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Get Early Intervention Project Eip Student Data Form

Early Intervention Project EIP STUDENT DATA FORM Rev. 01/12 Please refer to the instruction sheet for information on how to answer these questions. Student s SASID Student s First Name Initial of Student s Last Name Date of Birth Student s Current Grade Gender Is this a new case this year Yes 1 Primary language spoken at home Please check only one. English 1 Spanish 2 Other 3 Specify Male 1 12. End of Year Status Please check only one. Goal s achieved 1 Case on-going/continuing intervention s 3 Referred to 504 team 4 Referred to Planning and Placement Team PPT 5 Answer Month/Day/Year question 13 below. Complete questions 13a 13d for students referred to PPT. Female 2 Is the student Hispanic/Latino Yes No 2 No 13a* Rationale for student referral to PPT Request prior to completion of EIP 1 By whom EIP team determination 2 9a* Is the student from one or more races using the following Choose all that apply. American Indian/Alaska Native 1 Asian 2 Black or African American 3 Native Hawaiian or Other Pacific Islander 4 White 5 10. Primary reason for teacher s request for intervention 13b. Has the student continued to receive EIP support after referral to PPT Yes 1 No 2 13c* PPT status Please check only one. PPT determined evaluation not warranted at this time 1 Evaluation incomplete at time of data submission 2 education and related services 4 Please complete 13d. Please check only one. Pre-Reading/Reading 1 Math 3 Oral Language 5 Other 7 Specify Written Language 2 Behavior/Social-Emotional 4 Executive Functioning Skills 6 13d. Primary disability Please check only one. Intellectual Disability 1 Speech/Language Impairment 2 Learning Disability 4 Emotional Disturbance Other Health Impairment 5 11. Level of intervention student received Universal/Tier 1 1 Targeted/Tier 2 2 Intensive/Tier 3 3 School Year Date completed Completed by Name 25 Industrial Park Road Middletown CT 06457-1516 Tel 860 632-1485 Fax 860 632-8870 www. Student s SASID Student s First Name Initial of Student s Last Name Date of Birth Student s Current Grade Gender Is this a new case this year Yes 1 Primary language spoken at home Please check only one. English 1 Spanish 2 Other 3 Specify Male 1 12. End of Year Status Please check only one. Goal s achieved 1 Case on-going/continuing intervention s 3 Referred to 504 team 4 Referred to Planning and Placement Team PPT 5 Answer Month/Day/Year question 13 below. English 1 Spanish 2 Other 3 Specify Male 1 12. End of Year Status Please check only one. Goal s achieved 1 Case on-going/continuing intervention s 3 Referred to 504 team 4 Referred to Planning and Placement Team PPT 5 Answer Month/Day/Year question 13 below. Complete questions 13a 13d for students referred to PPT. Female 2 Is the student Hispanic/Latino Yes No 2 No 13a* Rationale for student referral to PPT Request prior to completion of EIP 1 By whom EIP team determination 2 9a* Is the student from one or more races using the following Choose all that apply. Complete questions 13a 13d for students referred to PPT. Female 2 Is the student Hispanic/Latino Yes No 2 No 13a* Rationale for student referral to PPT Request prior to completion of EIP 1 By whom EIP team determination 2 9a* Is the student from one or more races using the following Choose all that apply. American Indian/Alaska Native 1 Asian 2 Black or African American 3 Native Hawaiian or Other Pacific Islander 4 White 5 10.

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