1. Haysville USD 261
    2. Move-In Multidisciplinary Team Report



Haysville USD 261



Move-In Multidisciplinary Team Report
 

Student:____________________ DOB:_______________ Date:__________________
 
School:_____________________ Grade:______________
 
Parents:__________________________________________
 
A. PREVIOUS SCHOOL DATA: School:_________________________________
 
Student’s previous identified exceptionality: _________________________________
     
Student’s previous service setting was (where services were presented):____________
 
Related services were:___________________________________________________
B. ELIGIBILITY: (Check all that apply.)
  The presence of an exceptionality is substantiated by adequate data utilizing district eligibility criteria and student exhibits a need which can not be met with regular education alone.
 

(Check all criteria met)
 
AM:
Communication Social Interaction Before Age of 3
 
DB:
Vision Loss Hearing Loss
 
DD:
1.5 SD Delay Diagnosed Condition Assessment Unreliable
 
ED:
Interpersonal relationships Behavior/Emotions Physical Symptoms/Fears Time/Degree
 
GI:
Aptitude Achievement Products
 
HI:
Hearing Loss Educational Impact
 
LD:
Aptitude-Achievement Discrepancy Processing Deficit Exclusions
 
MD:
At Least Two Disabilities Severe Educational Needs
 
MR:
Aptitude Adaptive Behavior Achievement
 
OHI:
Health Condition Limited Strength Limited Vitality Limited Alertness
 
OI:
Orthopedic or Health Impairment Educational Impact
 
SL:
Language Voice Fluency Articulation/Phonology
 
TBI:
Injury to brain from external source Impaired Functioning
 
VI:
Vision Loss Education Impact

Student’s eligibility for special education based upon district eligibility criteria can not be determined due to a lack of data received from previous school.
 

  
Student has a current IEP and consent to implement the IEP and will receive special education services while a reevaluation is completed to determine district eligibility.

 Student does not have a current IEP or consent to implement the IEP and will receive special education services based on the last IEP for which written consent is known to have been given until an expedited reevaluation to determine district eligibility is completed.
 
  Adequate information is available to determine the student is eligible for special education services but does not require special education services and will attend regular education classes.
 
  Adequate information is available to determine the student is not eligible for special education services and will attend regular education classes.
 
C. RECOMMENDATIONS: The following areas of discrepancy/areas eligible for special education services. (Do not complete if the student’s eligibility can not be determined).
 
1.__________________________________________ 2._______________________________________
 
3.__________________________________________ 4._______________________________________
 
5.__________________________________________ 6._______________________________________
D. Individual Education Program.
The IEP from the student’s previous school will be adopted and implemented as written.
 
The IEP from the student’s previous school will be adopted and implemented with the following revisions: ____________________________________________________________________________________________________________________________________________________________________
 
The IEP from the student’s previous school will be adopted and implemented as written but a new IEP will be written by ______________________.
(date)
A new IEP was written on _____________________.
(date)
An IEP will not be written due to the student’s:
    Lack of meeting the district’s eligibility requirements; and/or
    Lack of identified need for special education services.
 
 
WRITTEN CERTIFICATION THAT THIS REPORT REFLECTS EACH TEAM MEMBERS CONCLUSIONS: If not, the dissenting team member shall submit a separate, written statement presenting the member’s conclusions.
 
Signature of Team Member    Date      Position
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
DISSENTING TEAM MEMBER (S) SIGNATURE AND ATTACHED STATEMENT REPRESENTING HIS/HER CONCLUSIONS:
 
Signature of Team Member    Date      Position
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
Attachments _______ Yes ______ No

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