XIII. APPENDICES

A. Sample Parent/Guardian Orientation Letter (A.1) and Sample Student Orientation Letter (A.2)

For use in preparing families and students to discuss transition during the IEP process. The mailing can include the Transition Questionnaire.

B. Transition Questionnaire: A Tool for Transition Planning

Can be used initially with the Orientation Letter described above or annually thereafter. Helps families to organize their thoughts about planning issues prior to the transition planning meeting.

C. Sample Notice Letter

Sample modification to the required Notice letter to parents about annual IEP meetings when transition is a focus of the meeting.

D. Confidentiality Release Form

Form to secure parental permission in advance for discussing individual case information with outside agencies whose expertise is needed to help identify transition options, services and resources.

E. Transition Planning Inventory

Form for taking notes during the IEP meeting about specific recommendations for action in key planning areas. Provides a checklist for participants to determine needs and action steps. Notes could guide the preparation of an appropriate IEP reflecting the results of the meeting.

F. Level I Vocational Assessment

Form to record information about the student's career awareness, goals, interests and needs. Completed forms may be of use during IEP meetings to discuss progress and activities for building career skills.

G. Sample Work Experience Progress Report

Form to record information about the student's in-school work experiences.

H. Sample IEP Addressing Transition Services

Part 200 Management System format demonstrating inclusion of transition planning and services within the computerized IEP format.

I. Sample Transition Goals and Objectives

Provides examples of transition goals and objectives.

J. VESID or CBVH Referral Form and Contacts

The Transition Referral Transmittal Sheet that can be used by districts to refer students to VESID or CBVH per criteria described in chapter XII. Includes contact information for specific District Offices.

A.1 SAMPLE PARENT/GUARDIAN ORIENTATION LETTER

Dear (parent/guardian)

During the Individualized Education Program (IEP) meeting this year we will be discussing long term planning with you and your child. We will look at where your child is going when completing school, what skills need to be developed in order to get there, and what linkages to other agencies may be necessary. The goal is to work together to ensure that your child has the opportunity to gain employability, academic, social, and living skills important to make the transition from school to work or further education and community living. We will also provide you with information about adult services that may be necessary to support your child's transition from high school to adult life.

Because the focus of this year's meeting is somewhat different, the following are some changes you might encounter:

1. Some skills that are important to develop are best taught at home by the parent, therefore, you and your child may be responsible for helping reach some of the goals listed on the IEP.
2. At the high school level, there will be a shift to skills that are important to employment, further education, and community living. The high school program will also relate to your child's needs and long term goals for further education, employment and community living.
3. As a parent/guardian you know your child better than anyone and we need input from you. Enclosed is the Transition Questionnaire that we ask you to fill out and bring with you to the IEP meeting. This form asks you to identify the skills you see as important for us to work on with your child during the next year.
4. Since transition planning will be a part of your child's CSE meeting, individuals representing adult service agencies may be invited to participate at the IEP meeting. Through this opportunity to hear about available services, program eligibility requirements, and resources, you will be better able to decide with your child what agencies and services can benefit him/her after school.
5. Because this is long term planning and is directly related to a student's goals for further education, living and working, it is important that your child and you be present at IEP meetings.

We feel that by teaching the skills needed to live, learn, and work in the community and by providing you with additional information about adult services and programs, we can better meet the goal for which we are all striving - the successful participation of your child in adult life.

We look forward to working together toward this goal at the IEP meeting.

Sincerely,

(CSE Chairperson)

Adapted from O'Leary and Paulson, 1991

A.2 SAMPLE STUDENT ORIENTATION LETTER

Dear (student)

You are invited to come to the next meeting with the Committee on Special Education, which is being held on <insert date> at <time> at <location>. We would like to talk with you about how you are doing in school, what you want to do in the future, and what activities your individualized educational program should include.

These activities are added to your program to help you prepare for your future and to learn the skills that you will need as an adult to be successful in living, learning and working after you leave school. Activities may be in the classroom, in the community, or at work sites, for examples. Transition services will be provided by the school district from the time you are age 15 until you leave school.

