Profile Info

Overall student information

Student Information:

Name: Last Name, First Name

Nickname: Name you want in IEP

Student ID: School ID number

State ID: State ID Number

Next School Year: School student will attend next year

Student Address Information:

Address: Mailing address

Phone: Home phone

Physical Address: Residence

Cell Phone: Primary parent phone

Student email: Optional

Parent/Guardian Address Information:

Name(s): Guardian names

Address(s): Mailing address

Phone (H/W)(s): Primary phone numbers

Cell Phone(s): Guardian’s cell phone

E-mail(s): Parent email address - give parent rights to parent portal for IEP information

Relationship(s): Guardian relationship

Comments/Notes(s): If anything is pertinent to know who the guardian is

Student’s Team Members:

Service Coordinator: Case manager

• uploads to Cover Page of IEP

• the rest of the team does not need to be added, only used for reporting

Student’s General Education Teacher Team Members:

Gen Ed Teacher: Name of general ed teacher

E-mail: Teacher email address - give teacher rights to teacher portal for IEP information

General Information:

Date of Birth: Complete

Gender: Complete

Grade: Current grade

Race/Ethnicity: Consistent with powerschool

Res. District: Where does the student reside

District of Attendance: Where is the student attending

Primary Lang. of Child: Complete - from PHLOTE form

Instructional Lang: Complete - from PHLOTE form

Home Lang: Complete - from PHLOTE form

Type of Placement: Primary special education services

Home School: Where student would attend if not in special education

Attending School: Where the student is attending

Emergency Contact: Who does the school contact if not able to reach parent/guardian

Emergency Phone: What phone number to be used if not able to reach parent/guardian

English Language Learner: Mark if considered EL

504 Student: Only mark if this is a 504 plan - students can only be special education or 504

Testing Dates and Results:

Hearing Date: Date of hearing screening Results: Complete

Vision Date: Date of vision screening Results: Complete

Language Survey Date: Date PHLOTE form completed Results: Complete if other than English

AZELLA Test Date: Only if taken the AZELLA Results: Only if taken the AZELLA

Test Result Clarification: Of the AZELLA test what needs to be clarified

Nursing Services: Does the student receive any regular support from the nurse - medication, seizure monitoring, etc?

Medical Notes: Does the student take medication, is there a diagnosis, etc?

Confidential Notes: Anything that needs to be noted about the student, but kept confidential with just the team

State and District Assessments: keep updated list of district benchmarks and state assessments

• • This will upload into the IEP.

  • Keep 3 years of testing history.

Current State Standardized Test Results

**optional

Parent consent for Medicaid Direct Service Claiming:

**optional