INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student’s Name:

INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

Student’s Name: Bo Gance

IEP Team Meeting Date (mm/dd/yy): 10/27/2018
IEP Implementation Date (Projected Date when Services and Programs Will Begin): 11/27/2018
Anticipated Duration of Services and Programs: 6 months
Date of Birth: 4/27/2015
Age: 3
Grade: Pre-school
Anticipated Year of Graduation: 2032
Local Education Agency (LEA): Jefferson County Schools
County of Residence: Jefferson County
Name and Address of Parent/Guardian/Surrogate: Phone (Home): 740-333-4444
Brad and Bella Gance Phone (Work): 740-234-7777
1234 Jamison Ave.
Steubenville, OH 43952

Other Information:

The LEA and parent have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:
Not Applicable

Date of Revision(s) Participants/Roles IEP Section(s) Amended

N/A N/A N/A
N/A N/A N/A
N/A N/A N/A

Page 1 of 24 April 2014

 IEP TEAM/SIGNATURES

The Individualized Education Program team makes the decisions about the student’s program and placement. The student’s parent(s), the student’s special
education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not
agreement.

Role Printed Name Signature

Parent/Guardian/Surrogate Bella Gance
Parent/Guardian/Surrogate Brad Gance
Student* Bo Gance
Regular Education Teacher** Natalie Berry
Special Education Teacher Mark Fioramonti
Local Ed Agency Rep Jude Ledyard
Career/Tech Ed Rep*** Kateri Spenser
Community Agency Rep Shannon Lawler
Teacher of the Gifted**** Savannah Thompson

* The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.
** If the student is, or may be, participating in the regular education environment
*** As determined by the LEA as needed for transition services and other community services
**** A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.
One individual listed above must be able to interpret the instructional implications of any evaluation results.

Written input received from the following members:

N/A

Transfer of Rights at Age of Majority

For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals
with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.

PROCEDURAL SAFEGUARDS NOTICE

I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights,
including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.

Signature of Parent/Guardian/Surrogate:

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical Assistance programs)

I understand that the school may charge the School-Based Access Program (“SBAP”)—or any program that replaces or supplements the SBAP—the cost of certain
special education and related services described in my child’s IEP. To make these charges to the SBAP, the school will release to the administrator of that
program the name, age, and address of my child, verification of Medicaid eligibility for my child, a copy of my child’s IEP, a description of the services
provided and the times and dates during which such services were provided to my child, and the identity of the provider of such services. I understand that
such information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have provided written
consent to disclose such information.

I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to
write, at any time. My refusal to consent or my withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my family,
any service or program to which my child is entitled under the Individuals with Disabilities Education Act (“IDEA”) or that is necessary to enable my child to
receive a free appropriate public education as described in my child’s IEP.

I understand that the school cannot—

Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a condition of receiving a free appropriate
public education for my child;

Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including co-payments and deductibles,
unless it agrees to pay such expenses on my or my family’s behalf;

Cause a decrease in available lifetime coverage or any other insured benefit;

Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that are required for my child
outside the time that he or she is in school;

Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.
I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS “YES” MUST BE ADDRESSED IN THE IEP.

Is the student blind or visually impaired?

Yes The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an
evaluation of the student’s reading and writing skills, needs, and appropriate reading and writing media (including an
evaluation of the student’s future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of
Braille is not appropriate for the student.
X No

Is the student deaf or hard of hearing?

Yes The IEP must include a communication plan to address the following: language and communication needs; opportunities for
direct communications with peers and professional personnel in the student’s language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the student’s language and communication mode;
and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The
Communication Plan must be completed and is available at www.pattan.net

X No

Does the student have communication needs?

X Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)

No

Does the student need assistive technology devices and/or services?

Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)

X No

Does the student have limited English proficiency?

Yes The IEP team must address the student’s language needs and how those needs relate to the IEP.

X No
 Does the student exhibit behaviors that impede his/her learning or that of others?
X Yes The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that
utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels
section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction
sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A
Positive Behavior Support Plan and a Functional Behavioral Assessment form are available at www.pattan.net

No

Other (specify):

N/A

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:

 Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based
assessments, transition assessments, progress toward current goals)
 Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
 Present levels related to current postsecondary transition goals if the student’s age is 14 or younger if determined appropriate by the IEP team
(e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)
 Parental concerns for enhancing the education of the student
 How the student’s disability affects involvement and progress in the general education curriculum
 Strengths
 Academic, developmental, and functional needs related to student’s disability

 Present levels of academic achievement

o Bo is in his first year as a preschool student and struggles in many different aspects of
his education. His academic achievement is among some of the higher scores he had
among the different domains of the Brigance assessment, but he still struggled.
His literacy skills he struggles with in multiple aspects which include his vocabulary and
letter skills. He fell into the 17th percentile for literacy and is in the instructional range
of a 2-year, 3-month student. Similarly, Bo struggled with mathematic as well. He
scored a total raw score of 12 out of 101 total points and fell into the 16 th percentile.
These struggles mostly included being able to count higher than the number 10 and
understanding number concepts.
 Present levels of functional performance
o Physical
- The results for Bo’s physical development were interesting. He did very well when it
came to his gross motor skills and was just below the average line in this category.
However, Bo struggles greatly with his fine motor skills. His total raw score for fine motor
skills was 27 out of 107 total points which put him at a <1 percentile. He struggled with
being able to build a tower without knocking it down. His ability to manipulate a writing
utensil is very behind his peers. He could not use a pencil to draw a person as well when
asked to write his numbers or letters even when prompted and given examples.

o Behavior

Bo’s behavior in class often gets him into trouble. He does not listen well when
it comes to specific instructions given to him by the teachers in the class and
often does the opposite of what he is told to do.
 His attention span is also a limiting factor that restricts Bo from improving in all
areas of schooling. He struggles to sit still for more then 5 minutes and often
distracts his peers and gets off task completely.
 Bo does excel when he is presented with a reward or works one on one with the
teacher. He responded well to attention and can stay on task if given enough
attention. He also loves to help out with jobs around the classroom and is very
eager to jump in and help.
o Communication
 In receptive language he scored a total of 63 out of 102 putting him in the 12 th
percentile. He was able to correctly identify 19 out of 26 pictures when
presented and was also familiar with body parts; being able to identify 18 out of
23 body parts when asked. He was familiar with verbal concepts as well and
could follow simple one, two, and three step directions but he does sometimes
struggle with these directions when not in a one-on-one setting.
 In expressive language, Bo scored 58 total points out of 128 which put him in
the tenth percentile and the instructional range of a 2-year 8-month year old.
He is able to point to something he wants and can nod his head yes and no. He
did not, however, pretend talk, repeat phrases, or use words in combination.
His speech is often not understandable, and he also does not say real words. He
struggled with being able to repeat sentences longer than four syllables. About
25% of what Bo says is intelligible.
 The struggles Bo has with communication create behavioral and academic issues
in the classroom. Having other students as well as teachers not understand
what he wants puts him at a disadvantage.

o Social Skills:
 Bo’s Social skills are among the higher achieved domains he scored in. With his
interpersonal scores he scored a total score of 7 out of 21 which placed him in
 the 21st percentile. Bo does show affection and responded well to praise and
rewards. For the most part, he does seek help from an adult when he cannot do
something and also likes to talk about himself. His interactions with adults are
not always respectful and, as previously stated, he struggles with listening to
directions. When it comes to peer interactions Bo is able to make friends and
find playmates. Where he struggles is being able to keep these friends
throughout the whole game or activity without getting into an argument with
them. This however is typical for kids of his age.
 Bo’s self-regulatory skills were scored at an 8 out of 29 which put him in the 25 th
percentile. He is able to recognize good and bad behavior in himself as well as
in his peers. Whether he follows that recognition varies among instances. He is
usually somewhat interested in small group activities, as he excels in small
group or one-on-one situations. He is also very helpful in the classroom and is
willing to clean up and do simple tasks in class.
o Adaptive Skills:
 Bo’s adaptive behavior skills scored a 27 out of 48 which placed him in the 13 th
percentile and in the 2-year 6-month instructional age. He is competent when
it comes to eating and occasionally makes a mess just as much as any typical
pre-school student. Bo is able to ask for food when he is hungry and cleans up
after himself. He is able to put his jacket on as well as his shoes. Bo knows to
wash his hands and flush the toilet but does need help to wipe himself in the
bathroom. Like other preschoolers, he does have the occasional accident but
for the most part he is able to use the restroom when needed. His personal
information is one aspect Bo does not know besides his first name.

 Parental concerns for enhancing the education of the student

o The parents would like for Bo to improve his communication skills.

