________________________________________________________
What school problems are you are aware of?_________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How does your child do his/her homework?
___ independently
___ with help
___ not at all
Attitude towards homework is: ___ good
___ poor
XIV. Community Agency Involvement
Which community agencies have been involved with the child/family, how did they become involved, what
was the outcome, is contact with family ongoing, if not, when was contact terminated?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
XV.
General Comments
What do you regard as your child’s greatest strengths or assets? _______________________________
___________________________________________________________________________________
ECP-S38
Rev. 8/01
p. 4 of 4
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
CONFIDENTIAL SOCIAL DEVELOPMENTAL UPDATE
Note: For Reevaluations only. Not to be used for Initial Placement
Completed by: ________________________________
Relationship to Student: _________________________
Date: ________________________________________
Student Information
Name: _________________________________________
School: _________________________
Age: ____
Gender: __________ Grade: _______
Date of Birth: ______________________
Address: ____________________________________________________________________________
Phone: _______________________________
Medical
Describe the child’s health:
Describe any recent physical/medical problems:
List medications the child takes and reasons taken:
Describe any severe illnesses, injuries, or accidents that have occurred within the last three years:
Parental Information
Mother / Step-Mother / Guardian
(circle)
Father / Step-Father / Guardian
Name: ________________________________
Name: ________________________________
Employer: _____________________________
Employer: _____________________________
Length of Employment: __________________
Length of Employment: __________________
Are the child’s parents (circle one)
married / divorced / separated / never married?
Child lives with __________________________________.
If parents divorced/separated, please explain current custody or visitation and source of this information:
Family Composition
List brothers and sisters and/or members of stepfamilies:
Name
Relationship
Gender
____________________ ____________________
______
____________________ ____________________
______
____________________ ____________________
______
____________________ ____________________
______
____________________ ____________________
______
ECP-S38A
Rev. 7/02
Age
___
___
___
___
___
Lives in the Home?
yes____ no_____
yes____ no_____
yes____ no_____
yes____ no_____
yes____ no_____
p. 1 of 2
Name:
Date:
CONFIDENTIAL SOCIAL DEVELOPMENTAL UPDATE (Continued)
Describe any different living/family arrangements during the past three years:
Describe how the child gets along with family members:
Describe anything in the family that may be worrying your child (deaths, sickness, moves, separations,
divorces, financial trouble, etc.)
School
How does your child feel about school?
What are the child’s favorite/least favorite things about school?
Describe the child’s study and homework habits:
Behavioral/Emotional
Describe the child’s current behavior at home:
How is the child disciplined for misbehavior?
How often does the child need discipline?
On an additional page, please add any additional information about the child or the family that you feel may
be helpful to the school. Thank you.
___________________________________________
Signature of person completing form
ECP-S38A
Rev. 7/02
p. 2 of 2
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Program
REQUEST FOR ASSIGNMENT OF SURROGATE PARENT
This form should be completed when a surrogate is needed because (1) no natural parent or legal guardian
can be located; and (2) there is no other adult who, with the permission of the parent, is acting in the place
of the parent, e.g., a grandmother, aunt or adult sibling. The surrogate may not be an employee of DPS or
any other school district or State agency. Send completed form to EC Central Office personnel in charge of
assigning Surrogate Parents.
