Forms

Transition meeting invitation letter for children and families anticipating transition to a community program or leaving early intervention. Form updated 05/09

This annotated document is effective December 14, 2020. This revised annotated Summary of Academic Achievement and Functional Performance (with a footer indicating “December 2020”) includes the addition of an Act 26 data collection question and related guidance.

This form is effective December 14, 2020. This revised Summary of Academic Achievement and Functional Performance (with a footer indicating “December 2020”) includes the addition of an Act 26 data collection question.

This publication outlines the procedures that are followed when complainants allege that the rights of one or more students eligible for services under the IDEA, Chapters 14 or 711 in the State Board Regulations or corresponding federal statutes or regulations have been violated. The IDEA requires the Bureau of Special Education (BSE) to encourage local and less adversarial resolutions to issues. However, federal regulations are clear that resolution activities cannot bar the complaint investigation process. The purpose of these procedures is to: 1. Clearly articulate the process to be followed. 2. Serve as a reference guide and training document. 3. Ensure compliance with federal and state guidelines.

This document provides guidance to Infant Toddler Early Intervention Service Coordinators on discussing enrollment in Pennsylvania’s Medical Assistance program with families.

This annotated form described the contents of the revised Reevaluation Report (July 2018), which replaces the July 2008 version and includes a change in terminology that replaces the term “mental retardation” with the term “intellectual disability.” This change also aligns the Commonwealth’s special education regulations in Chapters 14 and 711 to the Individuals with Disabilities Education Act (IDEA) regulatory revisions resulting from Rosa’s Law. The change in terminology does not affect the meaning or the eligibility determination associated with the term.

This revised Reevaluation Report (July 2018) replaces the July 2008 version and includes a change in terminology that replaces the term “mental retardation” with the term “intellectual disability.” This change also aligns the Commonwealth’s special education regulations in Chapters 14 and 711 to the Individuals with Disabilities Education Act (IDEA) regulatory revisions resulting from Rosa’s Law. The change in terminology does not affect the meaning or the eligibility determination associated with the term.

Procedural Safeguards Notice - Preschool Early Intervention form revised June 2009. The request forms for mediation and due process hearing are included as Appendix B in this document. They can also be downloaded from the Preschool EI Forms page on the PaTTAN website.

The Procedural Safeguards Notice includes a full explanation of all the rights available to parents of a child in Preschool Early Intervention when their child has been referred for or is receiving Early Intervention services.

The Procedural Safeguards Notice includes a full explanation of all the rights available to parents of a child with a disability ages 3-21 when their child has been referred for or is receiving special education services. This model form provides a format that LEAs may choose to use to provide information about procedural safeguards to parents. This revised Procedural Safeguards Notice includes a change in terminology that replaces the term “mental retardation” with the term “intellectual disability.” This change also aligns the Commonwealth’s special education regulations in Chapters 14 and 711 to the Individuals with Disabilities Education Act (IDEA) regulatory revisions resulting from Rosa’s Law. The change in terminology does not affect the meaning or the eligibility determination associated with the term. Also, this revised notice includes additional resources for parents in Appendix A. In addition, this document contains a revised Office for Dispute Resolution (ODR) Request Form for IEP/IFSP/GIEP Facilitation, Mediation, and a revised Due Process Compliant Request Form in Appendix B. The revised Procedural Safeguards Notice contains the footer “July 2018.” This notice is available in two formats - a Word document and a pdf. Below is the request form for Mediation, IEP/IFSP/GIEP Facilitation and the Due Process Complaint form. The form can be submitted via mail, fax or email; contact information can be found at the bottom of each form. Requests can also be submitted via the online submission form on ODR’s website. Mediation & IEP/IFSP/GIEP Facilitation Request (English) - http://odr-pa.org/iep-ifsp-med-request-form-english/ Mediation & IEP/IFSP/GIEP Facilitation (Spanish) – http://odr-pa.org/mediation-iep-online-request-spanish/ Due Process Complaint (English) - http://odr-pa.org/due-process-online-request/ Due Process Complaint (Spanish) - http://odr-pa.org/due-process-online-request-spanish/ *Note: The online submission forms can be accessed in 11 other languages via the ODR website. They include Albanian, Arabic, Chinese Simplified, Chinese Traditional, French, German, Italian, Japanese, Korean, Russian and Portuguese.