 How the student’s disability affects involvement and progress in the general education
curriculum
o Bo’s lack of attention span in class causes him to do whatever he wants during
instruction. This limits Bo’s ability to listen and absorb instruction which effects many
areas of his education.
o Bo struggles with following specific directions given to him in a whole group instruction.
He will often do the opposite of whatever is asked of him which not only gets him off
task but hinders his ability to get instruction and work on whatever activity is at hand.
o Bo’s lack and sometimes inability to communicate puts him at disadvantage among his
peers. He often struggles to communicate what he wants and why he wants it which
restricts him from creating friendships and staying out of trouble.

 Strengths
o Bo has many strengths that have been determined through testing as well as in class
 observation.
o Bo’s social and emotional development is one of these strengths. He does very well in
any one-on-one setting. This setting eliminates distractions, gives him attention, and
allows for him to be focused on the instruction. He also responds well to praise and is
very motivated by it as well as physical rewards. He recognizes good and bad behavior
in himself as well as his peers.
o One of the greatest strengths Bo has is his willingness to help. He loves to help out in
the classroom in any way he can which often is followed by praise which motivates Bo
and gives him confidence.
o Bo also does well when it comes to daily living skills. He is able to eat well without
making a mess and cleans up after himself for the most part. He is also able to dress
himself and use the bathroom in an appropriate way in which he remembers the steps
to using the restroom. Having this skillset will allow Bo to become more independent
and motivated to learn on his own which will greatly help him as he moves out of pre-
school.

 Areas for Improvement

o Bo struggles with 4 main areas in schooling. These include academic, fine motor,
communication, and following directions/attention span. He does not struggle with all
aspects of these domains but with major parts of them.
o Academic: Bo needs to work on three critical aspects of academics. These include his
letter skills, his number skills, and his colors. He struggles with being able to recognize
letters, letter sounds and singing his ABC’s. His number skill struggles mostly involve
just being able to recognize numbers, amounts, and being able to count to higher then
the number 10. Knowing his colors needs to involve knowing the difference between
colors and recognizing them.
o Fine Motor: Bo’s fine motor skills are significantly delayed. The majority of these
struggles involve not being able to use a writing device.
o Communication: Bo’s limited ability to communicate prohibits him from expressing
what he wants and from making friends. He struggles to verbally express things as well
as his feelings about something. This also includes his ability to ask for help.
o Following directions/attention span: Bo does not often comply when he is given
directions or instructions by the teachers in the classroom. He fails to complete or even
start directions which often involves him getting in trouble and not being able to
participate in the activity. Similarly, Bo’s attention span effects his ability to learn.
Especially in large group settings, Bo will lose focus on the task at hand and either
become distracted or distract his peers.

III. TRANSITION SERVICES – This is required for students age 14 or younger if determined appropriate by the IEP team. If the student does not attend the
IEP meeting, the school must take other steps to ensure that the student’s preferences and interests are considered. Transition services are a coordinated
set of activities for a student with a disability that is designed to be within a results oriented process, that is focused on improving the academic and
 functional achievement of the student with a disability to facilitate the student’s movement from school to post school activities, including postsecondary
education, vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent
living, or community participation that is based on the individual student’s needs taking into account the student’s strengths, preferences, and interests.

POST SCHOOL GOALS – Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education
and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal.
Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.

For students in Career and Technology Centers, CIP Code:

N/A

Postsecondary Education and Training Goal:

Measurable Annual Goal
N/A Yes/No
(Document in Section V)

Courses of Study: N/A

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A
Employment Goal:
Measurable Annual Goal
N/A Yes/No
(Document in Section V)
Courses of Study: N/A

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A
Independent Living Goal, if appropriate: N/A
Measurable Annual Goal
Yes/No
(Document in Section V)

Courses of Study: N/A

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Instructions for IEP Teams:
Please select the appropriate assessment option. Information on available testing accommodations may be found in the Accommodations Guidelines
available on www.education.state.pa.us.

State Assessments

Not Assessed
X No statewide assessment is administered at this student’s grade level.
X No English proficiency assessment administered because the student is not an English Language Learner.

PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5
and 8; and ELA*)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Math N/A N/A N/A
Science N/A N/A N/A
Reading N/A N/A N/A
Writing N/A N/A N/A
ELA* N/A N/A N/A
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11 th grade)
 Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1 N/A N/A N/A
Literature N/A N/A N/A
Biology N/A N/A N/A

Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam
module.)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1 N/A N/A N/A
Literature N/A N/A N/A
Biology N/A N/A N/A

Validated Local Assessment (Available when selected as option by LEA)

Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1 N/A N/A N/A
Literature N/A N/A N/A
Biology N/A N/A N/A

PASA (Administered in grades 3-8, 11 for Reading and Math; Grades 4, 8, 11 for Science)
N/A Student will participate in the PASA.