Name __________________________________________
DOB ____________________________
Address ________________________________________
City_____________________________
State __________
Zip Code ____________
Phone Number (
Grade _________
Ethnicity ____________
Sex ____________
)_______________
School ________________________________________
Primary Disability _________________
Foster Parents __________________________________
Work Number(s)___________________
Address ______________________________________________________________________________
D.S.S. Case Worker _______________________________
Phone Number____________________
Guardian ad Litem ________________________________
Phone Number ____________________
Referred by ______________________________________
Date Sent ________________________
Comments ___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
This section to be completed by Central Office Personnel
Surrogate Assigned ____________________________________________
Date _____________
Address __________________________________________________________________________
___________________________________________________ Phone _______________________
ECP-S39
Rev. 7/02
Special Education Class Enrollment
LEA:
Durham Public Schools
School: _________________________________________
Elem ________ MS ________ HS _________
Non-Duplicated Class Load by Disabilities (school wide caseload):
AU _______ SLD _______ SPD _______ DD _______
BED _______ OHI _______ TMD _______ SI _______
EMD _______ OI _______ TBI _______
HI _______ MU _______ VI
_______ *Total ______
Regular _______ Resource _______ Separate _______
Inclusion ______ Consult _______
*Total ______
Teacher:_______________________________________
EC Certification Area(s):_________________________
Percent employed by Regular Education/Exceptional
Ed.: ______%Regular ______%EC
Classroom Assistant(s)
(1)____________________________________________
SPEECH
THERAPISTS ONLY
FILL IN SHADED
BLOCK
Do not complete rest
of form
Show Total Served:
________
(2)____________________________________________
(3)____________________________________________
Inclusion Class Periods:______
*Totals must be the same
1) Indicate number of students by category
Daily Schedule
Period 1
MONDAY
1)
2)
2) Total per period
TUESDAY
3)
1)
_____
3) Number of assistants
WEDNESDAY
2)
3)
1)
2)
*highlight period(s) you are requesting to exceed class size
THURSDAY
3)
1)
______ ______ ______
FRIDAY
2)
3)
1)
Time:
Period 2
Time:
Period 3
Time:
Period 4
Time:
Period 5
Time:
Period 6
Time
Period 7
Time
Teacher’s Signature/Date : ____________________________________________________
EC Facilitator/Date: __________________________________________________________
DPI USE ONLY
Approval is requested to exceed maximum recommended class size, as highlighted above, based
on a review of teacher’s workload and the assurance that each student’s IEP can be met.
pApproved
Principal’s Signature/Date: _____________________________________________________
Assistant Superintendent of Exceptional Children
Signature/Date: _______________________________________________________________
__________________________________________ ___________
Fred J. Baars, Consultant
Date
ECP-DPI1
Rev. 8/01
pNot Approved
2)
3)
Durham Public Schools
Programs for Exceptional Children
SEPARATE DATABASE CODES AND EXPLANATIONS
Column Title
Explanation
School
Present school assignment
Teacher
Current EC teacher
Name
Student’s legal name (Last, First, MI)
Date of Birth
Year, day, month (e.g., 86/27/03)
Age
As of today’s date
Ethnicity
Use SIMS codes
Sex
Male or Female
Exceptionality
Area of eligibility as checked on IEP
Setting
Level of service
Street number
Street
Apartment number
Zip code
Most current home address available
Class
Type of classroom where the student is receiving EC services
(BED, EMD, AU, MU, SP, TMD, MC, SLD, HI)
0_- 0_
Grade level for this school year
Home School
To be completed by EC Central Services
Grade 0_- 0_
Projected grade level for next school year
Last Column*
Note whether student is due to graduate or age out of the program
*This column to be completed by high school teachers only!
PLEASE COMPLETE ANY MISSING INFORMATION! FILL IN ALL BLANKS
EXCEPT FOR “HOME SCHOOL”
15-15
WORKSHEET E C A D D / C H A N G E S T U D E N T I N F O R M A T I O N
STUDENT NAME:__________________________ YEAR___/___
EXIT DATE ___/___/___
STUDENT # ____________________
EXIT CODE_________________________
REFERRAL/RE-EVALUATE DATE ___/___/___
THIRD YEAR RE-EVALUATION (Y/N) ? ___Y___ N
PERMISSION/NOTICE EVALUATE ___/___/___
(Parent Permission to Eval. Or Re-Eval.)
SCREENINGIEVALUATION:
S-Procedures/EH
___/___/___
E-Educational
___/___/___
S-Procedures/LD
___/___/___
E-IQ/Aptitude %ile
___/___/___
S-Health
___/___/___
E-Medical
___/___/___
S-Hearing
___/___/___
E-Ophthal/Optometric
___/___/___
S-Multidisc. Team ___/___/___
E-Otological
___/___/___
S-Psychomotor
___/___/___
E-Performance on Grades ___/___/___
S-Speech-Language ___/___/___
E-Psychological
___/___/___
S-Vision
___/___/___
E-Psychomotor
___/___/___
E-Adaptive Beh.