Before the meeting, please think about what you want to do after leaving school, what you can do now and what skills you still need to learn. We would like you to come to the meeting ready to share your ideas, such as:

• What kind of job do you want to have?
• Where will you live - on your own or with others?
• What type of college or job training interests you?
• What will you do in your free time?
• How much money can you earn, and how will you pay bills?
• How you will get around - by car or by riding the bus or subway?

At the meeting you will also receive information to help you make choices. The following people have been invited to come to the meeting to help plan your program: <insert names or identities>. Some people know you and have suggestions to make, or they know about different programs for you to consider.

Remember this is the beginning step. You will have time during the next few years to try different ideas. The school district will work with you all along the way, to help you explore and decide what you want to do in the future, and to help you prepare for it.

I look forward to seeing you at the meeting, and to having your help to plan a good program for your future success.

Sincerely,

CSE Chairperson

B. TRANSITION QUESTIONNAIRE: A TOOL FOR TRANSITION PLANNING

As the student, family, school and other agencies begin working together to prepare the transition student to enter the world of work, further education, and community living, the following information will guide the process. It may help for the student and other family members to complete the questionnaire separately, and then compare ideas and discuss them prior to coming to the IEP meeting. Sharing the completed questionnaire with the other committee members at the meeting is one way to help them better understand the student's plans and ideas for the future.

Student Name ________________________________   Date ________________

Social Security Number __________________   Birthdate ___________________

Current Address __________________________________________________________

_______________________________________________________________________

Current Telephone Number __________________________________

Expected Date of Graduation/School Completion _____________________________

Parent's Name __________________________________________________________

I. Vocational Needs

1. After graduation from school, what career path would you like the student to follow:

______Competitive Part-Time Employment       ______Vocational School/Training

______Competitive Full-Time Employment       ______Adult and Continuing Education Program

______Supported Employment                   ______2 Year College

______Sheltered Employment                   ______4 Year College

______Military

______Other:___________________________________________________

2. What kind of jobs seem most interesting to the student?

3. What kinds of jobs does he or she most dislike?

4. What vocational training programs do you prefer for the student?

5. What are the jobs that you do not want the student to do?

6. What medical concerns do you have about the student's vocational placement, if any?

7. What skills does the student need to develop to reach career goals?

8. What vocational education classes would you like the student to enroll in?

9. What job do you foresee the student doing after school is completed?

II. Further education

Please answer the following if the student is considering the idea of attending college, business or trade school; if not, skip to section III.

1. What further education beyond high school would you like your son or daughter to obtain?

______ Adult and Continuing Education

______ Business School       ______ 2-year College Study

______ Trade School           ______ 4-year College Study

______ Apprenticeship         ______ Graduate Study

2. What career(s) would further education prepare the student to enter, or would the student need assistance to decide on a specific career?

3. What does the student like best about doing school assignments?

4. What does the student like least about doing school assignments?

5. What skills does the student need to develop in order to be a good student?

6. What living arrangements do you foresee for the student while going on to further education or training -- living at home and commuting or living away from home in a dormitory or other living arrangement?

7. What concerns do you have about the student's ability to commute to classes or to live in a dormitory?

8. What kinds of help on campus will the student need to get the most out of classes?

9. What kinds of financial aid will you need to be able to pay for the training?

III. Personal Management/Living Arrangements

1. What chores or responsibilities does the student presently have at home?

2. What other tasks would you like the student to be able to do at home?

3. After graduation from school, what do you think the student's living situation will be?

______At home       ______Foster home       ______Group home

______Apartment with support       ______Independent apartment

______Other: ____________________________________________________

4. In which of the following independent living areas does the student need instruction?

______Clothing care                               ______Sex education

______Meal preparation & nutrition       ______Household management

______Hygiene/grooming                         ______Health/first aid

______Transportation/Mobility Skills       ______Consumer skills

______Parenting/child development       ______Community awareness

______Measurement                         ______Time management/organization

______Safety                                     ______Self-advocacy

______Interpersonal Skills

______Other:____________________________________________________

IV. Leisure & Recreation Needs

1. In what leisure or recreational activities does the student participate alone?

2. In what leisure or recreational activities does the student participate with your family?

3. In what leisure or recreational activities does the student participate with friends?

4. What other leisure or recreational activities would you like to see the student participate?

5. What are leisure or recreational activities in which you do not want the student to participate?

6. What classes or activities do you recommend for the student's participation in order to develop more leisure interests and skills?