Letter to a parent on their rights and their child’s rights related to early intervention services.

Letter to a parent on their rights and their child’s rights related to Early Intervention services.

This revised Procedural Safeguards Letter (with a footer indicating “July 2018 Revisions”) replaces the current Procedural Safeguards Letter dated July 1, 2008. This revised letter includes a change in terminology that replaces the term “mental retardation” with the term “intellectual disability.” This change also aligns the Commonwealth’s special education regulations in Chapter 14 to the Individuals with Disabilities Education Act (IDEA) regulatory revisions resulting from Rosa’s Law. There are no other changes to the current regulations in Chapter 14 or 711.

This annotated document describes the new Prior Written Notice for Reevaluation and Request for Consent Form, which reflects the requirement that reevaluations are subject to the IDEA’s notice requirements in 34 CFR Sec. 300.503-300.504, and parental consent requirements in 34 CFR Sec. 300.300. Under 34 CFR Sec. 300.503(a) the local education agency (LEA) must provide written notice to the parents of a child with a disability that describes any reevaluation procedures the agency proposes to conduct, and must be given to the parents of a child with a disability a reasonable time before the public agency: (1) Proposes to initiate or change the identification, evaluation or educational placement of the child or the provision of a free appropriate public education (FAPE) to the child; or (2) Refuses to initiate or change the identification, evaluation or educational placement of the child or the provision of FAPE to the child. This Prior Written Notice for Reevaluation and Request for Consent Form includes the notice and consent requirements for the reevaluation. This form replaces the Permission to Reevaluate – Consent Form (Annotated). It contains the footer, “Revised January 2015.” This new form is effective beginning March 30, 2015.

This new form is effective beginning March 30, 2015 and reflects the requirement that reevaluations are subject to the IDEA’s notice requirements in 34 CFR Sec. 300.503-300.504, and parental consent requirements in 34 CFR Sec. 300.300. Under 34 CFR Sec. 300.503(a) the local education agency (LEA) must provide written notice to the parents of a child with a disability that describes any reevaluation procedures the agency proposes to conduct, and must be given to the parents of a child with a disability a reasonable time before the public agency: (1) Proposes to initiate or change the identification, evaluation or educational placement of the child or the provision of a free appropriate public education (FAPE) to the child; or (2) Refuses to initiate or change the identification, evaluation or educational placement of the child or the provision of FAPE to the child. This Prior Written Notice for Reevaluation and Request for Consent Form includes the notice and consent requirements for the reevaluation. This form replaces the Permission to Reevaluate – Consent Form. It contains the footer, “Revised January 2015.”

This annotated document describes the new Prior Written Notice for Initial Evaluation and Request for Consent Form, which reflects the requirement that initial evaluations are subject to the IDEA’s notice requirements in 34 CFR Sec. 300.503-300.504, and parental consent requirements in 34 CFR Sec. 300.300. Under 34 CFR Sec. 300.503(a) the local education agency (LEA) must provide written notice to the parents of a child with a disability that describes any evaluation procedures the agency proposes to conduct, and must be given to the parents of a child with a disability a reasonable time before the public agency: (1) Proposes to initiate or change the identification, evaluation or educational placement of the child or the provision of a free appropriate public education (FAPE) to the child; or (2) Refuses to initiate or change the identification, evaluation or educational placement of the child or the provision of FAPE to the child. This Prior Written Notice for Initial Evaluation and Request for Consent Form includes the notice and consent requirements for initial evaluation. This form replaces the Permission to Evaluate – Consent Form (Annotated). It contains the footer, “Revised January 2015.” This new form is effective beginning March 30, 2015.