___/___/___
E-Review Early History ___/___/___
E-Audiological
___/___/___
E-Social/Dev. Hist
___/___/___
E-Beh/Emotional
___/___/___
E-Speech-Language
___/___/___
E-Cognitive
___/___/___
___________________________________________________________________________________
WRITTEN SUMMARY OF EVALUATION TO PARENT/S
___/___/___
SBC DETERMINATION OF ELIGIBILITY
___/___/___(Date of eligibility determination)*
APC DECISION FOR PLACEMENT
___/___/___(Date of IEP completion)
INITIAL PLACEMENT (Y/N) ? ___Y___ N
___/___/___
PARENTAL CONSENT FOR PLACEMENT
___/___/___
PRIMARY EXCEPTIONALITY _______
SERVED DATE
___/___/___(Date IEP service begins in each LEA)
STUDENT SETTING
_______
BEGIN DATE
END DATE
FIRST IEP
___/___/___
___/___/___
SECOND IEP
___/___/___
___/___/___
THIRD IEP
___/___/___
___/___/___
___________________________________________________________________________________
EC IDENTIFIER CODE [computer]__
EC TEACHER [blank]__
IDENTIFICATION MATRIX _________
STATE OPERATED PROGRAM _________
COMPLIANCE OVERRIDE
___S___
ENTITLED (Y/N)? ___Y ___N
LEGALLY BLIND (Y/N) ___Y ___N
VISUAL ACUITY
L _____ (Do Not complete
R _____ if answer is "no")
VISUAL ACUITY CODE
L _____
R _____
READING MEDIUM CODE
_____
(S-System, C-Compliant, N-Not Compliant)
CODE
BEGIN DATE
END DATE
_____
___/___/___
___/___/___
(Date related service
_____
___/___/___
___/___/___
began/Date exited
_____
___/___/___
___/___/___
from related service)
_____
___/___/___
___/___/___
___________________________________________________________________________________
DO YOU WANT TO ADD WILLIE M DATA? (Y/N) N
----------------------------------------------------------------------------------F1
PROCESS
SBC: ______________
DATE: ___/___/___
SIMS: ______________
___/___/___
FOLDER: ________________
___/___/____
___________________________________________________________________________________
RELATED SERVICES
*This will be: (1) date of Re-Evaluation Determination Report if no additional assessment was needed to
determine continuing eligibility; or (2) date of the Summary of Evaluation Results and Eligibility
Determination if additional assessment was required to determine eligibility.
ECP-S40
Rev. 8/01
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
Health Screening Report
Child’s Name: ___________________________________________
Date of Birth: ___________________
Name of Interviewer: _________________________________
Date: _______________________
Name of Person Interviewed: _______________________________
Relationship: ____________________
I. Health History
Has the child had problems in any of the areas below? Explain “yes” answers.
Yes No
___ ___
Frequent Earaches/Infections _______________________________________________
___ ___
Frequent Headaches ______________________________________________________
___ ___
Diabetes _______________________________________________________________
___ ___
Asthma ________________________________________________________________
___ ___
Seizures _______________________________________________________________
___ ___
Sickle Cell Disease/Trait ___________________________________________________
___ ___
Allergies (List) __________________________________________________________
___ ___
Complications with Childhood Illnesses ______________________________________
___ ___
Serious Illness __________________________________________________________
___ ___
Serious Accident ________________________________________________________
___ ___
Hospitalization _________________________________________________________
___ ___
Surgery _______________________________________________________________
Other Pertinent Medical Information
Medication
List all medication taken on a regular basis.
Name of Medication
Date Prescribed
Dosage
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
ECP-S41
7/02
p.1 of 2
Name:
Date:
Health Screening Report (Continued)
II. Developmental Milestones
List approximate age at which child did the following:
Sat Alone ______________________
Fed Self __________________________
Crawled
______________________
Toilet Trained _____________________
Walked
______________________
Dressed Self ______________________
Talked
______________________
Peddled Tricycle ___________________
III. Dietary Habits
Approximately how many times a week does the child eat:
Breakfast: _________
Lunch: __________
Dinner: ___________
Does child eat foods from the following food groups?
