PEIMS – Special Programs Data Entry Form Please fill out all below information in order to code a student into their perspective Special Program.Student InformationStudent ID*Student Name* First Last Please select a School*Jubilee BrownsvilleJubilee KingsvilleJubilee Lakeview University PrepJubilee Leadership AcademyJubilee LivingwayJubilee HarlingenJubilee Highland HillsJubilee Highland ParkJubilee San AntonioJubilee SenderoJubilee Wells BranchJubilee WestwoodGrade Level*Pre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thProgram Entry or Exit* Entering Program Exit Program Status Change You can select both, if you need to input a Entry and Exit Date.Entering Program* Date Format: MM slash DD slash YYYY Exit Program* Date Format: MM slash DD slash YYYY Status Change Date* Date Format: MM slash DD slash YYYY Does this student have a Home Language Survey?*YesNoWhat is the Home Language*EnglishSpanishOtherOther Home Language*What is the Student Language*EnglishSpanishOtherOther Student Language*Which Special Program this student be Entering?* ESL Bilingual Gifted and Talented 504 Dyslexia RTI Dyslexia At -Risk Screening (Only for Kinder or 1st Grade) Which Special Program this student be Changing ?* ESL Bilingual Gifted and Talented 504 Dyslexia RTI Dyslexia At -Risk Screening (Only for Kinder or 1st Grade) Which Special Program this student be exiting?* ESL Bilingual Gifted and Talented 504 Dyslexia RTI Dyslexia At -Risk Screening (Only for Kinder or 1st Grade) Why was the change made?*Bilingual 1*0 - Does not participate in Bilingual Program2 - Transitional Bilingual/Early Exit3 - Transitional Bilingual/Late Exit4 - Dual Language Immersion/Two-Way5 - Dual Language Immersion/One-WayESL*0 – Does not participate in ESL Program2 – Content based3 – Pull-outLEP Code*0 – Non LEP1 – LEPF – Reclassified from LEP/EL - Monitored 1 (M1)S – Reclassified from LEP/EL - Monitored 2 (M2)3 – Reclassified from LEP/EL - Monitored 3 (M3)4 – Reclassified from LEP/EL - Monitored 4 (M4)5 – Former LEP/EL StudentParent Permission Code*3 – Parent/Guardian Request Bilingual (non-LEP/EL Student)7 – Parent/Guardian Did Not Respond8 – Parent/Guardian Was Not ContactedA – Parent/Guardian Denied BIL, Approved ESLC – Parent/Guardian Denied LEP/EL Placement in ALL Language ProgramD – Parent/Guardian Approved BIL PlacementE – Parent/Guardian Approved - Alt Lang Prog-BILG – Parent/Guardian Approved reclassified BIL/ESL(non-LEP/EP Student)H – Requested Placement of Non-LEP Student in ESLJ – Parent/Guard Approved-Alt Lang Prog-ESLK – Parent/Guardian Approved ESL PlacementBIL/ESL Fund Code*BE : Standard Bilingual/ESLD1 : Dual Language Immersion/One-WayD2 : Dual Language Immersion/Two wayAlt Lang Code*00 : No Alternative Program01 : Alternative Bilingual Language Program02 : Alternative ESL Language ProgramYears in U.S SchoolPlease enter a number less than or equal to 25.Date HLS Admin Date Format: MM slash DD slash YYYY OLPT English Test01 : Comprehensive English Language Learning (CELLA)02 : IPT I Forms G & H, Second Edition, 201604 : IPT I Online Forms G & H, Second Edition, 201606 : IPT II Forms E & F, Second Edition, 201608 : IPT II Online Forms E & F, Second Edition, 201610 : LAS Links Forms A & B, 201212 : LAS Links Online Forms A & B, 201214 : LAS Links Form C, 2012 Form D, 201316 : LAS Links Online Form C, 2012 Form D, 201318 : Pre IPT, Fifth Edition, 201619 : Pre IPT, Online, Fifth Edition, 201620: Pre LAS 2000 Forms C & D, 201122 : Texas English Language Proficiency Assessment (TELPAS)23 : Test of English Language Learning (TELL) Diagnostic, 201524: Woodcock-Munoz Language Survey III, 2016, Forms A & B26: Stanford ELPT 2nd Edition, Forms E & F Full Length, Forms E & F Abbreviated, 201298: Other English Assessment TestOLPT Spanish Test03 : IPT 1 Spanish, Fifth Edition, 201605 : IPT I Spanish, Online, Fifth Edition, 201607 : IPT Spanish, Fifth Edition, 201609 : IPT II Spanish, Online, Fifth Edition, 201611 : LAS Links Español, 201313 : LAS Links Español Online, 201315 : LAS Links Español, Second Edition, 201317 : LAS Links Español Online, Second Edition, 201318 : Pre IPT, Fifth Edition, 201619 : Pre IPT, Online, Fifth Edition, 201621 : Pre LAS 2000 Español Form C, 201125 : Woodcock-Muñoz Language Survey III, 2016, Spanish Form99 : Other Spanish Assessment TestOLPT English/Spanish Test Date Date Format: MM slash DD slash YYYY OLPT English/Spanish Test ScoreGifted and Talented* General Intellectual Ability Subject Matter Aptitude 504* Academic/Learning Auditory Impairment Behavioral/Emotional Health / Physical Temporary Impairment Visual Impairment Subject Matter Aptitude* Math Reading/ELA Science Social Studies Dyslexia Risk Indicator ( Kinder or 1st Grade)*Screened and not at riskScreened and at riskDyslexia Services* 01-Section 504 Services 02-SBEC/Trained Staff 03-Section39.023 Mods Submitter's name: First Last Your name here will also act as a signature.