This new form is effective beginning March 30, 2015 and reflects the requirement that initial evaluations are subject to the IDEA’s notice requirements in 34 CFR Sec. 300.503-300.504, and parental consent requirements in 34 CFR Sec. 300.300. Under 34 CFR Sec. 300.503(a) the local education agency (LEA) must provide written notice to the parents of a child with a disability that describes any evaluation procedures the agency proposes to conduct, and must be given to the parents of a child with a disability a reasonable time before the public agency: (1) Proposes to initiate or change the identification, evaluation or educational placement of the child or the provision of a free appropriate public education (FAPE) to the child; or (2) Refuses to initiate or change the identification, evaluation or educational placement of the child or the provision of FAPE to the child. This Prior Written Notice for Initial Evaluation and Request for Consent Form includes the notice and consent requirements for the initial evaluation. This form replaces the Permission to Evaluate – Consent Form. It contains the footer, “Revised January 2015.”

Preschool to School Age Transition Considerations for Children who are Deaf, Hard of Hearing or Deaf-Blind

Early Intervention Evaluation Report for use as of December 2018. The Evaluation Report documents information on a child and family, including strengths and needs, provides eligibility determinations, and provides recommendations for supports that can assist the young child to develop, learn and grow. This annotated form provides guidance to parents and early intervention staff completing the evaluation report. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

Early Intervention Evaluation Report for use as of December 2018. The Evaluation Report documents information on a child and family, including strengths and needs, provides eligibility determinations, and provides recommendations for supports that can assist the young child to develop, learn and grow.

This form is effective beginning March 2014. This form must be issued by the Local Education Agency to obtain written consent to conduct a reevaluation.This annotated form offers assistance and guidance to parents and early intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

This annotated document describes the contents of the Permission to Reevaluate - Oral Request Form, which is provided to the parent by the LEA upon a parent’s oral request for a reevaluation. This form provides the means of getting the parental request in writing.

This form is effective beginning June 8, 2021. This document must be issued by the Local Education Agency in response to a parent’s oral request for a reevaluation within 10 calendar days of the oral request. Annotated version available

This form is effective beginning March 2014. This form must be issued by the Local Education Agency to obtain written consent to conduct a reevaluation.

This form is effective beginning March 2014. This form must be issued by the Local Education Agency to obtain written consent to conduct an initial evaluation. This is the annotated version. This annotated form offers assistance and guidance to parents and early intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

This form is effective beginning March 2014. This form must be issued by the Local Education Agency to obtain written consent to conduct an initial evaluation.

This annotated document describes the contents of the Permission to Evaluate - Oral Request Form, which is provided to the parent by the LEA upon a parent’s oral request for an evaluation. This form provides the means of documenting the parental request in writing.

This form is effective beginning June 8, 2021. This document must be issued by the Local Education Agency in response to a parent's oral request for an evaluation within 10 calendar days of the oral request.

This is an annotated version of the Medical Assistance Billing Parental Notice form which provides notice to parents on giving consent for the Local Educational Agency (LEA) to access reimbursement from Medical Assistance for special education services. This annotation offers guidance to Early Intervention staff. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

This form allows parents to choose whether to give consent for the Local Educational Agency (LEA) to access reimbursement from Medical Assistance for special education services. This form offers assistance and guidance to parents and early intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

This is an annotated version of the Medical Assistance Billing Parental Consent form. This annotation provides guidance for understanding the options outlined in this form.

This form allows parents to choose whether to give consent for the Local Educational Agency (LEA) to access reimbursement from Medical Assistance for special education services.

The Early Intervention Communication Plan for use as of November 2019. The plan has detailed discussion points that families with children who are deaf or hard of hearing and IFSP or IEP team members should consider during plan development. Information in the plan addresses language and communication needs; communication options, opportunities for direct communication; and progress, assistive technology, devices and services. It also provides a glossary of terms for use.

This annotated document describes the contents of the Parental Consent To Excuse Members from Attending the IEP Team Meeting form, which is used by the LEA to obtain consent from the parent to excuse required members of the IEP team from attending an IEP team meeting.

