Oregon Department of Education
Working Gears

School Age Sample Forms


Form Form Number PDF RTF
Manifestation Determination
(English revised 6/07)
581-1279-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Summary of Performance
(English revised 3/13)
581-1278-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Agreement Between Parents and the District
(English revised 7/07)
581-1281-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Prior Notice of Special Education Action
(English revised 6/07)
581-5148y-p Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Prior Notice About Evaluation / Consent for Evaluation
(English revised 6/07)
581-5150b-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Prior Notice and Consent for Initial Provision of Special Education Services
(English revised 6/07)
581-5148p-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Notice of Team Meeting
(English revised 6/07)
581-5148s-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Medical Statement or Health Assessment
(English revised 3/14)
581-5149o-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Health Form Instructions (for Case Managers)
(English revised 3/14)
581-1452-p English
English
Statement of Eligibility   Autism Spectrum Disorder
(English revised 6/07)
581-5148l-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Statement of Eligibility   Communication
(English revised 4/16)
581-5148g-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Statement of Eligibility   Emotional Disturbance
(English revised 1/12)
581-5148j-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Statement of Eligibility   Deafblind
(English revised 6/07)
581-5148m-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Statement of Eligibility   Hearing Impairment
(English revised 6/07)
581-5148f-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Statement of Eligibility   Intellectual Disability
(Revised 7/11)
581-5148k-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Statement of Eligibility   Orthopedic Impairment
(English revised 6/07)
581-5148h-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Statement of Eligibility   Other Health Impairment
(English revised 6/07)
581-5148n-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Statement of Eligibility   Specific Learning Disability
(Revised 7/11)
581-5148i-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Statement of Eligibility   Traumatic Brain Injury
(English revised 6/07)
581-5148o-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Statement of Eligibility   Vision Impairment
(English revised 6/07)
581-5148e-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Special Education Placement Determination
(English revised 6/07)
581-5138b-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese

Related Forms Form Number PDF RTF
Authorized for Release of Information Form
(English revised 6/07)
581-1196-P Chinese
English
Russian
Spanish
Vietnamese
Chinese
English
Russian
Spanish
Vietnamese
Written Consent to Access Public Insurance (Medicaid) and Release Personally Identifiable Information for Medicaid Billing Purposes (For Ages 3 - 21)
(New 7/13)
581-1450-P English
Chinese
Russian
Spanish
Vietnamese
English
Chinese
Russian
Spanish
Vietnamese
Written Notification to Parent Proposed Use of Public Insurance by School District/ECSE Program
(New 7/13)
581-1449 English
Chinese
Russian
Spanish
Vietnamese
English
Chinese
Russian
Spanish
Vietnamese

Braille available upon request.

  • Oregon Standard IEP
    The Oregon Standard IEP form, revised to comply with IDEA 2004 and the federal regulations


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