Department of Special Education
Interim Transfer Individualized Education Plan (IEP)
Census Number:
Student Name (Last, First, M.I.)
Birthdate
Sex
Grade
Ethnic
Code
Name(s) of [ ] Parent(s) [ ] Guardian(s) [ ] Surrogate Parent
Address of
Parent Foster Parent Group Home
, Arizona Zip
Home Phone
Work Phone
Date of MET/ IEP:
Anticipated Duration of IEP:( No longer than 30 calendar
days
To:
Next Eligibility Review
Date:______________________
Based on MET:___________________________
Special Education Eligibility Category: (no abbreviations)
This student is transferring from_____________________School District in the state of _________________________, with a current IEP
dated______________.
IEP attached. OR This has been confirmed by District (name & title)_________________________ who
contacted (name & title)__________________________ by
phone fax mail on (date)_________________________________.
Date Meeting Notice Sent to the Parent(s): Date Procedural Safeguards given to the Parent(s):
ATTENDANCE
The following persons, as indicated by their signatures, participated in this conference and/or the development of the IEP.
Position / Relation to Student
* Required signatures
Signature - Please Sign Legibly
Date (Month / Day / Year)
District Representative
*General Education Teacher
*Special Education Teacher / Provider
*Parent(s)
Receiving School Representative *Required if
student is to be served by other than home
school.
New Goals/Objectives:
Changes to Special Ed Services:
Changes to Related Services:
Health Concerns:
Special Transportation Considerations:
