✕Check all purposes that apply to this PWN:

Identification — Proposing or refusing to identify a student as having a disability.
Evaluation — Proposing or refusing to conduct or change an evaluation.
Educational Placement — Any change to where or how services are delivered.
Provision of FAPE — Any change to the free appropriate public education offered.
Other — Any action not covered above; describe in the body.

⚠ A single PWN can cover multiple purposes — check every box that applies. An unchecked box for an applicable purpose is a procedural violation.

✕Explain WHY the LEA is proposing this action. Must reference specific data.

Sufficient example: "Based on the triennial psychoeducational assessment (3/1/2024) and progress monitoring data showing insufficient growth toward reading goals over two trimesters, the IEP team determined that the student requires more intensive intervention than can be provided in the general education setting."

⚠ Generic language like "to meet the student's needs" is legally insufficient. Connect the reason directly to specific assessment results or data.

✕List every data source the team reviewed in deciding to propose this action:

• Assessment names and dates (e.g., "WISC-V, 3/1/2024")
• Progress monitoring data and time period
• Teacher observations and reports
• Parent input received at or before the meeting
• Previous IEPs reviewed
• Medical or health records if applicable

⚠ Never leave blank. An empty field implies the team made a decision without reviewing data — a significant compliance and due process risk.

✕Explain specifically WHY the LEA is refusing this action.

Sufficient example: "The IEP team reviewed progress monitoring data from September–January showing adequate growth toward annual goals with existing services. Current assessment data does not indicate that the requested change is necessary to provide FAPE."

⚠ "Not appropriate at this time" alone is not sufficient. Must connect the refusal to specific data and the student's identified needs. Vague refusal reasons are frequently cited in due process hearings.

✕List the data and records the team reviewed when deciding to REFUSE this action.

Often similar to the "Proposed" column, but specifically reflecting what was considered in deciding NOT to take the requested action:
• Assessment results reviewed
• Progress data and time period
• Observations and teacher reports
• Prior IEPs referenced
• Parent input considered

If no refusal applies, write "N/A." A blank field suggests the team did not review data before refusing.

✕List every alternative the team discussed but did not choose. This is critically important — and most often incomplete.

Examples:
• "General education with push-in support only (no pull-out)"
• "Increased consultation without direct SAI"
• "Additional assessment before making a placement decision"
• "Maintaining current services without change"

⚠ IDEA requires consideration of a continuum of options. Listing only the chosen option — or leaving this blank — suggests the team did not genuinely consider alternatives. This is one of the most significant due process risks on this form.

✕For each option listed, explain why the team chose not to use it.

Sufficient example: "Push-in support only was considered but rejected because the student requires a distraction-reduced environment and a level of explicit, systematic phonics instruction that cannot be delivered with fidelity in the general education setting while meeting the needs of non-disabled peers."

⚠ "Not appropriate" without explanation is legally insufficient and is frequently cited in due process proceedings. Each rejected option needs its own specific reason.