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*
MM slash DD slash YYYY
Exit Program*
MM slash DD slash YYYY
Status Change Date*
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 will this student be entering?*
- ESL
- Bilingual
- Gifted and Talented
- 504
- Dyslexia
- RTI
Which special program will this student be changing to?*
- ESL
- Bilingual
- Gifted and Talented
- 504
- Dyslexia
- RTI
Which Special Program will this student be exiting?*
- ESL
- Bilingual
- Gifted and Talented
- 504
- Dyslexia
- RTI
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 EB/English Proficient
- 1 – EB/EL
- F – Reclassified from EB/EL - Monitored 1 (M1)
- S – Reclassified from EB/EL - Monitored 2 (M2)
- 3 – Reclassified from EB/EL - Monitored 3 (M3)
- 4 – Reclassified from EB/EL - Monitored 4 (M4)
- 5 – Former EB/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
- Leave Blank ( only use this if you are entering monitored)
BIL/ESL Fund Code*
- BE : Standard Bilingual/ESL
- D1 : Dual Language Immersion/One-Way
- D2 : Dual Language Immersion/Two way
- Leave Blank ( only use this if you are entering monitored)
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
MM slash DD slash YYYY
OLPT English Test
OLPT Spanish Test
OLPT English/Spanish Test Date
MM slash DD slash YYYY
OLPT English/Spanish Test Score
Gifted and Talented*
Select reason for exiting*
- Exiting Program
- Exiting Program going into special education
504*
- Academic/Learning
- Auditory Impairment
- Behavioral/Emotional
- Health / Physical
- Temporary Impairment
- Visual Impairment
Subject Matter Aptitude*
- Math
- Reading/ELA
- Science
- Social Studies
Dyslexia Services*
- 01-Student receives services for dyslexia or a related disorder through IDEA or Section 504. (Section 504 Service)
- 02- Receiving instruction that meets applicable dyslexia program criteria established by the State Board of Education (SBOE) provided by a person with specific training in providing that instruction (See Chapter IV in the Dyslexia Handbook (2018) for program criteria) (SBEC/Trained Staff)
- 03- On the basis of having dyslexia or a related disorder, the student is permitted to use modifications in the classroom or accommodations in the administration of assessments under Section 39.023. (Section39.023 Mods)
Please select the Tier the student qualifies
- Tier 1 (T1)
- Tier 2 (T2)
- Tier 3 (T3)
Submitter's name:*
First Last
Your name here will also act as a signature.
Submitter's Email

Student Information