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1、Phone (618) 355-4700Fax (618) 355-47582411 Pathways CrossingBelleville, IL 62221Student Information Tracking FormCOMPLETE ALL SIDES AND SUBMIT TO BASSC OFFICE Purpose of Tracking - Specify All Changes in:Submit to BASSC for Data Entry and Child Count Student Tracking Page 2 Student Identification In
2、fo. Program Location Program Type Teacher (s) / Case Manager Termination of Services Eligibility Not Eligible EEC or Percentages Related Services Transportation IEP Amendment Revocation of consent Move In Other (specify) Form Completed By: Date Completed:Purpose of Conference (Please specify each ty
3、pe of conference with a checkmark.)Review of Existing Data (Child Review)Initial PlacementManifestation DeterminationInitial EvaluationProgram Review RevisionFBA:Re-evaluationAnnual ReviewOther: Student Identification InformationSTUDENTS LAST NAME FIRST NAME MIDDLE NAMEPARENT / GUARDIAN NAME(S) Educ
4、ational Surrogate ParentELIGIBILITY Primary Secondary(ies) TRIENNIAL RE-EVALUATION DUEDATE OF MEETING (MM/DD/YYYY) STUDENTS DATE OF BIRTH (MM/DD/YYYY) RELATIONSHIP OF PARENT / GUARDIAN Parent Foster other (specify) bSTUDENTS ADDRESS (Street)PARENTS ADDRESS, If Different (Street) STUDENTS ADDRESS (Ci
5、ty, State, Zip) PARENTS ADDRESS (City, State, Zip) STUDENTS PHONE NUMBER()-PARENTS PHONE NUMBER()-STUDENTS GENDER EMERGENCY PHONE NUMBER-WHO IS AT THIS NUMBER()-LANGUAGE/MODE OF COMMUNICATION USED BY STUDENT LANGUAGE/MODE OF COMMUNICATION USED BY PARENTbSTUDENTS SIS ID NUMBERSTUDENTS MEDICAID #RESID
6、ENT DISTRICT NUMBEREthnic Code:RESIDENT DISTRICT NAMECASE MANAGER (Name/Title)SERVING DISTRICT NUMBER GRADE (indicate school year) for SY NOT ELIGIBLE FOR SERVICESSERVING DISTRICT NAMEADDITIONAL STUDENT IDENTIFICATION INFORMATION (DCFS Case Worker, address, Surrogate address,) Specific Program & Ser
7、vices InformationInitiation Date (effective date of change or new information)Date of Consent for Evaluation Date of Consent for Re-evaluationDate of Psychological EvaluationDate other evaluation (specify type) Date other evaluation. (specify type) Private Facility Placement and Facility CodeRoom an
8、d Board Payor Termination of Services Check if student is ISP eligible Check if parent revoked consent (date)Date of TerminationReason for Ineligibility Reason for TerminationDeaf/Hearing Services Yes NoItinerant Teacher (last name)Initiation DateTermination DateVisual Impairment Services Yes NoItin
9、erant Teacher (last name)Initiation DateTermination DateSpeech Services Yes NoPathologist / Therapist (last name)Initiation DateTermination DateSTUDENTS LAST NAME FIRST NAME MIDDLE NAMESTUDENTS DATE OF BIRTH (MM/DD/YYYY)Educational Environment (EE) Calculation (Ages 3-5) 1. Minutes spent in regular
10、early childhood program 2. Minutes spent receiving special education and related services outside regular early childhood (A+B) Educational Environment (EE) Calculation (Ages 6-21) 1. Total Bell to Bell Minutes 2. Total Number of Minutes Outside of the General Education Setting (A+B)Placement Determ
11、inationEnter the percentage of time the student will be outside regular education, select the educational environment code for delivery of the above services and confirm the consideration of the full continuum of services. Check boxes in the first column for each placement considered and rejected. I
12、ndicate in the second column the placement selected. State the justification for selection or rejection of placement options. Check if IEP is for students age 3 through 5 years. (Complete both percentages below and Educational Environment Code.)% Percentage of Time Inside Regular Education: Of the e
13、ntire school week, including lunch, recess and all other school day activities, what percentage of time is this student included in the regular classroom? Use this percentage to calculate the EEC below. Required.% Percentage of Time receiving Special Education: Divide the total special education tim
14、e (instructional plus related services) by the total instructional week. The instructional week includes PE, art, etc. but does not include lunch, recess, etc. This is for claims purposes. Required.PLACEMENT OPTIONS CONSIDEREDPOTENTIALLY HARMFUL EFFECT/REASONS REJECTEDTEAM ACCEPTS PLACEMENT Yes No Yes No Yes NoRELATED SERVICES Transportation NoneProvider Pick-up Location:Name of Day Care / CaretakerPhone ()-
