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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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.
Multipurpose Referral
Used by schools to refer a student for evaluation.
SS/SE 5A: Multipurpose Referral (Page 2)
Used by schools to refer a student for evaluation, page 2.
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.
Eligibility Forms Packet
Special Education Eligibility Bundle for Parent Meetings.
Includes Special Education Eligibility and Section 504 Qualification Forms.
SS/SE 2: Notice and Consent for Evaluation
Used by special education staff to give notice to as well as get consent from parents to conduct a special education evaluation.
SS/SE 6: Reevaluation Report
Used by schools to report on a student's reevaluation.
SS/SE 10: Special Education Eligibility Form
Used by special education staff to conduct a special education services eligibility for a student.
SS/SE 13: Notice Not to Evaluate
Used by special education staff to notify parents their student will not be evaluated for services.
SS/SE 14: Local Screening Committee Report
Used by the local screening committee to report on a student receiving services.
SS/SE 83: Notice of Local Screening Committee Meeting
Used by special education staff to notify parents of a screening committee meeting.
SS/SE 107: Parent Notice of Eligibility Determination
Used by special education staff to notify parents if a student is eligible for special education services.
SS/SE 126: Notice of Reevaluation
Used by special education staff to conduct a reevaluation of a student.
SS/SE 142: Notice of Eligibility Meeting
Used by special education staff to provide notice to the parents of an eligibility meeting.
Basis for Committee Decision (BCD) Forms
The following forms are ordered alphabetically by form title.
SS/SE 10A: Autism Basis for Committee Decision
Used by special education staff to show basis for decision - autism.
SS/SE 10P: Deaf-Blindness Basis for Committee Decision
Used by special education staff to show basis for decision - deaf/blindness.
SS/SE 10N: Deafness Basis for Committee Decision
Used by special education staff to show basis for decision - deafness.
SS/SE 10M: Developmental Delay Basis for Committee Decision
Used by special education staff to show basis for decision - developmental delay.
SS/SE 10B: Emotional Disability Basis for Committee Decision
Used by special education staff to show basis for decision - emotional disability.
SS/SE 10C: Hearing Impairment Basis for Committee Decision
Used by special education staff to show basis for decision - hearing impairment.
SS/SE 10D: Intellectual Disability Basis for Committee Decision
Used by special education staff to show basis for decision - intellectual disabilities.
SS/SE 10E: Multiple Disabilities Basis for Committee Decision
Used by special education staff to show basis for decision - multiple disabilities.
SS/SE 10F: Orthopedic Impairment Basis for Committee Decision
Used by special education staff to show basis for decision - orthopedic impairment.
SS/SE 10G: Other Health Impairment Basis for Committee Decision
Used by special education staff to show basis for decision - other health impairment.
SS/SE 10I: Specific Learning Disability Basis for Committee Decision
Used by special education staff to show basis for decision - specific learning disability.
SS/SE 10J: Speech/Language Impairment Basis for Committee Decision
Used by special education staff to show basis for decision - speech and language impairment.
SS/SE 10K: Traumatic Brain Injury Basis for Committee Decision
Used by special education staff to show basis for decision - traumatic brain injury.
Individualized Education Program (IEP) Forms
The following forms may be used throughout the IEP process.
IEP Forms Packet
IEP Bundle for IEP Meetings
IEP 101: IEP Meeting Agenda for Parents
Used by IEP team as a meeting agenda for parents and team.
IEP 102: Parent Information for IEP
Used by special education staff to gather information about parents prior to an IEP meeting.
IEP 105: Extended School Year Services
Used by IEP team to provide special education or related services beyond the school year.
IEP 106: Medicare/FAMIS Parental Consent Frequently Asked Questions
Used by special education staff to secure a release from a parent to make Medicare/Medicaid inquiries and support.
IEP 202: Notice - Initial/Annual
Used by IEP team to provide annual notification to parents of special education students.
IEP 203: Progress Report - Annual Goals
Used by IEP team to provide an update on annual goals for students receiving special education services.
IEP 204: 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 Reporting
Used by IEP team to provide parents with progress on extended school year objectives.
IEP 208: Non-Attendance of IEP Team Members
Used by IEP team to get parental consent for written IEP team members comments.
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
Used by MDR team as the cover page.
IEP 211: IEP Addendum Without a Meeting
Used by IEP team members to conduct an addendum to an IEP without a team meeting.
IEP 212: IEP Progress Report - Short Term Objectives
Used by IEP team to report short term objectives progress to parents.
IEP 213: Parent Notification of Manifestation Determination Review Meeting
Used by IEP team to notify parent of a MDR meeting.
IEP 216: Parent Consent for Billing Medicaid or FAMIS for Covered Services
Used by IEP team to document parental consent to bill medicaid for services received.
IEP 217: AIM-VA Verification Form
Used by IEP team to verify AIM-VA services.
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: Agenda for Meeting
Used by IEP team as a meeting agenda for parents and team.
