August, 1999

MM DD YY

	Subject Area	CIRCLE ALL Setting(s) of Instruction
		General education classroom	Resource room	Special education classroom	Homebound instruction	Not applicable
a.	Language arts	1	2	3	4	5
b.	Mathematics	1	2	3	4	5
c.	Science	1	2	3	4	5
d.	Social studies	1	2	3	4	5
e.	Art, music	1	2	3	4	5
f.	Physical education	1	2	3	4	5
g.	Life skills	1	2	3	4	5
h.	Study skills	1	2	3	4	5
i.	Vocational/prevocational training, industrial arts	1	2	3	4	5
j.	Social skills instruction	1	2	3	4	5
k.	Other (please specify): _______________________	1	2	3	4	5

1	A formal assessment of career skills or interests
2	Career counseling
3	Job readiness or prevocational training
4	Work exploration
5	Work experience
6	Specific job skills training
7	Referrals to potential employers
8	Instruction in looking for jobs
9	School staff worked with employer to modify jobs for this student
10	School staff contacted student or employer to monitor performance on the job
11	None of these

		None	1-24%	25-49%	50-74%	75-99%	100%	Don’t know
a.	School-based work experience	0	1	2	3	4	5	8
b.	Community-based work experience	0	1	2	3	4	5	8

1	Attend a 2- or 4-year college
2	Attend a postsecondary vocational training program
3	Get competitive employment (includes military)
4	Get into sheltered employment (where most other workers are also disabled)
5	Get supported employment (similar to competitive employment, but where supervision/training is provided by an agency/individual other than the employer)
6	Employment or postsecondary education is not a goal for this student. The educational program goal is to help this student become as self-sufficient as possible.
7	Other (please describe): ________________________________________________ _____________________________________________________________________
8	No goal as yet for this student beyond high school

1	Elementary to middle school	PLEASE CONTINUE WITH QUESTION A4b.
2	Middle school to high school
3	No transitions this past year	PLEASE GO TO QUESTION A6.
4	No, the student did not change schools for these transitions

1	Staff or students from your school visited the sending school to meet with groups of students who were preparing for the transition.
2	Groups of transitioning students visited your school before school started.
3	Information was provided to your school staff by the sending school about this student (e.g., student performance information, disability awareness).
4	Your school staff met with staff of the sending school specifically about this student.
5	Parent and/or student met with staff of this school before starting school here.
6	Preparatory strategies were developed specifically for this student (e.g., behavior plans, school scheduling modifications, etc.).
7	The sending school sent the student’s file before the student started school here.
8	Other: _____________________________________________________________
9	None of these
10	Don’t know

1	It was more than he/she needed.
2	It was appropriate to the needs of this student.
3	This student could have benefited from more transition support.
9	Don’t know

1	Elementary to middle school	PLEASE CONTINUE WITH QUESTION A5b.
2	Middle school to high school
3	No transitions this past year	PLEASE GO TO QUESTION A7.
4	No, the student did not change schools for these transitions

1	Groups of transitioning students will visit their next school before school starts.
2	Information will be provided to the receiving school about this student (e.g., student performance information, disability awareness).
3	Your school staff will meet with receiving school staff specifically about this student.
4	Parent and/or student will meet with staff of the receiving school individually before starting school there.
5	Preparatory strategies will be developed specifically for this student (e.g., behavior plans, school scheduling modifications, etc.).
6	Other: _____________________________________________________________
7	None of these
8	Don’t know

1	Same school as this year
2	Different school next year:	Name of school: ________________________________ School address: ________________________________ _________________________________

1	Yes, this student has an IEP Ô Ô for special education services.	PLEASE GO TO SECTION B, QUESTION B2, PAGE 7.
2	Yes, this student has a 504 plan. Ô Ô	PLEASE GO TO SECTION B, QUESTION B1a, PAGE 7
3	No Ô Ô Ô Ô Ô Ô Ô Ô	PLEASE GO TO SECTION C, QUESTION C1a.

1	Yes, this student has had an IEP for special education services Ô Ô PLEASE CONTINUE WITH B1b.
2	No PLEASE GO TO QUESTION B2a.
3	Don’t know

____________

School year discontinued special education services

Number of minutes/week	or	Number of hours/week
__________		__________	General education classroom
__________		__________	Special education self contained classroom
__________		__________	Special education resource classroom
__________		__________	Homebound instruction

A All disability categories	B Primary disability category
1	1	Autism
2	2	Deaf-blindness
3	3	Developmental delay
4	4	Emotional or behavioral impairment
5	5	Hearing impairment/deafness
6	6	Learning disability
7	7	Mental retardation
8	8	Orthopedic impairment
9	9	Other health impairment
10	10	Speech or language impairment
11	11	Traumatic brain injury
12	12	Visual impairment/blindness
13	13	Other: _____________________________

1	Improve overall academic performance
2	Improve academic performance in a specific area: _________________________
3	Build social skills
4	Improve appropriateness of general behavior
5	Increase functional skills
6	Improve speech and communication skills
7	Vocational preparation
8	Postsecondary education preparation
9	Other (please specify): ________________________________________________
10	Don’t know