V. Financial

1. As an adult, what financial support will the student have (check all that apply)?

______earned income                             ______unearned income

______insurance                               ______general public assistance

______food stamps                               ______trust/will

______supplemental security income       ______medicaid

______other support ____________________________________________________

2. What are the financial needs you think the student will have as an adult?

V. General

1. When transitions have been made in the past, such as from one school to another, were problems encountered, and if so, what were they?

2. What are other agencies that currently provide services for the student or are expected to do so after graduation?

3. What would you like the school district to do to assist you in planning for your son or daughter's living, working, and educational needs after completing high school?

Adapted from O'Leary & Paulson, 1991

C. SAMPLE NOTICE LETTER

<Date>

Dear <Parent Name>;

As part of reviewing each student's progress, the CSE is scheduling a meeting to discuss your child's accomplishments for the past year.

The purpose of the next meeting with the Committee on Special Education (CSE) will be to develop the Individualized Education Program (IEP) to incorporate transition services within your child's educational program.

We would also like to inform you that <Student Name> will be invited to participate in this meeting since it is crucial for your child's needs, preferences and interests to be addressed when developing the IEP.

The meeting is scheduled for <Date> at <Time> in <Location>. I hope that your can attend. The following persons are expected to attend:

Name            Title

<include district staff and, as appropriate, individuals providing services outside the school>

In addition, the following adult services agencies have been invited to send a representative to this CSE meeting to discuss your child's needs and determine whether or not the services provided by that agency are appropriate to address your child's needs: <indicate such agencies>.

You may bring others with your to this meeting if you choose. If the meeting time or place is not convenient, please call me so that we can make other arrangements. Please let me know if you need any accommodations for this meeting.

The results of the meeting and any changes in the IEP will be provided to you for your information. The recommendation will also be sent to the Board of Education for approval.

Sincerely,

<name>
Chairperson, Committee on Special Education

Attachments:

Due Process Rights
List of Legal and Other Relevant Services (locally developed)

D. CONFIDENTIALITY RELEASE FORM

AUTHORIZATION FOR THE RELEASE**
OF EDUCATION RECORDS

I, ________________________________, authorize representatives of the ______________________________ School District to release and discuss the educational records of ___________________________________ to the following:

List names and addresses of relevant agencies/individuals

______________________________   _______________________________________

______________________________   _______________________________________

______________________________   _______________________________________

I understand that these educational records are being released to assist in the planning and provision of transition services and include student testing, evaluations, etc.

________________________________________________________________________
(list the nature of any other information to be released)

I further understand that, upon request, I have the right to inspect and receive a copy of any records sent in accordance with this release.

_____________________________________________   __________________
Parent/person in parental relationship or student                           Date
over the age of 18

______________________________________________________
Relationship to student

I request that I be sent a copy of any education records released pursuant to this release.

______     ______
Yes             No

_______________________

** This form does not authorize the release of a student's HIV status or any information involving a student's drug/alcohol use to the extent the school maintains a school based substance abuse program. Separate forms will be required in such circumstances.

E. TRANSITION PLANNING INVENTORY

The form below may be helpful for recording action steps discussed at the IEP planning meeting when transition services are discussed.

Adapted from BOCES Erie I

F. LEVEL I VOCATIONAL ASSESSMENT

Date:

Student: DOB:

Time Period: Building:

Participants' Signatures:

(Student) (Special Education Rep)

(Parent) (Guidance Rep)

Definition of Long Term Vocational Goal

Student (What do you plan to be doing 2 years after completing your secondary level educational program?):

Parent (What would you like to see the student doing 2 years after completion of his/her secondary educational program?)

Areas of immediate need:

Current hobbies/interests/vocationally-related activities:

Adapted from Erie I BOCES

G. SAMPLE WORK EXPERIENCE PROGRESS REPORT

1. Training Period From ______________________ To _____________________________

2. Number of Days Absent ____________________________ Dates Absent _________________________________

Reason for Absence ______________________________________________________________________________ ____

3. Number of Days Tardy ___________ Dates __________________

Reasons _________________________________

4. Achievement and Performance. List Tasks Student Performs.

5. Other Factors of Training Program. Use Number Which Accompanies Best Description of Work.

(1) Student Manages Work VERY WELL. (3) Student Manages Work with MARGINAL Success.