IEP 302: IEP Cover Page
Used by IEP team as the cover page.
IEP 303: Transition Goals
Used by IEP team to establish transitions goals for student.
SS/SE 304: Residency Attestation
Used to supply a residence attestation in order for a parent or guardian to enroll their student.
IEP 306: Area of Need/Annual Goal and Short Term Objectives
Used by IEP team to identify areas of need.
IEP 307: Area of Need/Annual Goal
Used by IEP team to identify areas of need for annual report.
IEP 308: Curriculum/Classroom Accommodations and Modifications
Used by IEP team to determine curriculum or classroom adjustments or accommodations.
IEP 309: Information Related to Present Level of Educational Performance
Used by IEP team to record important information relating to student's educational performance.
IEP 310: Elementary Assessment
Used by IEP team to conduct an elementary assessment.
SS/SE 367: IEP/504 Plan Elementary School Accommodations
Used to identify IEP or 504 Plan Accommodations at the elementary school level.
IEP 312: Middle School Assessment
Used by IEP team to conduct a middle school assessment.
SS/SE 368: IEP/504 Plan Middle School Accommodations
Used to identify IEP or 504 plan accommodations at the middle school level.
IEP 314: High School Assessment
Used by IEP team to conduct a high school assessment.
SS/SE 369: IEP/504 Plan High School Accommodations
Used to identify IEP or 504 plan accommodations at the high school level.
IEP 316: VAAP Criteria
Used by IEP team to determine whether a special education student fits the criteria to participate in VAAP.
IEP 319: Least Restrictive Environment (LRE)
Used by IEP team to determine the least restrictive environment for a special education student.
IEP 320: Services
Used by IEP team to identify specially designed services for special education students.
IEP 321: Placement
Used by IEP team to identify placement of a special education student.
IEP 322: Extended School Year
Used by IEP team to identify if special education student needs extended year services.
IEP 323: Prior Notice and Consent
Used by IEP team to provide notice and consent to students and parents.
SS/SE 272: Calculator Criteria Form
Used by staff to request a calculator accommodation for a student.
SS/SE 274: 504 Plan Read Aloud or Audio Accommodation Criteria
Used by special education staff to list Read Aloud or Audio Accommodation criteria.
IEP 327: Behavioral Intervention Plan
Draft version of form used by IEP team to create a behavior intervention plan.
IEP 327A: Behavior Intervention Plan Review
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 Behavioral Assessment
Draft version of form used by IEP team to conduct a functional behavioral assessment.
SS/SE 353: Individualized Education Program/504 Plan Credit Accommodations Eligibility Form
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.
ISP 401: Individual Services Plan Meeting Notification
Used by FCPS school staff to notify an upcoming ISP meeting.
ISP 402: Parent Information Regarding Children with Disabilities Enrolled by Their Parents in Private Schools
Used to inform parents with children with disabilities who have enrolled their child in private education.
ISP 403: Individual Services Plan
Used to create an individual service plan.
ISP 404: Individual Services Plan Goals
Used to set goals from an individual services plan.
ISP 405: Individual Service Plan Progress Report
Used to report progress of an individual service plan.
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 Education Decisions Made Under the Individuals with Disabilities Education Act (IDEA)
Used by FCPS students to certify their inability to make educational decision under IDEA.
SS/SE 340: Specific Power of Attorney for Educational Decisions Made Under the Individuals with Disabilities Education Act (IDEA)
Used to obtain a specific power of attorney to make educational decisions under IDEA.
Medicaid Waiver Services for Students with Disabilities
A waiver is like a helping hand for people with disabilities who need ongoing care. When you get approved for a waiver, you can choose from different services. In Virginia, there are four waivers for people who need a certain level of care and meet specific criteria. Learn about Medicaid Waiver Services
Additional Forms
The following forms, ordered by form number, are related to the special education process and may be used as needed.
SS/SE 48: World Language Credit Accommodation Form
World Language credit accommodation for students who have an Individualized Education Program and are pursuing the Advanced Studies Diploma.
SS/SE 79: Consent for Release of Education Records
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.
SS/SE 127: Parent Information
Used by parents to share information with their student's school.
SS/SE 128: Unilateral Withdrawal from FCPS
Used by special education staff to confirm unilateral withdrawal of student from FCPS.
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.
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.
SS/SE 266: Parent Consent for Individualized Screening and Consultation
Used to obtain parental consent for individual screening and consultation.
SS/SE 274: 504 Plan Read Aloud or Audio Accommodation Criteria
Used by special education staff to list Read Aloud or Audio Accommodation criteria.
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.
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.
Related Pages
Special Education Procedural Support
Responsive, student-centered, collaborative guidance and leadership related to the implementation of and compliance with federal, state, and local regulations as they pertain to special education.
The Special Education Process
Learn how the special education process works and view our Special Education Handbook for Parents.
Special Education Instruction
Programs and services that meet the unique needs of students with disabilities.