This annotated document describes the contents of the Parental Consent to Excuse Members from Attending the IEP Team Meeting form. This form is effective beginning March 2014. This form is used along with an Invitation to Participate in an IEP Meeting if there are team members who are invited to attend but the program would like to excuse their participation. This annotated form offers assistance and guidance to parents and early intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

This form is effective beginning July 1, 2008 and reflects new provisions of revised Chapters 14 and 711. This new Invitation (with a footer indicating "July 2008 Revisions") replaces the current Invitation. This Invitation no longer contains the request for parental consent to excuse members of the IEP team from attending the IEP team meeting. This request now is made with a separate form, "Parental Consent to Excuse Members from Attending the IEP Team Meeting."

This form is effective beginning March 2014. This form is used along with an Invitation to Participate in an IEP Meeting if there are team members who are invited to attend but the program would like to excuse their participation.

This is an annotated version of the Parent Rights Agreement that provides guidance to parents and Early Intervention staff for understanding parent and child’s rights during the Early Intervention process.

This form summarizes the parent and child’s rights during the Early Intervention process.

his form is effective beginning March 2014. The Preschool Early Intervention program is responsible for sending this form on or before February 1st to the parents of all children approaching the age of kindergarten or 1st grade. This annotated form offers assistance and guidance to parents and early intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

This form is effective beginning March 2014. The Preschool Early Intervention program is responsible for sending this form on or before February 1st to the parents of all children approaching the age of kindergarten or 1st grade.

The recent supplemental regulations to 34 CFR Part 300, effective December 31, 2008, require that Local Education Agencies provide parents with prior written notice upon parental revocation of consent for the continued provision of special education and related services. This annotated form, revised December 31, 2008, describes how to use the current NOREP/PWN to provide this notice to the parents.

This annotated NOREP/PWN form provides explanation for the document that LEAs may choose to communicate to parents the recommended educational program for their child and other actions taken by the LEA. This revised annotated NOREP/PWN includes additional resources for parents on page 6. The revised form contains the footer “October 2014.”

This NOREP/PWN form provides a format that LEAs may choose to provide to parents the recommended educational program for their child and other actions taken by the LEA. This revised NOREP/PWN includes additional resources for parents on page 4. The revised form contains the footer "February 11, 2011 Revisions.”

This is an annotated version of the Notice of Recommended Educational Placement (NOREP). It provides guidance to preschool Early Intervention staff on using and explaining the NOREP to families. It also provide additional information on the special education process.

This form summarizes recommendations for a child’s preschool educational program and other actions proposed by the Preschool Early Intervention program. The form also includes state and local resources that provide additional information on the special education process.

This form is effective beginning March 2014. The Preschool Early Intervention program is responsible for sending this form on or before February 1st to the parents of all children approaching the age of kindergarten or 1st grade.

Transition from Preschool Early Intervention to School Age Program – The Preschool Early Intervention program should include this form as an attachment to the Notice Of Your Child’s Transition to School Age Meeting. 10/2009

Mediation Request Form is effective beginning July 2008. This new form can also be found in Appendix B of the Procedural Safeguards Notice which can be downloaded from the Preschool EI Forms page on the PaTTAN website.

This revised annotated form describes the new Invitation to Participate in the IEP Team Meeting or Other Meeting(with footer indicating “May 2015 Revisions”), which adds supplementary purposes for an IEP team meeting, removes the requirement to use two separate Invitation to Participate in the IEP Team Meeting or Other Meeting forms for transition planning/services, and supplements the explanations for transition planning and services, including a statement that the local education agency (LEA) will invite the student, if age 14 or above. This form is effective beginning June 30, 2015.

