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Items denoted with a red asterisk
*
are required.
*
Student NCWISE Number:
*
Student Name:
*
Case Manager Name:
*
Forms Completed and Closed in CECAS:
Yes
No - do not submit this form until all forms are completed and closed
*
Exit COSF Completed and Verified in CECAS (PK Students Only)
NA
Yes
No - do not submit this form if COSF is required and not completed
*
Ineligibility Date:
*
Medicaid Billing Completed:
Yes
No
NA
*
Ineligibility Reason:
Returned to Regular Education
Not Referred for Evaluation
Not Eligibile for EC Services
Parent Refused Placement
Ineligible for a Service but Remains Eligible for Other EC Service/s
If the student remains eligible for an EC service, choose the INELIGIBLE service below.
Choose the Exited Service
Speech
OT
PT
Counseling
Special Ed
You will choose "Special Ed" for students that are exiting the academic portion of EC but remains eligible for Speech