(2) Student Manages Work ADEQUATELY. (4) Student is UNABLE to Manage Work.

6. Total Hours of Supervision Given This Period __________ Supervision Hours to Date ____________

7. Explain how the student has adapted to the program:

8. Have situations occurred during this training period which may affect employment of this student?

If yes, please specify:

9. Recommendations and Remarks:

Supervisor's Signature _______________________________________ Date:______________________

INDIVIDUALIZED EDUCATION PROGRAM

I. SAMPLE TRANSITION GOALS AND OBJECTIVES

EMPLOYMENT

Goal: Explore a variety of career options.

Objectives: Student will identify 2 major career fields of interest.

Activities:

    1. Job shadow three businesses of interest.
    2. Participate in two volunteer work experiences.
    3. Interview worker in career area of interest.
    4. Tour supported employment programs.
    5. Enroll in Careers class and participate in related work experiences.
    6. Attend a "Career Days" seminar.

LIVING SKILLS

Goal: Live independently.

Objectives: Student will increase awareness of community living options.

Activities:

    1. Determine personal needs/limitations in a living situation.
    2. Visit two apartments for rent.
    3. Look through ads and choose three possible living options.
    4. Explore dorm possibilities on campus of choice.
    5. Determine criteria for subsidized housing.
    6. Visit a group home.

Objectives: Student will increase independent living skills.

Activities:

    1. Take Home Economics.
    2. Review a lease.
    3. Cook dinner one time per week.
    4. Shadow maintenance person to learn basic home maintenance skills.
    5. Develop a personal budget.
    6. Open a checking/savings account.
    7. List strengths/weaknesses and achievements.
    8. List hobbies/interests and how they may relate to a realistic occupation.

VOCATIONAL

Goal: Review vocational options.

Objectives: Student will participate in vocational options.

Activities:

    1. Shadow Vo-Tech program for two days.
    2. Contact VESID to determine eligibility.
    3. Tour a Vo-Tech school.
    4. Identify two vocational programs; tour and arrange an interview with instructor.
    5. Identify a vocational program which would meet personal vocational needs.
    6. Take vocational aptitude test.
    7. Participate in high school vocational program of choice.

EDUCATION

Goal: Identify educational options.

Objectives: Student will select and apply for a college program.

Activities:

    1. Complete and submit financial aid packet.
    2. Contact career learning center to determine options.
    3. Work with counselor/instructor to determine credits.
    4. Contact/visit college of choice.
    5. Contact guidance counselor to determine most appropriate high school classes to take to reach long-term goal.
    6. Review three postsecondary catalogs.
    7. Take SAT/ACT exam.

ASSESSMENT

Goal: Update vocational assessment.

Objectives: Student's current vocational preferences, interests and aptitudes will be identified.

Activities:

    1. Review vocational aptitude scores with instructor or counselor.
    2. Complete an interest inventory.
    3. Self-assess vocational abilities and interests after completing work samples.
    4. Shadow a vocational program/business and access necessary skills.
    5. Collect assessment data.

FINANCIAL

Goal: Obtain needed financial assistance.

Objectives: Student will determine all possible financial resources available.

Activities:

    1. Call identified financial resources to determine eligibility requirements.
    2. Apply for SSI.
    3. Make applications through college Financial Aid Office for Scholarships.
    4. Discuss work incentive options with local social security administration office.

RECREATION/LEISURE

Goal: Become aware of/participate in community recreation/leisure programs or activities.

Objectives: Student will identify local recreation options.

Activities:

    1. Visit/contact three recreation options.
    2. Determine cost, rules, and hours of recreation option of interest.
    3. Evaluate recreation/leisure options of interest.
    4. Participate in a specific recreation activity.
    5. Explore school activities/sports.

TRANSPORTATION

Goal: Travel independently.

Objectives: Student will review and determine best mode of transportation.