	Accommodations/modifications
1	More time in taking tests
2	Test read to student
3	Modified tests
4	Modified grading standards
5	Slower-paced instruction
6	Additional time to complete assignments
7	Shorter assignments
8	Physical adaptations (e.g., preferential seating, special desk)
	Learning aids
9	Books on tape
10	Communication aids (e.g., Touch Talker, manual printing board)
11	Use of spell checker
12	Computer software designed for students with disabilities
13	Computer hardware adapted for student’s unique needs (e.g. alternative keyboards, switch interface)
14	Other: ___________________________________________________________
15	None of these were provided

1	Yes
2	No

1	Yes
2	No

	Services provided during the current school year	Approximate minutes per week service provided
a.	Adaptive physical education
b.	Audiology
c.	Communication services (e.g., instruction in sign language or lip reading, Braille, augmentative communication)
d.	Training, counseling, and other supports/services provided to student’s family
e.	Health services (e.g., administering of medication, oxygen, tracheostomy care, tube feeding, catheterization)
f.	Mental health services, personal/group counseling, therapy, or psychiatric care provided to student
g.	Occupational therapy
h.	One-to-one paraeducator/assistant (e.g., full-inclusion assistant, behavioral assistant, nurse’s aide)
i.	Physical therapy
j.	Social work services
k.	Speech or language therapy
l.	Vision services
m.	Reader or interpreter
n.	Additional academic tutoring/remediation by a special education teacher
o.	Behavioral interventionist/specialist
p.	Learning strategies/study skills assistance by a special educator
q.	Other (specify): _________________________________

YES	NO
1	2	a. Special transportation because of disability (e.g., help in travel or special equipment such as lifts, ramps)
1	2	b. Assistive technology services/devices
1	2	c. Service coordination/case management

0	There is no such testing at this grade level.
1	Student did not take such tests.		PLEASE GO TO
2	Student participated in most or all of the testing program without accommodations or modifications.		QUESTION B10.
3	Student participated in most or all of the testing program with accommodations or modifications.	Ô Ô	PLEASE CONTINUE WITH QUESTION B9b.

1	Given test orally
2	Reader provided
3	Dictated responses
4	Shortened test
5	Alternative setting
6	Additional time
7	Alternative format for responding (e.g., pointing, typing, etc.)
8	Braille/large-print version of test
9	Other: ______________________________________________________________

1	General education academic subject teacher(s)
2	General education vocational teacher(s)
3	Special education teacher(s)
4	School administrator (e.g., principal, special education director, program coordinator)
5	School counselor or psychologist
6	Related services personnel (e.g., speech therapist/pathologist, occupational therapist, physical therapist)
7	Parent/guardian(s)
8	Student
9	Staff of outside service agency or outside consultant
10	Employer
11	Representative of postsecondary institution
12	Advocate
13	Other (please specify): _______________________________________________

1	Yes
2	No

1	General education academic subject teacher(s)
2	General education vocational teacher(s)
3	Special education teacher(s)
4	School administrator (e.g., principal, special education director, program coordinator)
5	School counselor or psychologist
6	Related services personnel (e.g., speech therapist/pathologist, occupational therapist, physical therapist)
7	Parent/guardians
8	Student
9	Staff of outside service agency (please specify type of staff): _________________
10	Outside consultant (please specify type of consultant): ______________________
11	Employer
12	Representative of postsecondary institution
13	Advocate
14	Other (please specify): _______________________________________________

1	Yes, this student has had an IEP for special education services Ô Ô PLEASE CONTINUE WITH C1b.
2	No PLEASE GO TO QUESTION C2.
3	Don’t know

____________

School year discontinued special education services

Number of incidents		Number of days
__________			Suspensions (may include in-school suspensions)
__________	OR	_________	Disciplinary actions (e.g., referral to the office, detentions, etc.), excluding suspensions or expulsions
999		999	Don’t know

Grade level in:
Reading	Mathematics
999	999	No grade level determined
0	0	Preschool/Kindergarten
1	1	Grade 1
2	2	Grade 2
3	3	Grade 3
4	4	Grade 4
5	5	Grade 5
6	6	Grade 6
7	7	Grade 7
8	8	Grade 8
9	9	Grade 9
10	10	Grade 10
11	11	Grade 11
12	12	Grade 12 or above

1	Yes
2	No
3	We do not have parent conferences or "back-to-school night. "
4	Don’t know

0	Never
1	Once
2	A few times over the school year
3	Once every other month
4	Once a month
5	Once a week or several times a month
6	Every day or several times a week

1	A language other than English Please specify language: ________________________________
2	English
3	Don’t know

1	General education classroom teacher
2	Special education classroom teacher
3	Resource room teacher
4	Related services provider (e.g., speech therapist)
5	Program specialist (e.g., full inclusion specialist)
6	Case manager
7	School psychologist
8	School counselor
9	Other: ___________________________________

1	Provide instruction directly to this student
2	Provide related services directly to this student
3	Provide consultation services to student’s teacher(s)
4	Provide case management (e.g., program monitoring) for this student
5	Program administrator/supervisor
6	Supervise instructional assistant or paraeducator assigned to work with this student
7	Other: _____________________________________________________________

1	Daily
2	Two to three times per week
3	Once a week
4	Several times per month
5	Once per month
6	Once every two to six months
7	Very rarely

SEELS DESIGN DOCUMENTS