C.M.R. 14, 197, ch. 4, app 197-4-B
Child: ________________________ D.O.B. ____________________
Parents Name/Address_________________CXC/CDW ____________________
__________Address: __________
_____________Tel. ____________
Handicapping, Condition: ___________________________________________________
______________________________________________
______________________________________________
__________________
Brief Description of current services:___________________________________________
____________________________________________
____________________________________________
_____________________________________________
_________________
Date___________ Place _____________ Time _______________
(attached is explanation of IDT process).
RESPONSIBILITY GRID FOR IEP/ITP COMPONENTS
| BMR | BMR | |||
| CDW | CSC | LEA | DSE | |
| Home based special instruction for | ||||
| developmentally delayed students | P | N | N | N |
| School based special program 3-5 yr. | P/S | N | P | S |
| if avail.) | ||||
| Family Support | P | P | S | N |
| (0 - 5) | (5-on) | (5-20) | ||
| Medical Services | P | P | N | N |
| (O - 5) | ||||
| Specialized Education) (5-20) | N | N | P | S |
| Related Services - Speech, OT, PT | P | S | P | S |
| (0 - 5) | ||||
| Evaluations | P | P | P | S |
| (0 - 5) | ||||
| Program Evaluation: | ||||
| a. I.E.P. | S | S | P | S |
| b. I.P.P. | P | P | S | N |
| Referral to Vocational Rehabilitation | N | P | P | N |
| (20 on) | ||||
| S | ||||
| (16 on) | ||||
| Vocational Options or Adult Program | N | P | N | N |
| Placement in Residential or Foster Home | ||||
| Non-State Ward | P | P | N | N |
| Advocacy | P | P | P | P |
| Placement in ICFMR's | P | P | N | N |
| P - Primary | ||||
| S - Secondary |
C.M.R. 14, 197, ch. 4, app 197-4-B