CHANGES IN PLACEMENT *This form must be completed by the case manager after every IEP meeting. Student Name:_____________________________ Case Manager:_____________________________ Effective Date:________________

 New IEP

 Amendment

Changes/Determinations: (Please indicate if consult only) Disability:  No Change

 New Identification: _______

 Not Identified

Added Services:

 OT

 PT

 Speech

 Nurse

 Social Worker  Sweetser SW

Dismissed from:

 OT

 PT

 Speech

 Nurse

 Social Worker  Sweetser SW

 Exited to Regular Education  Other: ________________________________

% of time in Regular Education Time arriving at school (getting off the bus): Time departing school (getting on the bus): Total time at school daily (hrs. or mins.) Time in SPED: Specially Designed Instruction: SW: S/L: OT: PT: Total time in pull out SPED:

daily daily daily daily daily daily

weekly weekly weekly weekly weekly weekly

* Be sure that SPED time includes only time spent in a SPED setting (Lunch, recess, & specials do not count in percentage of SPED even when supported by an ed. tech.) Determine percent of time in SPED: ___________ Record percent of time in Regular Ed:_________

(Divide total SPED hours by total School hours)

 Less than 40% in Reg. Ed. daily  Between 40% and 79% in Reg. Ed. daily

 Testing