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.
Multi-Purpose Referral Forms
- Multi-Purpose Referral Form (SS/SE-5)
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 Multi-Purpose Referral form. - Multi-Purpose Referral Form (page 2) (SS/SE-5A)
Page two of the Multi-Purpose Referral form must be completed by the student's classroom teacher or other appropriate school staff members, prior to the local screening committee meeting. 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
- Virginia Special Education Procedural Safeguard Requirements
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.
- Local Screening Committee Report (SS/SE-14)
- Translations: se24-Arabic | se14-Chinese | se14-Farsi | se14-Korean | se14-Spanish | se14-Urdu | se14-Vietnamese
- Notice of Reevaluation (SS/SE-126)
- Translations: se126-Arabic | se126-Chinese | se126-Farsi | se126-Korean | se126-Spanish | se126-Urdu | se126-Vietnamese
- Notice of Eligibility Meeting (SS/SE-142)
- Translations: se142-Arabic | se142-Chinese | se142-Farsi | se142-Korean | se142-Spanish | se142-Urdu | se142-Vietnamese
Basis for Committee Decision (BCD) Forms List (Ordered Alphabetically by 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 100s
IEP 200s
- IEP Meeting Notification Contact Log (IEP 201)
- IEP Notice - Initial/Annual (IEP 202)
- IEP Progress Report - Annual Goals (IEP 203)
- IEP Progress Report - Annual Goal/Short Term Objectives (IEP 204)
- ESY Progress Reporting (IEP 205)
- Non-Attendance of IEP Team Members (IEP 208)
- Manifestation Determination Review(IEP 209 draft)
- IEP Addendum Without a Meeting (IEP 211)
- IEP Progress Report - Short Term Objectives (IEP 212)
- Preschool Transmittal Letter (IEP 215)
IEP 300s
- IEP Meeting Agenda (IEP 301)
- IEP Cover Page (IEP 302)
- Transition Goals (IEP 303)
- Transition Services (IEP 304)
- Area of Need/Annual Goal and Short Term Objectives (IEP 306)
- Area of Need/Annual Goal (IEP 307)
- Curriculum/Classroom Accommodations and Modifications (IEP 308)
- Information Related to Present Level of Educational Performance (IEP 309)
- Elementary Assessment (IEP 310)
- Elementary Accommodations (IEP 311)
- Middle School Assessment (IEP 312)
- Middle School Accommodations (IEP 313)
- High School Assessment (IEP 314)
- High School Accommodations (IEP 315)
- VAAP Criteria (IEP 316)
- Least Restrictive Environment (LRE) (IEP 319)
- Services (IEP 320)
- Placement (IEP 321)
- Extended School Year (IEP 322)
- Prior Notice and Consent (IEP 323)
- Calculator Criteria Form (IEP 325)
- Read Aloud and Audio Accommodation Criteria Form (IEP 326)
- Draft form IEP-327 Behavior Intervention Plan (IEP 327 draft)
- Draft form IEP-327a Behavior Intervention Plan Review (IEP 327a draft)
- Transfer Student Documentation (IEP 328)
- Draft form IEP-329 Functional Behavior Assessment (IEP 329 draft)
- Credit Accommodations Eligibility Form (IEP 331)
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.
Additional Forms
These forms are related to the special education process and may be used as needed. These forms are ordered by form number.
- Release of Student Records Authorization (SS/SE-79)
- Consent to Exchange Confidential Student Information (SS/SE-79a)
- Parent Information (SS/SE-127)
- Notice of Appeal (SS/SE-130)
- Request for Wavier of Full-Day Schedule Requirement (SS/SE-215)
- Functional Behavior Assessment (SS/SE-217 draft)
- Behavior Intervention Plan (SS/SE-218 draft)
- Behavior Intervention Plan Review (SS/SE-218a draft)
- Identification of Military Connected Students (SS/SE-329)
- 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-338)
- Specific Power Of Attorney for Educational Decisions Made Under the Individuals with Disabilities Education Act (IDEA) (SS/SE-340)
- Special Permission Locally Awarded Verified Credit Accommodation (SPLAVC-A) Criteria Form (SS/SE-348)