This form is effective beginning March 2014. This form is used to invite team members to an IEP or other meeting. This annotated form offers assistance and guidance to parents and early intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

Revised May 2015 – This new Invitation to Participate in the IEP Team Meeting or Other Meeting (with footer indicating “May 2015 Revisions”) replaces the current Invitation. This revised form adds supplementary purposes for an IEP team meeting, removes the requirement to use two separate Invitation to Participate in the IEP Team Meeting or Other Meeting forms for transition planning/services, and supplements the explanations for transition planning and services, including a statement that the local education agency (LEA) will invite the student, if age 14 or above. This form is effective beginning June 30, 2015.

This form is effective beginning March 2014. This form is used to invite team members to an IEP or other meeting.

Letters of invitation for transition to the Preschool EI Program or to other community services. Invitation letters must be sent to the family, Preschool EI Program and other participants no later than 30 days before the scheduled transition meeting date, unless the parties all agree to meet within shorter timelines.

This form is effective beginning March 2014. The Preschool Early Intervention program is to provide this form to the parent at the Transition meeting (that is to be held by the end of February) and is to be completed jointly by the preschool and the school district or charter school. This annotated form offers assistance and guidance to parents and early intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

This form is effective beginning March 2014. The Preschool Early Intervention program is to provide this form to the parent at the Transition meeting (that is to be held by the end of February) and is to be completed jointly by the preschool and the school district or charter school.

This form is effective beginning March 2014. The Preschool Early Intervention program is to provide this form to the parent at the Transition meeting (that is to be held by the end of February) and is to be completed jointly by the preschool and the school district or charter school. This annotated form offers assistance and guidance to parents and early intervention providers. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

This form is effective beginning March 2014. The Preschool Early Intervention program is to provide this form to the parent at the Transition meeting (that is to be held by the end of February) and is to be completed jointly by the preschool and the school district or charter school.

Infant Toddler Early Intervention Evaluation Report for use as of December 2018. The Evaluation Report documents information on a child and family, including strengths and needs, provides eligibility determinations, and provides recommendations for supports that can assist the young child to develop, learn and grow. This annotated form provides guidance to parents and early intervention staff completing the evaluation report. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

Infant Toddler Early Intervention Evaluation Report for use as of December 2018. The Evaluation Report documents information on a child and family, including strengths and needs, provides eligibility determinations, and provides recommendations for supports that can assist the young child to develop, learn and grow.

Infant Toddler and Preschool Early Intervention plan document for use as of December 2018. The IFSP and IEP are plans that identify services and supports for children and families involved in Early Intervention. The IFSP and IEP consider the strengths of the child; concerns of the parent/guardian and most recent evaluation results so that family members and early education programs are actively engaged in promoting the child’s learning and development.

Infant Toddler Early Intervention plan document for use as of December 2018. The IFSP and IEP are plans that identify services and supports for children and families involved in Early Intervention. The IFSP and IEP consider the strengths of the child; concerns of the parent/guardian and most recent evaluation results so that family members and early education programs are actively engaged in promoting the child’s learning and development. This annotated form provides guidance to parents and early intervention staff completing the evaluation report. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

Preschool Early Intervention plan document for use as of December 2018. The IEP is a plan that identify services and supports for children and families involved in Early Intervention. The IEP considers the strengths of the child; concerns of the parent/guardian and most recent evaluation results so that family members and early education programs are actively engaged in promoting the child’s learning and development. This annotated form provides guidance to parents and early intervention staff completing the evaluation report. It is not intended as an exclusive manner for complying with state and/or federal special education statutes and regulations.

Revised IEP February 1, 2020 – This revised form (with footer February 1, 2020) provides changes to section IV (the elimination of required video recording and narrative notes for students taking the PASA) per the PENN*LINK issued December 16, 2019.

This revised Evaluation Report (Annotated) includes a change in terminology that replaces the term “mental retardation” with the term “intellectual disability.” This change also aligns the Commonwealth’s special education regulations in Chapters 14 and 711 to the Individuals with Disabilities Education Act (IDEA) regulatory revisions resulting from Rosa’s Law. The change in terminology does not affect the meaning or the eligibility determination associated with the term. (July 2018)

This revised Evaluation Report (July 2018) replaces the July 2008 version and includes a change in terminology that replaces the term “mental retardation” with the term “intellectual disability.” This change also aligns the Commonwealth’s special education regulations in Chapters 14 and 711 to the Individuals with Disabilities Education Act (IDEA) regulatory revisions resulting from Rosa’s Law. The change in terminology does not affect the meaning or the eligibility determination associated with the term.

