Complete All Sides and Submit to Bassc Office

2411 Pathways Crossing Phone (618) 355-4700 Belleville, IL 62221 Student Information Tracking Form Fax (618) 355-4758

COMPLETE ALL SIDES AND SUBMIT TO BASSC OFFICE Purpose of Tracking - Specify All Changes in: Student Identification Info. Termination of Services Related Services Program Location Eligibility Transportation Program Type Not Eligible IEP Amendment Teacher (s) EEC or Percentages Revocation of consent Other (specify) ______Other (specify)

Form Completed By Date Completed

Purpose of Conference date Indicate all that apply date Indicate all that apply date Indicate all that apply Referral/Reev Review (Child Review) Initial Placement Manifestation Determination Initial Evaluation Program Review/Revision Amendment Reevaluation Annual Review Other

Student Identification Information STUDENT'S LAST NAME FIRST NAME MIDDLE NAME PARENT / GUARDIAN NAME(S) check if Surrogate involved

STUDENT'S DATE OF BIRTH (Month/Day/Year) RELATIONSHIP OF PARENT / GUARDIAN Parent FOSTER other (specify) b STUDENT'S ADDRESS (Street) PARENT'S ADDRESS, If Different (Street)

STUDENT'S ADDRESS (City, State, Zip) PARENT'S ADDRESS (City, State, Zip) 622 622 STUDENT'S PHONE NUMBER PARENT'S PHONE NUMBER ( ) - ( ) - STUDENT'S GENDER EMERGENCY PHONE NUMBER-WHO IS AT THIS NUMBER Male Female b ( ) - LANGUAGE/MODE OF COMMUNICATION USED BY STUDENT LANGUAGE/MODE OF COMMUNICATION USED BY PARENT English, verbal other (specify) b English, verbal other (specify) b STUDENT'S SOCIAL SECURITY # STUDENT'S MEDICAID # RESIDENT DISTRICT (Name and Number) - - Ethnic Code: White African American CURRENT SERVING DISTRICT AND SCHOOL (Name and Number) Hispanic Asian American Indianb CASE MANAGER (Position/Title) HOME SCHOOL GRADE (indicate school year) for SY ELIGIBILITY Primary Secondary(ies) TRIENNIAL RE-EVALUATION DUE

ADDITIONAL STUDENT IDENTIFICATION INFORMATION (DCFS Case Worker, address, Surrogate address,…)

Parent receipt of Procedural Safeguards (date) Parent has waived 10-day requirement for meeting notification (date) Parent has waived 10-day requirement for initial placement (date) Parent has waived 10-day requirement for change of placement (date)

INDICATE ELIGIBILITY (P = Primary, S = Secondary - Mark only ONE Primary Eligibility and all others as Secondary) P S P S P S P S Cognitive Disability (A) Blind (E) Speech/Lang. Impairment (I) Multiple Disabilities (M) Orthopedic Impairment (C) Hearing Impairment (F) Emotional Disability (K) Developmental Delay 3 – 9 (N) Learning Disability (D) Deafness (G) Other Health Impairment (L) Autism (O) Visual Impairment /Blind (E) Deaf-Blind (H) Specify Traumatic Brain Injury (P)

04768c895b3ad00d17263a0fee1c6202.doc page 1 Submit to BASSC for Data Entry and Child Count Student Student Last Name First Name Student's Date of Birth (Mo/Day/Yr)

Location of Services Type of Program Teacher Initiation Date

Check if student is a Move In Not Eligible/Termination Services Date of Termination/Ineligibility Reason for Ineligibility/Termination Check if student is 504 Check if student is ISP eligible Check if a non-public student Check if parent revoked consent (date) Date of Referral Date of Psychological Evaluation Date other evaluation (specify type) Date other evaluation. (specify type)

Date of Parent Consent for Evaluation Eligibility Determination Date (Initial Date of Parent Consent for Initial Transition Planning Data (applicable) or Re-evaluation) Placement yes no Deaf/Hearing Services Itinerant Teacher (last name) Initiation Date Date of Termination Yes No Visual Impairment Services Itinerant Teacher (last name) Initiation Date Date of Termination Yes No Speech Services Speech Pathologist (last name) Initiation Date Date of Termination Yes No

INDICATE EDUCATIONAL ENVIRONMENT (Ages 6 through 21 years) % Percentage of Time Inside Regular Education: Of the entire 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 Educational Environment Code (below). Required. Reg. Ed. Instruction 80% or more, INSIDE the regular education Full Time Class in Special Public Homebound Instructional Program (11) classroom (01) Day School (04) Reg. Ed. Instructional 79% to 40%, INSIDE the regular education Private Day Program or out-of- Hospital Instructional Program (12) classroom (02) state public day program (08) Reg. Ed. Instructional 39% or less, INSIDE the regular education Public School Residential (05) Other (specify Below)

classroom (03) Private School Residential (09,10) % Percentage of Time in Special Education: Divide the total special education time (instructional plus pull-out 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.

INDICATE EDUCATIONAL ENVIRONMENT (Ages 3 through 5 years) % Percentage of Time Inside Regular Education: Of the entire 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 Educational Environment Code (below). Required. Early Childhood Program at least 80% of time: Child receives all special education Home: All Sp. Ed. Services instructional and/or related services in a regular early childhood or kindergarten Separate Class with less than 50 provided in the principal program for 80% or more of time. (20) percent non-disabled children (23) residence of child’s family or caregiver (26) Early Childhood Program 79% to 40% of time: Child receives special education Separate Public or Private Day Service Provider location: All instructional and/or related services in the regular early childhood or kindergarten School for children with Sp. Ed. Services at service program for no more than 79% but no less than 40% of time. (21) disabilities (24) providers location (27) Early Childhood Program 39% or less of time: Child receives special education Residential Facility (25) instructional and/or related services in a regular early childhood or kindergarten program 39% or less of time. (22) % Percentage of Time in Special Education: Divide the total special education time (instructional plus pull-out 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.

INDICATE RELATED SERVICES

Transportation(25) Adapted PE(01) Ind. Care Aide(03) OT(13) PT (19) Speech(23) SSW(24) Other(s) (mpw) (mpw) (mpw) (mpw) (mpw) (mpw) (mpw) Transportation None Provider BASSC Resident District Other Type Bus Cab Other Pick-up Location: Name of Day Care / Caretaker Phone ( ) - Drop-off Location (after School): Name of Day Care / Caretaker Phone ( ) - Busing … Begins Change Drop on Date Adaptations listed on the IEP None Wheelchair Lift Air Conditioning Car Seat Child Safety Vest

04768c895b3ad00d17263a0fee1c6202.doc page 2 Submit to BASSC for Data Entry and Child Count Student Tracking Attendant - Individual Attendant - Entire Bus Tinted Windows Other Clarifying Comments:

04768c895b3ad00d17263a0fee1c6202.doc page 3 Submit to BASSC for Data Entry and Child Count Student Tracking