Instructions: Complete this form forĀ each student served by IDEA or Section 504, upon severing attendance or denial of admission. Please note that the CALPADS code appears to the right of many of the reasons for severance as applicable.

DEADLINE: July 1, 2018 for the 2017-2018 School Year

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* 1. District Information

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* 2. Student Information

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* 4. Date of severance or denial

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* 5. School Referred to:

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* 6. Check all that apply:

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* 7. Action taken/reason for action (check all that apply):

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* 8. Severance of attendance from the district of residence, county school or program, or private school (Explanation of response to #7)

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* 9. Expelled, under Education Code 48915, from the district of residence, county school or program, private school or charter school (Explanation of response to #7)

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* 10. Excluded from the district of residence, county school or program, or private school (Explanation of response to #7)

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* 11. Exemption from the district of residence, county school or program, or private school (Explanation of response to #7).

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* 12. Transfer from the district of residence, county school or program, private school, or charter school (Explanation of response to #7)

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* 13. Denial of Admission (to district of residency, other district, county school or program, private school, or charter school. (Explanation of response to #7):

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* 14. Status

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* 15. Identified Disability:

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* 16. Reason for Action Taken:

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