Forms Related to Special Education
Forms related to the eligibility process, the reevaluation process, and the Individualized Education Program (IEP). Additional forms related to the special education process are also included here.
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This page includes Multipurpose Referral Forms, Procedural Safeguards, Eligibility Related Forms (including Basis for Committee Decision (BCD) Forms), Individual Education Program (IEP) Forms, Individual Service Plan (ISP) Forms, Age of Majority Information, and additional forms related to the special education process.
NOTE: Fillable forms may create problems in Google Chrome. Please open using another web browser, such as Internet Explorer, or download from the web to your device, then open in a PDF reader, such as Adobe Reader.
Multipurpose Referral Forms
When there is reason to suspect that a student has a disability and is in need of special education and related services, a referral can be made to the local screening committee through the use of the Multipurpose Referral (SS/SE-5).
Page two of the Multipurpose Referral (SS/SE-5A) must be completed by the student's classroom teacher or other appropriate school staff members, prior to the local screening committee meeting.
SS/SE-5: Multipurpose Referral
SS/SE-5A: Multipurpose Referral (Page 2)
Note: This fillable form may create problems in Google Chrome. Please open using another web browser, such as Internet Explorer, or download from the web to your device, then open in a PDF reader, such as Adobe Reader.
Procedural Safeguards
Key parts of the Individuals with Disabilities Education Improvement Act of 2004 (IDEA), a federal law governing the education of students with disabilities.
Further explanation of the procedural safeguards is available by contacting:
Due Process and Eligibility, 571-423-4470
Special Education Procedural Support, 571-423-4290
Parent Resource Center, 703-204-3941
Eligibility Related Forms
The following forms are used throughout the initial eligibility and reevaluation processes, including the basis for committee decision (BCD) forms for each area of disability.
SS/SE-2: Notice and Consent for Evaluation
SS/SE-6: Reevaluation Report
SS/SE-10: Special Education Eligibility
SS/SE-13: Notice Not to Evaluate
SS/SE-14: Local Screening Committee Report
SS/SE-83: Notice of Local Screening Committee Meeting
SS/SE-107: Parent Notice of Eligibility Determination
SS/SE-126: Notice of Reevaluation
SS/SE-142: Notice of Eligibility Meeting
SS/SE-251: Eligibility Committee Additional Data Required
Basis for Committee Decision (BCD) Forms
The following forms are ordered alphabetically by form title.
Autism Basis for Committee Decision: SS/SE-10A
Deaf-Blindness Basis for Committee Decision: SS/SE-10P
Deafness Basis for Committee Decision: SS/SE-10N
Developmental Delay Basis for Committee Decision: SS/SE-10M
Emotional Disability Basis for Committee Decision: SS/SE-10B
Hearing Impairment Basis for Committee Decision: SS/SE-10C
Intellectual Disability Basis for Committee Decision: SS/SE-10D
Multiple Disabilities Basis for Committee Decision: SS/SE-10E
Orthopedic Impairment Basis for Committee Decision: SS/SE-10F
Other Health Impairment Basis for Committee Decision: SS/SE-10G
Specific Learning Disability Basis for Committee Decision: SS/SE-10I
Speech/Language Impairment Basis for Committee Decision: SS/SE-10J
Traumatic Brain Injury Basis for Committee Decision: SS/SE-10K
Visual Impairment Basis for Committee Decision: SS/SE-10L
Individualized Education Program (IEP) Forms
The following forms may be used throughout the IEP process.
IEP 202: IEP Notice - Initial/Annual
IEP 203: IEP Progress Report - Annual Goals
IEP 204: IEP Progress Report - Annual Goal/Short Term Objectives
IEP 205: ESY Progress Report
IEP 208: Non-Attendance of IEP Team Members
IEP 209: Manifestation Determination Review
IEP 209A: Manifestation Determination Review - Cover Page
IEP 211: IEP Addendum Without a Meeting
IEP 212: IEP Progress Report - Short Term Objectives
IEP 213: Parent Notification of Manifestation Determination Review Meeting
IEP 216: Parent Consent for Billing Medicaid or FAMIS for Covered Services
IEP 217: AIM-VA Verification Form
IEP 220: Prior Written Notice
IEP 224: Meeting Minutes
IEP 301: IEP Meeting Agenda
IEP 302: IEP Cover Page
IEP 303: Transition Goals
IEP 304: Transition Services
IEP 306: Area of Need/Annual Goal and Short Term Objectives
IEP 307: Area of Need/Annual Goal
IEP 308: Curriculum/Classroom Accommodations and Modifications
IEP 309: Information Related to Present Level of Educational Performance
IEP 310: Elementary Assessment
SS/SE-367 (Previously IEP 311): Elementary School Accommodations
IEP 312: Middle School Assessment
SS/SE-368 (Previously IEP 313): Middle School Accommodations
IEP 314: High School Assessment
SS/SE-369 (Previously IEP 315): High School Accommodations
IEP 316: VAAP Criteria
IEP 319: Least Restrictive Environment (LRE)
IEP 320: Services
IEP 321: Placement
IEP 322: Extended School Year
IEP 323: Prior Notice and Consent
SS/SE 272 (Previously IEP 325): Calculator Criteria Form
SS/SE 274 (Previously IEP 326): Read Aloud and Audio Accommodation Criteria Form
IEP 327: Behavior Intervention Plan (Draft)
IEP 327A: Behavior Intervention Plan Review (Draft)
IEP 328: Transfer Student Documentation
IEP-329: Functional Behavior Assessment (Draft)
IEP 331: Credit Accommodations Eligibility Form
Note IEP 331 is now SS/SE-353
Individual Services Plan (ISP) Forms
An individual services plan (ISP) documents the service(s) a student may receive when the student is receiving homeschooling or attends a parentally placed private school.
