Special Education

Student Profile - PDFPDF document (153 KB)

A Name of Student
Last Name __________________First___________Middle_________

Date of Birth Month_____ /Day_____/Year

Gender ___ Male ____Female

Date of CSE Recommendation for Residential Placement

Month____ /Day____ /Year _____

With consent of parent, has the CSE made a referral to the Office for People with Developmental Disabilities (OPWDD)? __ Yes  __ No __ N/A

Parent ___ Legal Guardian ___

Last Name____________________________ First_______________________

Address Street_______________________________

City_______________ County___________________ State_____ Zip______

Home Telephone Number (      ) ___________
Work Telephone Number (      ) ____________

School District

District Contact - Last Name ____________________First________________

Title _______________________________________

Address - Street ______________________________

City ______________ County

________________ State________ Zip


Telephone Number (      )

Fax Number (      )

B Request for Out-Of-State Placement:


Signature, CSE Chairperson                                                                  

C Name of Current Educational Program (not proposed program):

(Please check the appropriate box below)

Name of Hospital__________________________

Emergency Interim Placement
Other State Agency Program

D CSE Classification:
(Please check one box to indicate the primary disability classification made by the CSE)

- Description:______________________________

E Student Functioning Level:  Results of Latest Test of Intelligence
(Check the box that most closely indicates the results)

Intellectual ability

Adaptive Functioning

Language Functioning

Interpreter Needed:

Does this student require a sign language interpreter? ___ Yes ___ No
Does this student require instruction in Braille and the use of Braille? ___ Yes ___ No
Does this student require bilingual education? ___ Yes ___ No
Native Language:                                                                                     

Physical Functioning:




Medical Diagnosis: (Indicate any medical problems which may impact on the education of the child)

Psychiatric Disorder

Medical Needs:
Does this child have medical needs beyond the administration of medications which require daily individualized attention from health care staff? __ Yes __ No
Does this child require 24 hour nursing care?  __ Yes __ No
Please specify any medical alerts:   _____________________     

Behaviors Exhibited:

Behavior Frequency:

F Related Services Recommended:


G Diploma goal: 

Last Updated: March 9, 2012