Pre-ETS Activity Tracker

1. Student Name (First & Last)

2. Name of School / Educational Program

3. Student Date of Birth

4. How does the individual meet the definition of a student with a disability?
Individual is a student with a disability, and is receiving transition services under an Individualized Education Program (IEP)
Individual is a student with a disability, and has a Section 504 accommodation (504 Plan)
Individual is a student with a disablity who does not have a Section 504 accommodation and is not receiving services under an IEP

5. Unique Student Identifier (USI)

6. Student Social Security Number (SSN) if available (if unknown, please enter 000-00-0000).

7. Student Race/Ethnicity - Check all that apply
Hispanic or Latino or Spanish Origin
Non-Hispanic/Latino/Spanish Origin
American Indian or Alaska Native
Asian
Black/African American
Native Hawaiian or Other Pacific Islander
White

8. Type of Pre-ETS Provided - Check all that apply
Job Exploration
Work Based Learning Experience
Counselling on Post-Secondary Education & Training
Workplace Readiness Training
Self Advocacy Instruction

9. Date of Initial Pre-ETS Service

10. Pre-ETS Eligibility Documentation:

As per requirements in 34 CFR 361-47 and 34 CFR 361-56, the state VR agency must maintain supporting documentation of the disability, which may include school records; statements of education staff; a referral form for pre-employment transition services with the identification of a student's disability, signed by school staff and parent/guardian if the student is under the age of majority in a state, (parental consent to participate in pre-employment transition services is governed by State law, as well as policies of the educational programs); a copy of an individualized education program (IEP) document; SSA beneficiary award letter; school psychological assessment; documentation of a diagnosis or disability determination; or documentation relating to 504 accommodation(s). Please upload documentation that supports student Pre-ETS eligibility status below.

11. Referral Source
Please include Name, Position/Title, Name of the Company/Organization, and Contact Information (Phone/Email)

12. Email Address (Person filling the form)

Thank you for your submission.