100 East Third Street, P.O. Box 578 Piketon, Ohio 45661 Phone: 740-289-4171
475 Western Avenue Chillicothe, OH 45601   Phone: 740-702-3120
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Ross Pike ESC Cooperative Unit Request Form
In the event a district's planning team believes that the least restrictive environment for a student is to be an MD/ED or Cross Categorical unit, please fill out the electronic form below. The response will generate an electronic form to Lori Lowe, Director of Special Education. The district will be contacted to initiate the next steps in the process to determine if placement in one of our cooperative units is the LRE for the student. Please be certain to include the six factors of intervention documentation below.


District Requesting Consideration









Date of Request
District Representative Submitting Request
Phone where district representative can be reached
Email to reach district representative
Student Name
Student DOB
Student Current Grade
Parent Phone Number
Please provide a brief history of the student and of behaviors and concerns. Please include an explanation of factors that lead the team to believe that unit placement is the least restrictive environment and what other options on the continuum of services were considered for this child. Please be sure to include: Description of the Evidence Based Interventions that have been used,the baseline measurement before the interventions, the length of time the interventions took place, the intensity of the interventions, the measurable result compared to the baseline, and the decisions that were made as a result.

To validate your submission, please type the answer to the following question:


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