NOTIFICATION OF DEC FORM ACTIONS (Becky Form) Directions: Complete this form ANY time information changes (See Activities below). Make sure copy is legible. This form alerts CO that there is new information on EasyIEP; CO will use EasyIEP for the data source for headcount (thus all information in EasyIEP must be correct, up to date, and FINALIZED). Form will not be returned to school. This form may be faxed, emailed, or send copy to Becky Garrison at Central Office and is due within one week of any DEC form activity including IEPs. Only complete relevant sections. STUDENT: Last Name: ____________________

First Name: _____________________

Middle Name: _______________________

DOB: _____________ Sex: ____________ Race: __________________School: ______________________Grade: _________ ACTIVITIES: (Check any/all that apply)

 Transfer From: School: ___________________________,

Enrollment Date at Your School: _____/_____/______ If out of county transfer: IEP meeting date: ____/____/____ Powerschool #: __________ City: _______________State: ______ (circle one) initial or reevaluation IEP begin date: _____/ ______/ ______ IEP end date: ______/______/_______ Eligibility Determination Date: (DEC3) _____/_____/______ Label: _____________Setting: ___________

 Yes /  No – We are following the IEP received.

Related Service SPPA  OCCT  PHYT  TRAN  OTHER ____________________

 Initial Placement Powerschool #: _______________ Label: ________Setting: ____________ (If LD, note area(s): _______________________) Date School Received Written Referral (located on DEC 1) _____/_____/______ Placement Date (Eligibility Determination on DEC 3) _____/_____/______ Service Delivery: Pullout/ Non-disabled peers IEP From: _____/_____/______ IEP To: _____/_____/______ Related Service SPPA  OCCT  PHYT  TRAN  OTHER ____________________

 Reevaluation Eligibility Determination Date on DEC 3_____/_____/______ IEP From: _____/_____/______ IEP To: _____/_____/______ Service Delivery: Pullout/ Non-disabled peers  Change Setting – From _____________ To _____________  Change Label – From _______________ To _____________

(If LD, note area(s): _______________________)

 Related Service SPPA  OCCT  PHYT  TRAN  OTHER ____________________  Add  Delete Continue  Annual Review Date on DEC 5 _____/_____/______ IEP From: _____/_____/______ IEP To: _____/_____/______ Service Delivery: Pullout/ Non-disabled peers Setting__________________  If Change Setting – From _____________

 Addendum Date on DEC 5 _____/_____/______ IEP From: _____/_____/______ IEP To: _____/_____/______ Service Delivery: Pullout/ Non-disabled peers Setting__________________  If Change Setting – From _____________

 Kindergarten Transition Date on DEC 5 _____/_____/______ IEP From: _____/_____/______ IEP To: _____/_____/______ Related Service SPPA  OCCT  PHYT  TRAN  OTHER__________  Change Setting – From _____________ To _____________

 For Exit Only: Date of Exit: _____/_____/______ Reason: (circle) Exit EC (DE) Grad/Certificate

Grad/Diploma

Dropout

Moved

Max Age

Completed by: _______________________________________________

Date: _____/_____/______

CO Database entry by: _______________________________________

Date: _____/_____/______

Died

Private/Home

Unable to locate

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