Model Forms for Services to Students in Special Education
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Special Education   >   WISM    >   Model State Forms

Model Forms for Services to Students in Special Education

The forms contained on this webpage have been developed by the Office of Superintendent of Public Instruction  (OSPI), Special Education Section, in compliance with the requirements of applicable state regulations contained in chapter 392-172A WAC.  The information on the forms does not substitute for reading the regulations.  Adoption of these forms by school districts or educational service districts is optional.  Federal regulations do not require or endorse any specific format for a particular form.  School districts may reformat and/or revise these forms to meet their own school district needs, or they may develop their own forms.  School districts that do not choose to use these model forms should make sure that the forms they are using address the requirements in the regulations.  Please note that, in addition to revising all of the previous model state forms, a number of new forms have been added (as specified next to the link to each form at the bottom of this page).

Throughout the process of developing these forms, several points were maintained as being important in their design and content.  These were:

  • Each form in this document is preceded by a purpose statement.  This statement provides to the users of the forms a concise description of how the form is to be used and for what purpose(s).
  • Points to consider are included on the forms as cues to provide instructional personnel, parents, and students (if appropriate), information that will directly assist them in developing an appropriate Individualized Education Program (IEP) to meet each student’s unique needs.
  • All forms were developed with the understanding that state regulations are explicit regarding the role of the parent in all procedures that affect potential educational decisions regarding their child. These forms reflect this increased role of parental involvement and associated parental responsibilities.
  • Parents would be fully informed as to how information requested or notification provided to them regarding their child would be used in assisting in the education for their child.
  • The evaluation report and IEP forms reflect the increased importance of a special education student’s participation in the general education curriculum or, for preschool children, in appropriate activities. School districts should address a student’s educational needs consistent with education reform initiatives in Washington State.  The evaluation report forms are designed so that evaluation data documented by the evaluation group will lead directly to the development of the IEP.
  • Evaluation and IEP Review Forms – These are user-friendly review forms that can assist staff when reviewing their own evaluations, reevaluations, and IEPs for compliance.  These forms can also be used in practice training activities by having staff review other evaluations and IEPs, such as the samples provided in this module, for compliance. IEP Review Form (Word) / Evaluation Review Form (Word)

The development of statewide forms is seen as an ongoing process.  These forms will be subject to review in the future and will be revised, as necessary, to comply with federal and state statutes and regulations.

The Office of Superintendent of Public Instruction, Special Education section, would like to thank all of those individuals and agencies that contributed to the development of these forms, including but not limited to the Special Education Advisory Council, the Washington Education Association, the Center for Change in Transition Services, the State Auditor’s Office, and the Committee of Practitioners.

Translated forms are also available in the following languages: Cambodian, Korean, Russian, Somali, Spanish, Ukrainian, and Vietnamese.

View the comparison of WAC citations to the forms listed below click here. (10/13/09)

Guidance

Model State Forms

Please note Medicaid forms 12a and 12b regarding Medicaid Verification and Billing have been revised in response to recent federal regulation changes.

Complete Forms Package (zip) (Click to download all of the model forms in Word version)

  1. Special Education Referral Review (Word)

  2. Prior Written Notice (Word) updated 10/09
    1. Assessment Plan (Word) updated 11/09
  3. Parent Consent (Word)
    1. Revocation of Consent (Word)
    2. Prior Written Notice for Revocation of Consent (Word)
  4. Meeting Invitation (Word)
  5. Evaluations and Reevaluations:
    1. Evaluation Report and Eligibility Determination (Word) updated 10/13
      1. Supplementary report for SLD (severe discrepancy) (Word) updated 10/13
      2. Supplementary report for SLD (response to scientific, research-based interventions) (Word) updated 10/13
    2. Agreement that Reevaluation is Unnecessary (Word) updated 10/13
    3. Agreement to Extend Evaluation Timeline (Word)
  6. Individualized Education Programs:
    1. IEP Team Member Excusal (Word) updated 10/09
    2. Parent Input Form (Word)
    3. IEP Form – without Secondary Transition (Word) updated 10/14
    4. IEP Form – with Secondary Transition (Word) updated 10/14
    5. Aversive Intervention Plan addendum (Word) updated 10/13
    6. Extended School Year (ESY) addendum (Word)
    7. IEP Amendment Without Reconvening the IEP Team (Word)
  7. Behavior:
    1. Functional Behavioral Assessment (Word)
    2. Behavioral Intervention Plan (Word)
    3. Manifestation Determination (Word)
  8. Private Schools:
    1. Private School Consultation (Word)
    2. Private School Affirmation (Word)
    3. Private School Services Plan (Word) updated 10/13
  9. Summary of Performance (Word)
  10. Request for Due Process Hearing (Word)
  11. Resolution Agreement (Word)
  12. Medicaid
    1. Annual Notification for Disclosure of Student Information - Medicaid (Word)
    2. Medicaid Consent for Verification and Billing (Word)
  13. Consent to Bill Private Insurance (Word) updated 10/13
  14. File Access Log (Word)
  15. Release of Records (Word)

**Please note: many of these forms contain interactive checkboxes. Simply double click on the checkbox and a menu will appear.  Select “checked” or “not checked” to change the content of the checkbox.

Translated Forms (PDF format unless otherwise indicated)
Complete Forms Package (.zip)

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