Yes No
___ ___ Dairy products
___ ___ Meat
___ ___ Fruits and vegetables
___ ___ Breads and cereals
___ ___ Does your child eat sweets frequently?
___ ___ If yes, does it interfere with or substitute for meals?
IV. Physical Condition (To be completed by school nurse)
Height _____________________
Blood Pressure ___________________________
Weight _____________________
Pulse ___________________________________
Teeth
Respirations _____________________________
_____________________
General Physical Condition _____________________________________________________
Referral for a medical evaluation (circle one):
Yes
No
___________________________________
Nurse’s Signature and Date
ECP-S41
7/02
p.2 of 2
Durham Public Schools
Programs for Exceptional Children
SEPARATE DATABASE CODES AND EXPLANATIONS
Column Title
Explanation
School
Present school assignment
Teacher
Current EC teacher
Name
Student’s legal name (Last, First, MI)
Date of Birth
Year, day, month (e.g., 86/27/03)
Age
As of today’s date
Ethnicity
Use SIMS codes
Sex
Male or Female
Exceptionality
Area of eligibility as checked on IEP
Setting
Level of service
Street number
Street
Apartment number
Zip code
Most current home address available
Class
Type of classroom where the student is receiving EC services
(BED, EMD, AU, MU, SP, TMD, MC, SLD, HI)
0_- 0_
Grade level for this school year
Home School
To be completed by EC Central Services
Grade 0_- 0_
Projected grade level for next school year
Last Column*
Note whether student is due to graduate or age out of the program
*This column to be completed by high school teachers only!
PLEASE COMPLETE ANY MISSING INFORMATION! FILL IN ALL BLANKS
EXCEPT FOR “HOME SCHOOL”
15-15
WORKSHEET E C A D D / C H A N G E S T U D E N T I N F O R M A T I O N
STUDENT NAME:__________________________ YEAR___/___
EXIT DATE ___/___/___
STUDENT # ____________________
EXIT CODE_________________________
REFERRAL/RE-EVALUATE DATE ___/___/___
THIRD YEAR RE-EVALUATION (Y/N) ? ___Y___ N
PERMISSION/NOTICE EVALUATE ___/___/___
(Parent Permission to Eval. Or Re-Eval.)
SCREENINGIEVALUATION:
S-Procedures/EH
___/___/___
E-Educational
___/___/___
S-Procedures/LD
___/___/___
E-IQ/Aptitude %ile
___/___/___
S-Health
___/___/___
E-Medical
___/___/___
S-Hearing
___/___/___
E-Ophthal/Optometric
___/___/___
S-Multidisc. Team ___/___/___
E-Otological
___/___/___
S-Psychomotor
___/___/___
E-Performance on Grades ___/___/___
S-Speech-Language ___/___/___
E-Psychological
___/___/___
S-Vision
___/___/___
E-Psychomotor
___/___/___
E-Adaptive Beh.
___/___/___
E-Review Early History ___/___/___
E-Audiological
___/___/___
E-Social/Dev. Hist
___/___/___
E-Beh/Emotional
___/___/___
E-Speech-Language
___/___/___
E-Cognitive
___/___/___
___________________________________________________________________________________
WRITTEN SUMMARY OF EVALUATION TO PARENT/S
___/___/___
SBC DETERMINATION OF ELIGIBILITY
___/___/___(Date of eligibility determination)*
APC DECISION FOR PLACEMENT
___/___/___(Date of IEP completion)
INITIAL PLACEMENT (Y/N) ? ___Y___ N
___/___/___
PARENTAL CONSENT FOR PLACEMENT
___/___/___
PRIMARY EXCEPTIONALITY _______
SERVED DATE
___/___/___(Date IEP service begins in each LEA)
STUDENT SETTING
_______
BEGIN DATE
END DATE
FIRST IEP
___/___/___
___/___/___
SECOND IEP
___/___/___
___/___/___
THIRD IEP
___/___/___
___/___/___
___________________________________________________________________________________
EC IDENTIFIER CODE [computer]__
EC TEACHER [blank]__
IDENTIFICATION MATRIX _________
STATE OPERATED PROGRAM _________
COMPLIANCE OVERRIDE
___S___
ENTITLED (Y/N)? ___Y ___N
LEGALLY BLIND (Y/N) ___Y ___N
VISUAL ACUITY
L _____ (Do Not complete
R _____ if answer is "no")
VISUAL ACUITY CODE
L _____
R _____
READING MEDIUM CODE
_____
(S-System, C-Compliant, N-Not Compliant)
CODE
BEGIN DATE
END DATE
_____
___/___/___
___/___/___
(Date related service
_____
___/___/___
___/___/___
began/Date exited
_____
___/___/___
___/___/___
from related service)
_____
___/___/___
___/___/___
___________________________________________________________________________________
DO YOU WANT TO ADD WILLIE M DATA? (Y/N) N
----------------------------------------------------------------------------------F1
PROCESS
SBC: ______________
DATE: ___/___/___
SIMS: ______________
___/___/___
FOLDER: ________________
___/___/____
___________________________________________________________________________________
RELATED SERVICES
*This will be: (1) date of Re-Evaluation Determination Report if no additional assessment was needed to
determine continuing eligibility; or (2) date of the Summary of Evaluation Results and Eligibility
Determination if additional assessment was required to determine eligibility.