Explain why the student cannot participate in the PSSA or the Keystone Exam for Reading/Literature, Math/Algebra 1,
Science/Biology, and Composition (The Composition exam will be available for the 2016-17 school year):
N/A

Explain why the PASA is appropriate:

N/A

Choose how the student’s performance on the PASA will be documented.

Videotape (preferred method)

Written narrative notes (requires prior approval in accordance with PDE

guidance)

ACCESS for ELLs (Administered in grades K-12)

 Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to
Accommodations Accommodations Participate Participate in Selected Domains
Listening N/A N/A N/A N/A
Reading N/A N/A N/A N/A
Writing N/A N/A N/A N/A
Speaking N/A N/A N/A N/A

Alternate ACCESS for ELLs (Administered in grades 1-12)

N/A Student will participate in the Alternate ACCESS for ELLs.

Explain why the student cannot participate in the ACCESS for ELLs:
N/A

Explain why the Alternate ACCESS for ELLs is appropriate:

N/A

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to

Accommodations Accommodations Participate Participate in Selected Domains
Listening N/A N/A N/A N/A
Reading N/A N/A N/A N/A
Writing N/A N/A N/A N/A
Speaking N/A N/A N/A N/A

Local Assessments

Local assessment is not administered at this student’s grade level; OR

X Student will participate in local assessments without accommodations; OR

Student will participate in local assessments with the following accommodations; OR

N/A

The student will take a local alternate assessment.

Explain why the student cannot participate in the local regular assessment:
N/A

Explain why the local alternate assessment is appropriate:

N/A
V. GOALS AND OBJECTIVES – Include, as appropriate, academic and functional goals. Use as many copies of this page as needed to plan appropriately.
Specially designed instruction may be listed with each goal/objective or listed in Section VI.

Short term learning outcomes are required for students who are gifted. The short term learning outcomes related to the student’s gifted program may be
listed under Goals or Short Term Objectives.

MEASURABLE ANNUAL GOAL Describe HOW the

Describe WHEN periodic
Include: Condition, Name, Behavior, and Criteria student’s progress toward
reports on progress will be Report of Progress
(Refer to Annotated IEP for description of these meeting this goal will be
provided to parents
components) measured

When given a picture card with any letter of the At the end of each school The progress report will be
alphabet on it, Bo will be able to pronounce the week, Bo will be tested visualized through a chart of
sound the letter makes in 3 out of every 5 times on 3 new letters of the the letters Bo have learned
during structured schooling activities throughout alphabet that he learned that week and a graph of
the day. at the start of the week. how many times he
This assessment will be answered correctly when
recorded through given a letter flash card.
frequency by giving Bo the This report will be sent
opportunity to respond 15 home and signed by the
times. To ensure parent and returned to the
automaticity, Bo will work special education teacher.
on these three new letters
with flash cards each day
for 5 minutes.
During a writing activity, Bo will be able write out Progress will be The progress report will be
his name when given a visual prompt on how to monitored through the piece of paper in which
write his name with 70% accuracy across 5 incorporating his letter he wrote the particular
consecutive sessions in the preschool setting. skills with his fine motor letter. This report will be
skills. He will practice sent home weekly, signed
writing one letter of his by the parent, and returned
name everyday for a week to the special education
and move on to the teacher.
following letter the next
week. He will be assessed
at the end of the week by
writing out the particular
letter 5 times on a lined
piece of paper.
Throughout the course of a 5-minute instructional Progress will be A monthly update will be
period, Bo will be able to stay on task by not monitored twice a week sent home to the parents
interrupting the teacher, not causing the other through direct observation that include the checklist
students to be distracted by switching seats, and and progress monitoring. data that is collected
being able to retell one part of the instruction A checklist of the students weekly as well as an
measured through frequency. three objectives within emailed report written by
the goal will be the special education
completed by the special teacher.
education teacher during
the biweekly monitoring.
After a read aloud activity, Bo will be able to Progress will be A monthly report in the
correctly annunciate and retell one aspect of the monitored weekly by form of an email will be
story using a complete sentence with 70% asking Bo to retell and sent to Bo’s parent,
accuracy across 3 consecutive sessions. correctly annunciate a reporting on the improved
complete sentence about or not improved
a read aloud that was just communication aspects Bo
completed. has struggled with.