This standardized session note form is to be used by all Infant/Toddler Early Intervention programs. The session note form documents the provision of services and supports, assures communication with families/caregivers and provides a mechanism to monitor the quality of services. Updated March 2013.

This Due Process Complaint Notice is effective beginning July 2014. This new form can also be found in Appendix B of the Procedural Safeguards Notice which can be downloaded from the Preschool EI Forms page on the PaTTAN website.

The Formal Complaint Form/Contact Information for (Infant Toddler and Preschool) is a form that parents can complete to request a formal complaint through the Bureau of Early Intervention Services.

The primary purpose of the Communication Plan is to establish discussion among all IEP team members who review the student’s needs based on communication skills and access. The Communication Plan should be the starting point for the IEP, and the results of this discussion should be used to identify the student’s present educational levels as well as to complete other sections of the IEP. The Annotated Communication Plan was revised in December 2010. Changes have been made to the following areas: annotation added for Section I, question 5; to Section III concerning the definition of qualified interpreters, and to the glossary to include definitions of qualified interpreters and communication modes and assistive technology devices and services for students who are deafblind. The revised version has December 2010 in the footer.

The Communication Plan must be included in the IEP of any student who is deaf or hard of hearing. The Communication Plan form was revised December 2010. At that time additions were made in Sections I and III of the plan to include communication needs and assistive technology devices and services for students who are deafblind. The revised plan has a footer reading December 2010. Annotated version available

This form is used to submit a formal complaint to the PA Department of Education, Bureau of Special Education (BSE) - Division of Compliance. If you need more information about the complaint process or if you are unable to print the form and would like to receive a complaint form by mail, please contact the Special Education ConsultLine at 1-800-879-2301 (within the state of Pennsylvania) or 717-901-2146.

A standard release form that will allow Early Intervention and the Department of Health to exchange information with a family of a child who is deaf or hard of hearing.

This standard release form is used to obtain permission to share information with community agencies who are currently involved with local Early Intervention programs.

This annotated document is effective December 14, 2020. It provides guidance on the development of the Individual Education Program; guidance related to school closures associated with COVID-19; and guidance pertaining to the October 2020 revision to Act 26 questions associated with postsecondary transition. Note: The annotated IEP was reformatted as of June 14, 2021. Features were added to enhance navigation, search capabilities, and previewing of sections. The content has not changed.

This annotated document is effective December 14, 2020. It provides guidance on the development of the Individual Education Program; guidance related to school closures associated with COVID-19; and guidance pertaining to the October 2020 revision to Act 26 questions associated with postsecondary transition.

This document provides guidance for writing the standardized session note form that is to be used by all Infant/Toddler Early Intervention programs. Updated March 2013.

This annotated document describes the contents of the Agreement to Waive Reevaluation form, which is used by the LEA to obtain agreement from the parent to waive a child’s reevaluation. This document also replaces the September 2008 version and includes a change in terminology that replaces the term “mental retardation” with the term “intellectual disability.” This change aligns the Commonwealth’s special education regulations in Chapter 14 and Chapter 711 to the Individuals with Disabilities Education Act (IDEA) regulatory revisions resulting from Rosa’s Law. The change in terminology does not affect the meaning or the eligibility determination associated with the term.

This form is effective beginning July 1, 2008. This new form is used to obtain parental agreement to waiving a reevaluation. This request previously was included in the "Permission to Reevaluate/Agreement to Waive Reevaluation" form.

Act 26 Questions and Answers

This booklet explains how to request Early Intervention services; eligibility criteria; rights and responsibilities; individualized family service planning for ages birth to three; and individualized education planning for ages three to school age. For copies, please contact connecthelp@tiu11.org.