ECP-S40
Rev. 8/01
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
Health Screening Report
Child’s Name: ___________________________________________
Date of Birth: ___________________
Name of Interviewer: _________________________________
Date: _______________________
Name of Person Interviewed: _______________________________
Relationship: ____________________
I. Health History
Has the child had problems in any of the areas below? Explain “yes” answers.
Yes No
___ ___
Frequent Earaches/Infections _______________________________________________
___ ___
Frequent Headaches ______________________________________________________
___ ___
Diabetes _______________________________________________________________
___ ___
Asthma ________________________________________________________________
___ ___
Seizures _______________________________________________________________
___ ___
Sickle Cell Disease/Trait ___________________________________________________
___ ___
Allergies (List) __________________________________________________________
___ ___
Complications with Childhood Illnesses ______________________________________
___ ___
Serious Illness __________________________________________________________
___ ___
Serious Accident ________________________________________________________
___ ___
Hospitalization _________________________________________________________
___ ___
Surgery _______________________________________________________________
Other Pertinent Medical Information
Medication
List all medication taken on a regular basis.
Name of Medication
Date Prescribed
Dosage
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
ECP-S41
7/02
p.1 of 2
Name:
Date:
Health Screening Report (Continued)
II. Developmental Milestones
List approximate age at which child did the following:
Sat Alone ______________________
Fed Self __________________________
Crawled
______________________
Toilet Trained _____________________
Walked
______________________
Dressed Self ______________________
Talked
______________________
Peddled Tricycle ___________________
III. Dietary Habits
Approximately how many times a week does the child eat:
Breakfast: _________
Lunch: __________
Dinner: ___________
Does child eat foods from the following food groups?
Yes No
___ ___ Dairy products
___ ___ Meat
___ ___ Fruits and vegetables
___ ___ Breads and cereals
___ ___ Does your child eat sweets frequently?
___ ___ If yes, does it interfere with or substitute for meals?
IV. Physical Condition (To be completed by school nurse)
Height _____________________
Blood Pressure ___________________________
Weight _____________________
Pulse ___________________________________
Teeth
Respirations _____________________________
_____________________
General Physical Condition _____________________________________________________
Referral for a medical evaluation (circle one):
Yes
No
___________________________________
Nurse’s Signature and Date
ECP-S41
7/02
p.2 of 2
DURHAM PUBLIC SCHOOLS
Exceptional Children’s Programs
MODIFIED TEXTBOOK ORDER FORM
For Use by VI Staff Only
Date Submitted:
_______________________________
School:
_____________________________________
School Contact*:
_______________________________
Student’s Name:
_______________________________
Student’s EC Placement: _______________________________
Date order placed:
_________________________
Date order sent to school:
_________________________
Modifications Available: A = Audio Cassette, B = Braille, L = Large Print
Quantity
Textbook Title
Grade
Level
Publisher
* The School Contact is responsible for receiving and returning these materials.
ECP-F9
7/02
Copyright
Date
ISBN #
Mod.
Needed
FOR DELIVERY TO THE RECORDS CENTER, HAMLIN ROAD
BOX ______ OF ______
CONTENTS: Confidential Files for Students:
FROM: _________________ TO: ____________________
(Last name)
(Last name)
FROM (school):___________________________
___Alpha order
___List enclosed (or previously sent by e-mail)
(This form must be affixed to each box of records transferred to the records center)
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
FOR DELIVERY TO THE RECORDS CENTER, HAMLIN ROAD
BOX ______ OF ______
CONTENTS: Confidential Files for Students:
FROM: _________________ TO: ____________________
(Last name)
(Last name)
FROM (school):___________________________
___Alpha order
___List enclosed (or previously sent by e-mail)
(This form must be affixed to each box of records transferred to the records center)
State Forms
State Forms and Directions for Use
DEC/Prior Notice
Invitation to Conference/Prior Notice
DEC 1/Prior Notice
Exceptional Children Referral
DEC 2/Prior Notice
Prior Notice and Parent/Guardian Consent for
Evaluation/Reevaluation
DEC 3/Prior Notice
Summary of Evaluation Results and Eligibility Determination
DEC 3(a)/Prior Notice
Eligibility Report/Specific Learning Disabilities (Revised 8/01)
DEC 3(a) –alt/Prior Notice
Eligibility Report/Specific Learning Disabilities Alternative Discrepancy
Revised (8/01)
DEC 3(b)/Prior Notice
Eligibility Report – Behaviorally Emotionally Disabled
DEC 3(c)/Prior Notice
Eligibility Report – Other Health Impaired
DEC 4
Individualized Education Program (IEP)
NCTP/Table 1
NC Testing Program: Tests Required for Graduation
NCTP/Table 2
NC Testing Program: Grades 3-8
NCTP/Table 3
NC Testing Program: Grades 9-12
DEC 5/Prior Notice
Prior Written Notice
DEC 6/Prior Notice
Prior Notice and Consent for Initial Placement for Special
Education Services
DEC 7/Prior Notice
Reevaluation Determination Report
Note: Copies of Spanish-language forms can be obtained from the EC Facilitator.