Activities:

    1. Obtain driver's license.
    2. Find co-worker with whom to ride.
    3. Compare cost/purchase insurance.
    4. Complete driver's education training.
    5. Call Rapid Transit to determine cost/services.
    6. Practice riding Rapid Transit.
    7. Explore transportation option in nearest city.
    8. Purchase a car.

PERSONAL/FAMILY RELATIONSHIPS

Goal: Become aware of appropriate community resources to meet counseling/support needs.

Objectives: Student will determine personal and family support agencies and services.

Activities:

    1. Identify counseling/support needs.
    2. Contact and interview potential professionals/groups to determine suitability to individual needs.
    3. Participate in mentor program.

MEDICAL

Goal: Determine and manage health care needs.

Objectives: Student will become aware of/obtain medical support and assistance.

Activities:

    1. Identify helping professionals in medical field.
    2. Contact/locate medical assistance agencies in area of need.
    3. Apply for Medicaid/appropriate medical resources in the community.
    4. Determine appropriate questions to ask medical professional.
    5. Call medical professionals to compare services and costs.
    6. Visit/research local community health services.
    7. Design a file with all pertinent medical information.

Adapted from O'Leary and Paulson, 1991

J. VESID OR CBVH REFERRAL FORM AND CONTACTS

This Appendix contains:

The Transition Referral Transmittal sheet that districts can use to refer students who meet referral criteria to the local VESID or CBVH offices. It may be completed by hand or typewritten. Please complete it legibly in black or other dark ink. A student signature on the form (plus the signature of the parent or legal guardian, as appropriate) will constitute an application for services.

Lists of CBVH and VESID District Offices for phone or written communication.

Remember to attach selected documents to the transmittal package that will assist VESID or CBVH to expedite determining eligibility, and planning vocational rehabilitation services that coordinate with district efforts in this regard.

In the near future, districts using the Part 200 Management system may be able to transmit referral data, applications and selected records electronically to VESID offices. Please look for future announcements, or after June 1994, please call VESID's Technology Unit at 518-486-4609 for further information.

NYS VESID DISTRICT OFFICE LISTING

ALBANY
Mr. Joseph Piccolino
Office Manager
55 Elk Street
Albany, NY 12207
Telephone: (518) 473-8097

Counties served: Albany, Columbia, Greene,
Rensselaer, Saratoga, Schenectady, Schoharie,
Warren, Washington.

SOUTHERN TIER

Mr. Richard Andres
Office Manager
Binghamton Office
92 Hawley Street
Binghamton, NY 13901
Telephone: (607) 773-7830

Elmira Office
110 West Second Street
Elmira, NY 14901
Telephone: (607) 734-5294

Counties served: Broome, Chemung,
Chenango, Delaware, Otsego, Schuyler,
Steuben, Tioga, Tompkins.

BUFFALO

Mr. Duane Reggentine
Office Manager
Donovan State Office Building
125 Main Street
Buffalo, NY 14203
Telephone: (716) 847-3294

Counties served: Allegany, Cattaraugus,
Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming.

BRONX

Ms. Mary E. Faulkner
Office Manager
1500 Pelham Parkway South
Bronx, NY 10461
Telephone: (718) 931-3500

County served: Bronx.

BROOKLYN

Ms. Danna Mitchell
Office Manager
State Office Building
55 Hanson Place, Second Floor
Brooklyn, NY 11217
Telephone: (718) 722-6731

County served: Kings.

HAUPPAUGE
Mr. Frederick Shenn
Office Manager
NYS Office Building
Veterans Highway
Hauppauge, NY 11788
Telephone: (516) 952-6357

County served: Suffolk.

HEMPSTEAD

Dr. Leo Schechter
Office Manager
50 Clinton Street, Room 708
Hempstead, NY 11550
Telephone: (516) 483-6510

County served: Nassau.

MALONE

Mr. John Ray
Office Manager
East Main Street Road
RD #1, Box 39
Malone, NY 12953
Telephone: (518)483-3530

Counties served: Clinton, Essex, Franklin,
St. Lawrence.

MANHATTAN

Mr. John Bertrand
Office Manager
116 West 32nd Street
6th Floor
New York, NY 10001
Telephone: (212) 630-2300

Counties served: New York, Richmond.