SHORT TERM OBJECTIVES – Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).

Short term objectives / Benchmarks

N/A

N/A

N/A
VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS – Include, as appropriate, for nonacademic
and extracurricular services and activities.

A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)

 SDI may be listed with each goal or as part of the table below.
 Include supplementary aids and services as appropriate.
 For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or modifications to the general
education curriculum, as appropriate for a student with a disability.

Modifications and SDI Location Frequency Projected Beginning Date Anticipated Duration
Goal 1:

1. The paraeducator will provide

direct, one-on-one instruction on 1. School
the pronunciation of letter sounds resource
2. At the beginning of each class and room
during circle time, the general 1. Twice a week
education teacher will go through 2. General
each student’s name and have the education 2. Daily 11/25/2018 11/24/2019
students verbally mirror the sounds classroom
of the student’s names 3. Twice a week
3. The general education teacher will 3. General
provide small group instruction education
which will include the beginning classroom
sounds of words and matching
these sounds to their appropriate
letters.
Goal 2: 1. School resource 1. Daily 11/25/2018 11/24/2019
1. The paraeducator will provide room
daily, one-on-one instruction in 2. Twice a week
which she will complete full 2. General
physical prompts with Bo and help education 3. Weekly
him form letters. This prompt will classroom
be faded to a partial physically and
eventually to verbal and gestural 3. General
prompts. education
2. Bo will be given the opportunity, a classroom
couple times a week, to color
anything he wants on a blank piece
of paper. He will be prompted by
the paraeducator on how to hold
the writing device.
3. In large group instruction, the
 general education teacher will give
examples of how to hold a writing
utensil and how to draw shapes.
This will be mirrored by the
students.
Goal 3:
1. Bo will self-reflect with a teacher
on how he listened each day and
what he can do better the next
1. General
day.
education
2. Bo will be given a visual on what
classroom 1. Daily
should be done during large and
small group instruction that will be
2. All learning 2. Daily 11/25/2018 11/24/2019
taped to his desk and hung up at
environments
the front of the room.
3. Daily
3. With the help of the paraeducator
3. In the school’s
and during transition times, Bo will
hallways
practice folding his arms and
walking down the hallway without
distracting his peers and without
talking.
Goal 4:
1. Bo will work once a week with a 1. Speech therapy
speech therapist room
2. With the help of the paraeducator 1. Weekly
and in one on one instruction, Bo 2. School resource
will work on repeating simple room 2. Weekly 11/25/2018 11/24/2019
sentences the paraeducator says.
3. During large group instruction with 3. General 3. Twice a week
the general education teacher, Bo education
will be able to repeat one detail of classroom
a read aloud.

B. RELATED SERVICES – List the services that the student needs in order to benefit from his/her special education program.

Service Location Frequency Projected Beginning Date Anticipated Duration

Speech Therapy Speech therapy room Weekly 11/25/2018 11/24/2019
One-on-one with
School resource room Daily 11/25/2019 11/24/2019
paraeducator
C. SUPPORTS FOR SCHOOL PERSONNEL – List the staff to receive the supports and the supports needed to implement the student’s IEP.

School Personnel to Projected Beginning

Support Location Frequency Anticipated Duration
Receive Support Date
N/N N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A
D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS IDENTIFIED AS A STUDENT WITH A DISABILITY – Support services are
required to assist a gifted student to benefit from gifted education (e.g., psychological services, parent counseling and education, counseling services,
transportation to and from gifted programs to classrooms in buildings operated by the school district).

Support Service N/A

Support Service N/A
Support Service N/A

E. EXTENDED SCHOOL YEAR (ESY) – The IEP team has considered and discussed ESY services, and determined that:

x Student IS eligible for ESY based on the following information or data reviewed by the IEP team:
X
Bo needs to be in school for the entirety of the year because he is behind his fellow peers in almost every academic, social,
emotional, and physical domain. If he is not in school and misses 3 months of instruction this gap will become larger and effect Bo’s
ability to move on to kindergarten. Three specific goals are set for Bo that he needs help and that he can work on throughout the
entire year. These three include academic, motor skills and communication needs. Bo needs continued help in learning his letters,
numbers, and colors. He needs help improving his communication and attention span. And most importantly he needs help
developing his fine motor skills. Without these services, Bo is at risk for falling behind even more and entering kindergarten late.