Rev. 7/02
16-1
Directions for DEC 3(a)/Prior Notice
Eligibility Report/Specific Learning Disabilities
This form must be completed by the LD Eligibility Team as part of (and at the same time as) the Eligibility Determination
(DEC 3/Prior Notice) whenever Specific Learning Disabilities (SLD) is being considered as an area of eligibility. This form
must be completed under the following circumstances:
• Initial placement in LD
• Reevaluation resulting in change of label to LD from another area of identification (e.g., SI)
• Change in area of eligibility is considered (e.g., adding reading comprehension)
• Reevaluation when new ability and achievement testing are obtained (it is not good practice to use data
more than one year old to calculate discrepancies)
The date on the DEC3(a) must be the same as the date on the corresponding DEC3. The DEC3(a) is to be attached to
the DEC 3. A copy of the DEC 3(a) must be given to the parent along with the DEC 3.
This revised DEC 3(a) (effective August 2001) represents changes to the prior version in order to reflect federal law that
requires identification in one or more of the seven areas of learning disabilities (e.g., reading comprehension and basic
reading but not broad reading). There is also an increased emphasis on documenting information processing difficulties
which reflects current research and thought.
Although there is no separate specific section to describe observational data, the team’s written report must include “the
relevant behavior noted during the observation of the child” and “the relationship of that behavior to the child’s academic
functioning.”(300.543) This information can be included in Sections A, C, and/ or D.
Section A: Information Processing
Section A allows the team to determine if there is evidence of a processing difficulty. The team considers each of the
three items (#1-2-3) related to processing difficulties. If a processing difficulty is not found, document this by writing
“none found.” If a processing difficulty is found, describe the learning behaviors associated with that processing difficulty.
Sources of evidence of a processing difficulty include, but are not limited to, observations of the student engaged in
learning, data from evaluations, outcomes from focused interventions, and work samples.
Section B: Ability-Achievement Discrepancy
Write the name of the general ability instrument and the ability standard score (e.g., Full Scale IQ, General Cognitive
Abilities, Broad Cognitive Abilities, etc.) in this section. When there is a Verbal/Performance IQ discrepancy of at least 20
points on the Wechsler scale, the higher scale IQ may be used to determine the ability/achievement discrepancy if
evidence is documented that the higher score accurately reflects the student’s intellectual functioning.
Section C: Alternative Discrepancy
If the team determines that the standardized assessment data do not accurately reflect a substantial discrepancy, place a
check mark at C and complete the DEC 3(a)-alt/Prior Notice. Any time an alternative discrepancy is used there must be
compelling documentable justification.
Section D: Substantial Learning Difficulties
The evidence may address observational data, grades, learning rate, basic skills for learning and concept development.
Appropriate interventions should reflect interventions designed to address the concerns noted in the SAP referral.
Section E: Other Impacting Factors
These factors may exist concomitantly with a Specific Learning Disability. However, if the team determines that a factor is
the primary cause of the student’s disability, the student may not be identified as having SLD.
Section F: SLD Eligibility
Check each SLD area that the student meets eligibility criteria. Each member of the LD Eligibility Team indicates whether
he/she agrees or disagrees on the DEC 3. If the student is not found to be eligible in any area, check ( ) not eligible.
For more information, see “Specific Learning Disabilities Eligibility” in Section 2 of this manual.