POUGHKEEPSIE

Mr. Bruce Solomkin
Office Manager
120 Dutchess Turnpike
Canterbury Plaza
Poughkeepsie, NY 12603-1798
Telephone: (914) 452-5325

Counties served: Dutchess, Orange, Putnam, Sullivan, Ulster.

QUEENS

Ms. Lois Benjamin
Office Manager
1 LeFrak City Plaza
Corona, NY 11368
Telephone: (718) 271-9346

County served: Queens.

ROCHESTER

Mr. Paul Pfrommer
Office Manager
109 South Union Street
2nd Floor
Rochester, NY 14607
Telephone: (716) 238-2900

Counties served: Livingston, Monroe, Ontario, Seneca, Wayne, Yates.

SYRACUSE

Mr. Marvin Reed
Office Manager
State Office Building, Room 230
Syracuse, NY 13202
Telephone: (315) 428-4179

Counties served: Cayuga, Cortland, Jefferson, Madison, Onondaga, Oswego.

UTICA

Mr. Anthony Serra
Office Manager
State Office Building
207 Genesee Street
Utica, NY 13501
Telephone: (315) 793-2536

Counties served: Fulton, Hamilton, Herkimer, Lewis, Montgomery, Oneida.

WHITE PLAINS

Dr. Sandra Countee
Office Manager
55 Church Street
White Plains, NY 10601
Telephone: (914) 946-1313

Counties served: Rockland, Westchester.

NYS CBVH DISTRICT OFFICE LISTING

ALBANY

Mr. Bob Ross, District Manager, or
Andy Cook, Children's Consultant
74 State Street, 6th Floor
Albany, NY 12207
Telephone: (518) 474-8553

Satellite Office,
c/o Sunmount Developmental Center
Building 11
Tupper Lake, NY 12986
(315) 359-2141

Counties Served: Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, St. Lawrence, Saratoga, Schenectady, Schoharie, Warren, Washington.

270 BROADWAY

Ms. Josephine Blaine, District Manager
or Tony D'Angelo, Senior Counselor
270 Broadway, 6th Floor
New York, NY 10007
Telephone: (212) 587-5228

Counties Served: Kings, Richmond, Queens.

BUFFALO

Mr. Fred Keller, District Manager, or
Kevin Meegan, Children's Consultant
295 Main Street, Room 1000
Buffalo, NY 14203
Telephone: (716) 847-3526

Counties Served: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming.

HARLEM

Mr. Tony Candela, District Manager, or
Vincent Anderson, Transition Counselor
163 West 125th Street, 13th Floor
New York, NY 10027
Telephone: (212) 870-4442
Counties Served: Manhattan, Bronx.

HEMPSTEAD

Ms. Georginne Volkommer
District Manager, or
Joe Polansky, Children's Consultant
175 Fulton Avenue, Room 402
Hempstead, NY 11550
Telephone: (516) 538-7111

Counties Served: Nassau, Suffolk.

ROCHESTER

Mr. Robert Pfohl, District Manager, or
Janice Beutner, Children's Consultant
Monroe Square
259 Monroe Avenue
Rochester, NY 14607
Telephone: (716) 238-8109

Satellite Office:
c/o Human Resources Center
425 Pennsylvania Ave.
Room 312
Elmira, NY 14904
(607) 737-1007 or
in Bath (607) 776-7460

Counties Served: Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates.

SYRACUSE

Ms. Earleen Foulk, District Manager, or
Karen School-Hess, Children's Consultant
333 East Washington Street, Room 517
Syracuse, NY 13202
Telephone: (315) 428-4135

Satellite Office:
c/o State Office Bldg. Annex
164 Hawley St., Room 304
Binghamton, NY 13902
(607) 773-7819

Counties Served: Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, Tioga, Tompkins.

WHITE PLAINS

Mr. William Kane, District Manager, or
Joanne Rusotti, Children's Consultant
150 Grand Street, 2nd Floor
White Plains, NY 10601
Telephone: (914) 993-5370

Counties Served: Dutchess, Orange Putnam, Rockland, Sullivan, Ulster, Westchester.

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