1. Name of School District or Private School:

2. Name of School:

3. School District/School/Private School Contact Person:
(required)

4. Phone Number:
(required)

5. E-mail Address:

6. Name of Student:
(required)

7. Student's Date of Birth:

8. CSIS Number:

9. Grade:

10. Student's last known address:

11. Check only one:
Individual with exceptional needs under IDEA
Qualified handicapped person under Section 504

12. Action taken/reason for action (check only one):
Severance of attendance from the district of residence, county school or program, or private school (explain in question #13)
Expelled, under Education Code 48915, from the district of residence, county school or program, or private school.
Excluded from the district of residence, county school or program, or private school (explain in question #14)
Exemption from the district of residence, county school or program, or private school (explain in question #15)
Transfer from the district of residence, county school or program, or private school (explain in question #16)
Suspension beyond ten school days.
Other:

13. Severance of attendance from the district of residence, county school or program, or private school (Explanation of response to #12)
Withdrew, did not pass CAHSEE
Withdrew, no known enrollment
Enrolled in adult education, dropped
Completed 12th grade, non-graduate, dropped
Dropout or reason unknown
Incarcerated
No Show
Other, please specify:

14. Excluded from the district of residence, county school or program, or private school (Explanation of response to #12)
Ages 18-21, disruptive
Ages 18-21, no graduation progress
Below minimum age for enrollment
For medical or health reasons
Other:

15. Exemption from the district of residence, county school or program, or private school (Explanation of response to #12)
Graduated, earned high school diploma
Exceptional needs student with certificate of completion
Deceased
Entered college
Completed GED
Passed CHSPE
Entered health care facility
Left, medical reasons
Ages 12-18 and entered attendance area from another state within 10 school days before end of term
Leave of Absence
Work permit
Private School
Private tutor
Other, please specify:

16. Transfer from the district of residence, county school or program, or private school (Explanation of response to #12)
Intradistrict transfer
Continuation High School
District Community Day School
County Community Day School
Interdistrict transfer
County program
Opportunity class or program
Independent Study
Home & Hospital Program
Other, please specify:

17. Status
RSP
SDC
504
Other, please specify:

18. Identified Disability:

19. Reason for Action Taken:

20. School Referred to: