PEIMS – Special Programs Data Entry Form

Please fill out all below information in order to code a student into their perspective Special Program.
Student Information
Student ID*
Student Name*
First Last
Please select a School*
Grade Level*
Program 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?*
- Yes
- No
What is the Home Language*
- English
- Spanish
- Other
Other Home Language*
What is the Student Language*
- English
- Spanish
- Other
Other 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 Program
- 2 - Transitional Bilingual/Early Exit
- 3 - Transitional Bilingual/Late Exit
- 4 - Dual Language Immersion/Two-Way
- 5 - Dual Language Immersion/One-Way
ESL*
- 0 – Does not participate in ESL Program
- 2 – Content based
- 3 – Pull-out
LEP Code*
- 0 – Non LEP
- 1 – LEP
- F – 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 Student
Parent Permission Code*
- 3 – Parent/Guardian Request Bilingual (non-LEP/EL Student)
- 7 – Parent/Guardian Did Not Respond
- 8 – Parent/Guardian Was Not Contacted
- A – Parent/Guardian Denied BIL, Approved ESL
- C – Parent/Guardian Denied LEP/EL Placement in ALL Language Program
- D – Parent/Guardian Approved BIL Placement
- E – Parent/Guardian Approved - Alt Lang Prog-BIL
- G – Parent/Guardian Approved reclassified BIL/ESL(non-LEP/EP Student)
- H – Requested Placement of Non-LEP Student in ESL
- J – Parent/Guard Approved-Alt Lang Prog-ESL
- K – Parent/Guardian Approved ESL Placement
BIL/ESL Fund Code*
- BE : Standard Bilingual/ESL
- D1 : Dual Language Immersion/One-Way
- D2 : Dual Language Immersion/Two way
Alt Lang Code*
- 00 : No Alternative Program
- 01 : Alternative Bilingual Language Program
- 02 : Alternative ESL Language Program
Years in U.S School
Please enter a number less than or equal to 25.
Date HLS Admin
Date Format: MM slash DD slash YYYY
OLPT English Test
OLPT Spanish Test
OLPT English/Spanish Test Date
Date Format: MM slash DD slash YYYY
OLPT English/Spanish Test Score
Gifted 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 risk
- Screened and at risk
Dyslexia 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.

Student Information