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PRIOR WRITTEN NOTICE AND MEETING NOTIFICATION FORM 18jan21

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SCDHHS/IDEA PART C/18JAN2021/ALL PREVIOUS VERSIONS ARE VOID
PRIOR WRITTEN NOTICE & MEETING NOTIFICATION FORM
PRIOR WRITTEN NOTICE
AND MEETING NOTIFICATION
Date of Notice:
SECTION 1: SERVICE COORDINATOR AND FAMILY INFORMATION
FROM:
TO:
Intake or Service Coordinator Name:
Parent:
Address:
Address:
City/State/Zip:
City/State/Zip:
Email:
Email:
Phone number:
Child’s Name:
SECTION 2: NOTICE OF PROPOSED ACTION
As required by Federal law, this notice is being sent to you because a change in IDEA/Part C activities has been planned or
proposed for your child, or a meeting with you is needed. The planned or proposed action(s) are checked below. Please
contact the Intake Coordinator or Service Coordinator listed above within seven days of the date of this notice if you:
✓ Have questions about this notice, or
✓ Do not agree to the action(s) listed below, or
✓ Want to change the date, time, or location of a proposed meeting.
An appointment is needed for the following activity or
activities:
Orientation and Intake
Screening
Initial or annual eligibility evaluation
Initial or annual family assessment
Initial or annual child assessment
An Individual Family Service Plan (IFSP) meeting is
needed:
Initial IFSP
Annual IFSP
Review or revision of IFSP*
A transition conference
Other (Please Explain):
*The revisions may include changing the source of payment,
location, frequency, or duration for one or more IFSP
services, or adding or removing one or more services to the
current IFSP.
APPOINTMENT DETAILS:
The IDEA/Part C Record will be closed seven days from
this notice for the following reason:
We have not been able to contact you to discuss
IDEA/Part C services.
You were unable to come to one or more appointments
for the intake, evaluation, or assessment activities to
determine eligibility for IDEA/Part C services.
You have chosen to decline an eligibility evaluation after
receiving a screening of your child’s development.
Your child is not (or is no longer) eligible for IDEA/Part
C services.
You have notified IDEA/Part C that you are not (or no
longer) interested in IDEA/Part C services for the child.
Other (please explain)
Date:
Time:
Location:
Note: The proposed appointment time can be held sooner than 7 days at the request of the parent. The service coordinator
should document this choice in the child’s electronic record.
THIS FORM MUST BE ACCOMPANIED BY THE PARENT NOTICE OF FAMILY RIGHTS AND SAFEGUARDS
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PRIOR WRITTEN NOTICE AND MEETING NOTIFICATION FORM 18jan21

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Completed 6 March 2022

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