OR

As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:

N/A

The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the student’s ESY Program are:

N/A

If the IEP team has determined ESY is appropriate, complete the following:
 ESY Service to be Provided Location Frequency Projected Beginning Date Anticipated Duration
Tutoring (letter skills, Public school’s resource Twice a week 11/25/2018 11/24/2019
numbers, colors) room
Speech Therapy Public School Weekly 11/25/2018 11/24/2019
VII. EDUCATIONAL PLACEMENT

A. QUESTIONS FOR IEP TEAM – The following questions must be reviewed and discussed by the IEP team prior to providing the explanations regarding
participation with students without disabilities.

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:
The extent to which this student is to be taken out of the general education classroom only involves
one-on-one instruction. This one-on-one instruction will be daily with a tutor or the paraeducator as
well as weekly speech therapy. Sessions will last no more then an hour.

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Bo will be given three specific aids that will help him succeed as well as allow the special education
teacher to respond. These involve being given the opportunity to respond during read aloud, reflecting
with the general education teacher about the day, and being given visual prompts as to what the
correct behavior is during large group instruction. These aids, along with daily one-on-one instruction
and speech therapy are the extra help Bo will receive to succeed in and out of the classroom.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

B. Type of Support

1. Amount of special education supports

Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day

X Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than
80% of the school day

Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day

2. Type of special education supports

Autistic Support

Blind-Visually Impaired Support

Deaf and Hard of Hearing Support

Emotional Support

X Learning Support

Life Skills Support

Multiple Disabilities Support

Physical Support

X Speech and Language Support

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

C. Location of student’s program

Jefferson County School District
Name of School District where the IEP will be implemented:

Name of School Building where the IEP will be implemented: East Garfield Elementary

Is this school the student’s neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
X Yes

No. If the answer is “no,” select the reason why not.

Special education supports and services required in the student’s IEP cannot be provided in the neighborhood school

Other. Please explain:

Page 23 of 24 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one Educational Environment)
To calculate the percentage of time inside the regular classroom, divide the number of hours the student spends inside the regular classroom by the total number of hours in the school day (including
lunch, recess, study periods). The result is then multiplied by 100.
SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers – Indicate the Percentage of time INSIDE the regular classroom for this student:
Time spent outside the regular classroom receiving services unrelated to the student’s disability (e.g., time receiving ESL services) should be considered time inside the regular classroom.
Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time
spent inside the regular classroom.
Calculation for this Student:
Column 1 Column 2 Calculation Indicate Percentage Percentage Category
Total hours the student Total hours in a typical (Hours inside regular Section A: The percentage of
school day classroom ÷ hours in Using the calculation result – select the appropriate percentage category
spends in the regular time student spends inside the
(including lunch, recess school day) x 100 = %
classroom per day & study periods) (Column 1 ÷ Column 2) x regular classroom:
100 = %

4 7 (4/7) x 100 = 57.1% 57.1% of the day INSIDE the Regular Classroom 80% or More of the Day
X INSIDE the Regular Classroom 79-40% of the Day
INSIDE the Regular Classroom Less Than 40% of the Day

SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day – select and indicate the Name of School or
Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP team must do the calculation
in Section A)
Approved Private School (Non Residential) _________________________ Other Public Facility (Non Residential) _________________________
Approved Private School (Residential) _________________________ Hospital/Homebound _________________________
Other Private Facility (Non Residential) _________________________ Correctional Facility _________________________
Other Private Facility (Residential) ________________________ Out of State Facility _________________________
Other Public Facility (Residential) ________________________ Instruction Conducted in the Home _________________________

EXAMPLES for Section A: How to Calculate PennData–Educational Environment Percentages

Column 1 Column 2 Calculation Indicate Percentage

Total hours the student spends in the Total hours in a typical school day (Hours inside regular classroom ÷ hours in school day) Section A: The percentage of time student
(including lunch, recess & study x 100 = % spends inside the regular classroom:
regular classroom per day
periods) (Column 1 ÷ Column 2) x 100 = %

Example 1 5.5 6.5 (5.5  6.5) x 100 = 85% 85% of the day
(Inside 80% or More of Day)
Example 2 3 5 (3 5) x 100 = 60% 60% of the day
(Inside 79-40% of Day)
Example 3 1 5 (1 5) x 100 = 20% 20% of the day
(Inside less than 40% of Day)
For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on the website. If you do not have access
to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.

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