Notice Of Eligibility Committee And/or Individualized Education Program Team Meeting Form
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1NOTICE OF ELIGIBILITY COMMITTEE AND/OR INDIVIDUALIZED
EDUCATION PROGRAM TEAM MEETING
____________________County Schools
Date ________________________________
Student’s Full Name___________________________________________
School ______________________________________________________
DOB ________________________________
Parent(s)/Guardian(s) _________________________________________
Grade_______________________________
Address _____________________________________________________
____________________________________________________________
WVEIS#_____________________________
___
______________
City/State____________________________________________________
Telephone____________________________
Dear Parent(s)/Guardian(s) and Student:
_____________________________________
___________________________________
A meeting will be held on _______________________________ at _______
a.m.
p.m. at___________________________.
The purpose of the meeting is checked below:
Eligibility Committee (EC) Meeting - The EC will review information to determine eligibility for special education. If the
EC determines the student is eligible, an Individualized Education Program (IEP) Team meeting will be held. (See
description below.) If found not eligible, recommendations from the EC will be provided to a school team for consideration,
and no IEP Team meeting will be held. If the EC determines further information is needed, you will be informed.
Individualized Education Program (IEP) Team Meeting - An IEP Team meeting will be convened to develop, review
and/or revise the IEP. Additionally, the IEP Team may:
st
identify transition services for the student with a disability (beginning with 1
IEP to be effective at age 16)
identify preschool transition needs
plan for reevaluation
determine if the student’s conduct is a manifestation of a disability
document transfer of student’s rights
other _______________________________________________
(age of majority)
We invite you to participate in this meeting so we may plan an educational program together. Please be informed you and the county
school district have the right to invite other individuals who have knowledge or special expertise regarding the student.
Enclosed
Provided earlier this school year.
Procedural Safeguards Brochure:
No
Yes Consent Date: _______________
If an agency representative is needed, prior written consent was obtained:
Copy to Invited Members:
Administrator
General Education Teacher
Evaluator
Special Education Teacher or Provider
Birth to Three Representative
Other ___________________
Student (when transition will be addressed)
Agency Representative(s) _______________________________________
IEP Team Member Excusal(s): The following IEP Team members will be excused from attending the IEP Team meeting. Members
whose curricular area or related service will be discussed will provide a written summary for consideration in developing the IEP.
Name/Position: ____________________________
Name/Position: __________________________________
Sincerely,
________________________________________________
_______________________________________________
Name/Position
Phone Number
Parent(s): Please return this form within 5 days and retain a copy for your records.
STUDENT RESPONSE (when transition will be addressed)
PARENT RESPONSE (check one)
I will attend the meeting as scheduled.
I will attend the meeting as scheduled.
I do not wish to attend.
I do not wish to attend.
I wish to have the meeting rescheduled.
I cannot attend in person, but will participate by phone.
I can be reached at ____________.
I wish to have the meeting rescheduled.
________________________________________________
PARENT OPTIONS (check all that apply)
Student Signature
I agree to waive the 8-day notification requirement.
Date
I agree to excuse the IEP Team members above.
I request the district to invite the Birth to Three
representative.
Note: Meeting may be rescheduled due
__________________________________________________
to a school delay or cancellation.
Parent Signature
Date
West Virginia Department of Education
July 2013
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