Age of Majority Information
Information and forms for parents and students as students reach the age of 18.
- Age of Majority
Under most circumstances, when a student reaches the age of majority on his or her eighteenth (18) birthday, the rights related to special education provided by the school system transfer from the parents or guardians to the student. - Educational Representation for Adult Students
Information for parents and guardians who, due to the nature or severity of their student’s disability, desire to continue to serve as their students’ educational representative.
SS/SE-338: Certification of the Inability of a Student to Provide Informed Consent for Educational Decisions Made Under the Individuals with Disabilities Education Act (IDEA)
SS/SE-340: Specific Power Of Attorney for Educational Decisions Made Under the Individuals with Disabilities Education Act (IDEA)
Additional Forms
The following forms, ordered by form number, are related to the special education process and may be used as needed.
Additional Forms (Ordered by Form Number)
-
SS/SE-79: Release of Student Records Authorization
Used by parents to give FCPS schools authorization to release their student's record. -
SS/SE-79A: Consent to Exchange Confidential Student Information
Used by parents to give FCPS schools authorization to share confidential information.
English (SE-79A: English)
العربية (SE-79A: Arabic)
中文 (SE-79A: Chinese)
فارسی (SE-79A: Farsi)
한국어 (SE-79A: Korean)
español (SE-79A: Spanish)
اردو (SE-79A: Urdu)
Tiếng Việt (SE-79A: Vietnamese) -
SS/SE-127: Parent Information
Used by parents to share information with their student's school.
English (SE-127: English)
العربية (SE-127: Arabic)
中文 (SE-127: Chinese)
فارسی (SE-127: Farsi)
한국어 (SE-127: Korean)
español (SE-127: Spanish)
اردو (SE-127: Urdu)
Tiếng Việt (SE-127: Vietnamese) -
SS/SE-128: Unilateral Withdrawal from FCPS
Used by special education staff to confirm unilateral withdrawal of student from FCPS.
English (SE-128: English)
العربية (SE-128: Arabic)
中文 (SE-128: Chinese)
فارسی (SE-128: Farsi)
한국어 (SE-128: Korean)
español (SE-128: Spanish)
اردو (SE-128: Urdu)
Tiếng Việt (SE-128: Vietnamese) -
SS/SE-130: Notice of Appeal
Used by parents to serve as notice of disagreement over a special education evaluation or placement. -
SS/SE-141: Prior Written Notice
Used by special education staff to provide prior notice to parents of FCPS refusal for the placement of their child.
English (SE-141: English)
العربية (SE-141: Arabic)
中文 (SE-141: Chinese)
فارسی (SE-141: Farsi)
한국어 (SE-141: Korean)
español (SE-141: Spanish)
اردو (SE-141: Urdu) - SS/SE-215: Request for Wavier of Full-Day Schedule Requirement
Used to obtain permission by FCPS for a student to attend less than a full day.
- SS/SE-217: Functional Behavior Assessment (Draft)
Draft version of the form used by school staff to conduct a functional behavioral assessment
- SS/SE-218: Behavior Intervention Plan (Draft)
Draft version of the form used by school staff to create a functional behavioral plan.
-
SS/SE-218A: Behavior Intervention Plan Review (Draft)
Draft version of the form used by school staff to review a functional behavioral plan. -
SS/SE-264: Emergency Use of Physical Restraint & Seclusion (Incident Documentation)
Used by school staff to document emergency use of physical restraint
English (SE-264: English)
العربية (SE-264: Arabic)
中文 (SE-264: Chinese)
فارسی (SE-264: Farsi)
한국어 (SE-264: Korean)
español (SE-264: Spanish)
اردو (SE-264: Urdu)
Tiếng Việt (SE-264: Vietnamese) -
SS/SE-266: Parent Consent for Individualized Screening and Consultation
Used to obtain parental consent for individual screening and consultation.
English (SE-266: English)
العربية (SE-266: Arabic)
中文 (SE-266: Chinese)
فارسی (SE-266: Farsi)
한국어 (SE-266: Korean)
español (SE-266: Spanish)
اردو (SE-266: Urdu) -
SS/SE-274: Read Aloud or Audio Accommodation Criteria Form
Used by special education staff to list Read Aloud or Audio Accommodation criteria.
English (SE-274: English)
العربية (SE-274: Arabic)
中文 (SE-274: Chinese)
فارسی (SE-274: Farsi)
한국어 (SE-274: Korean)
español (SE-274: Spanish)
اردو (SE-274: Urdu)
Tiếng Việt (SE-274: Vietnamese) -
SS/SE-329: Identification of Military Connected Students
Used to identify students who are military connected. -
SS/SE-348: Special Permission Locally Awarded Verified Credit Accommodation (SPLAVC-A) Criteria Form
Used by special education staff to request special permission for a locally awarded verified credit.
English (SE-348: English)
العربية (SE-348: Arabic)
中文 (SE-348: Chinese)
فارسی (SE-348: Farsi)
한국어 (SE-348: Korean)
español (SE-348: Spanish)
اردو (SE-348: Urdu)
Tiếng Việt (SE-348: Vietnamese) -
SS/SE-349: Request for Principal's Approval for Student Use of GPS Bracelet/Device
Used by parents to request principal approval of their student wearing a GPS device.
English (SE-349: English)
العربية (SE-349: Arabic)
中文 (SE-349: Chinese)
فارسی (SE-349: Farsi)
한국어 (SE-349: Korean)
español (SE-349: Spanish)
اردو (SE-349: Urdu)
Tiếng Việt (SE-349: Vietnamese)