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.

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. 

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. 

SS/SE-4: Virginia Special Education Procedural Safeguard Requirements

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

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

Used by IEP team to provide an update on annual goals for students receiving special education services.

IEP 204: IEP Progress Report - Annual Goal/Short Term Objectives

Used by IEP team to provide an update on annual goals and short term objectives for students receiving special education services.

IEP 205: ESY Progress Report

IEP 208: Non-Attendance of IEP Team Members

IEP 209: Manifestation Determination Review

Used by IEP team to conduct a manifestation determination review for a special education student involved in disciplinary action.

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

Used by IEP team to provide prior written notice to parents that certain special education services would not be updated or offered.

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)

Draft version of form used by IEP team to create a behavior intervention plan.

IEP 327A: Behavior Intervention Plan Review (Draft)

Draft version of the form used by IEP team to review with student the behavior intervention plan.

IEP 328: Transfer Student Documentation

Used by IEP team to review IEP requirements for a student transferring into FCPS whose registration indicated they received special education services.

IEP-329: Functional Behavior Assessment (Draft)

Draft version of form used by IEP team to conduct a functional behavioral assessment.

IEP 331: Credit Accommodations Eligibility Form

Note IEP 331 is now SS/SE-353

Used by IEP staff to determine credit accommodations eligibility.

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.


Additional Forms

The following forms, ordered by form number, are related to the special education process and may be used as needed.