Date:_____________

INDEPENDENT SCHOOL DISTRICT 199

Inver Grove Heights, MN

Administrator Requisition: Special Education

Vendor________________________________

Ship to ______________________________________

Address_______________________________

______________________________________

City___________________________________

______________________________________

Fax____________________________________

______________________________________

Answer the following questions to determine special education eligibility:

1.

In the absence of special education needs, would the cost exist?

(If you answered no, then the cost may be eligible.)
2. Is this cost also generated by students without disabilities?

Yes______ No______
Yes______ No______

(If you answered no, then the cost may be eligible.)

3.

If it is a child-specific service, is the service documented in the IEP?

Yes______ No______

(If you answered yes, then the cost may be eligible.)

QTY

FD

Unit

ORG

Price

PRG

Item#

FIN

Description

OBJ

CRS

Amount

AMT

Statement of special education need:______________________________________________________

APPROVAL SIGNATURE(S):
Administrator:______________________________________________

Date:

Business Manager:___________________________________________

Date:_______________

P.O. Number:_______________________________________________