INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student’s Name: Ken Harris

INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

Student’s Name: Ken Harris

IEP Team Meeting Date (mm/dd/yy): 11/25/20
IEP Implementation Date (Projected Date when Services and Programs Will Begin): 11/26/20
Anticipated Duration of Services and Programs: 11/26/2021
Date of Birth: 11/11/2016
Age: 4
Grade: Pre-K
Anticipated Year of Graduation: 2032
Local Education Agency (LEA): Steubenville City Schools
County of Residence: Jefferson County
Name and Address of Parent/Guardian/Surrogate: Phone (Home): (555) 555-5555
Jack Malloy Phone (Work): (777) 777-7777
0000 Streetname Road
Steubenville, OH 43952

Other Information: Ken’s grandparents have been his babysitters up until he started school.

The LEA and parent have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:
N/A

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

Page 1 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

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 Jack Malloy
Parent/Guardian/Surrogate Christina Malloy
Student* N/A
Regular Education Teacher** Peter McManus
Special Education Teacher Natalia Perdomo
Local Ed Agency Rep Ed Maher
Career/Tech Ed Rep*** N/A
Community Agency Rep Sarah Schriner
Teacher of the Gifted**** Melissa Flannery

* 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.

Page 2 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

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.

Page 3 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

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?

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

x 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

Page 4 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

Does the student exhibit behaviors that impede his/her learning or that of others?
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

x No

Other (specify):

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:

Literacy: When assessed for literacy using the Brigance Inventory of Early Development III (from here
on, referred to as the Brigance), Ken performed at an age equivalent level of 3 years and 9 months. He
obtained a total raw score of 47/170 and a composite score of 97. It is clear from the assessment that
Ken demonstrates little knowledge of the alphabet. He is unable to identify most letters of the
alphabet, whether they are upper case or lower case. He is also unable to recite more than 9 letters of
the alphabet in the correct order. He shows experience with books and text and knows the proper way
to read the text, from left to right and from top to bottom. He is able to engage with stories and talk
about story characters. He also asks questions and makes comments about the stories he reads as well.
Ken struggles with phonological awareness and has difficulty identifying rhymes and blending two words
into one. He shows strength in segmenting the words when they are given to him.
Page 5 of 26 April 2014
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

Mathematics: When assessed for mathematics using the Brigance, Ken performed at an age equivalent
level of 4 years and 3 months. He obtained a raw sore of 40/101 and a composite score of 102. He
understands number concepts for the most part and counts by rote up to 13. He is able to compare
different amounts well as well as sort objects by size, color and shape with 100% accuracy, per the
Brigance assessment. He is also able to match most quantities with numerals. He struggles to read
numerals and did not complete any of the items on the Brigance for this objective. He also has a hard
time with solving word problems and scored 1/10 on this objective of the Brigance assessment. He hit
the ceiling on knowing missing numerals in sequences and struggles in this area, having scored 1/12.
This corresponds with the information given in the teacher interview. According to his teacher, he can
count up to 14, is able to identify the numerals 1-3 in print, and is able to identify all colors when
displayed to him but not read their names.

Present Levels of Function Performance:

Behavior: According to his classroom teacher, Ken is able to wait for extended period of times well. He
listens to the teacher and is able to follow multistep directions. He is self-motivated and wants to do
well. He is intrinsically motivated. He shares well and is good at turn taking. He is able to stay on task
for long periods of time and demonstrates respect for both his teachers and his classmates. The
student does not have a Behavior Intervention Plan in place.

Communication: When assessed for receptive language development using the Brigance, Ken performed
at an age equivalent level of 3 years and 7 months. He obtained a raw score of 91/102 and a composite
score of 104. He is strong in his early receptive language skills and is able to point to pictures and parts
of the body. He also scored well on following verbal directions. He needs some improvement on
understanding verbal concepts and identifying colors, where he only scored 8/16. For expressive
language development, Ken obtained a raw score of 118/128 and a composite score of 112. His early
expressive language skills are strong and is able to do things like use two or three words in combination
and repeat phrases that are said to him. He obtained a perfect score in identifying pictures by name,
identifying parts of the body, verbal fluency, and using grammar and language in context. Areas for
improvement in this domain are identifying colors and articulation. The articulation corresponds with
information provided in the teacher interview. His teacher stated that he needs help in articulation for
some sounds he makes. For example, he often substitutes the letter “c” in place of “t,” so instead of
saying the word “crayon” he will say “trayon.” He is currently receiving RTI Tier 1 Intervention for
speech. 50% of his speech is intelligible.

Social Skills: When assessed for social and emotional development in the interpersonal subdomain using
the Brigance, Ken performed at an age equivalent level of 7 years and 3 months. He obtained a raw
score of 20/21 and a composite score of 119. Ken gives affection, demonstrates warmth when
interacting with adults and demonstrates pride in response to praise. When he was given the
assessment, he interacted with the administrator respectfully. He responds appropriately to directions
from adults and shares his feelings as well. Overall, he demonstrates very positive relationships with
adults. With his peers, he forms temporary attachments to one playmate as well as shows preference
to some friends over others. He has a best friend. He plays cooperatively in group games and
Page 6 of 26 April 2014
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

incorporates verbal directions into play activities. He plays games with rules and pretends to have a
career/professional role in play. When assessed in the self-regulatory subdomain of social and
emotional development, Ken obtained a raw score of 28/29 and a composite score of 125. He scored in
the age range equivalent of 6 years and 9 months. He is aware of good and bad behavior in himself and
others. He maintains interest when engaged in a small-group activity and is eager to comply with class
rules and activities. He shows independence and is able to do things for himself and demonstrates
satisfaction with himself. He maintains positive attitudes in activities and listens to feedback given to
him. He demonstrates many prosocial skills and behaviors such as helping to put things away and
performing simple errands. He shows concern for his classmates and is good at taking turns. He gives
as well as takes and participates well in group activities. He offers apologies for his mistakes and
accidents and reacts to disappointment and failure in an acceptable manner.

Gross and Fine Motor Skills: When assessed for gross motor skills using the Brigance, Ken performed at
an age equivalent of 5 years and 9 months. He obtained a raw score of 62/63 and a composite score of
134. He is able to stand on either foot for up to ten seconds as well as stand on one foot with his eyes
closed for one second. He can tiptoe and walk heel to toe as well as toe to heel. He can skip but
cannot gallop without difficulty. He can also hop and jump on either foot, as well as forwards and
backwards. He can throw and catch a tennis ball with both hands. When assessed for his fine motor
skills using the Brigance, Ken placed in the age equivalent of 3 years and 11 months. He obtained a raw
score of 46/107 and a composite score of 95. He can squeak a toy with his hands and can put objects
into a container and take them out. He grasps and releases objects easily and can unwrap them as
well. He imitates a scribble and deliberately pours or dumps objects from their container. He can also
build a tower of 12 blocks. In visual motor skills, he successfully drew a vertical and horizontal line, as
well as a circle and a square. He was unable to draw a plus sign, a rectangle, a triangle, or a diamond
and does not hold a pencil correctly. When drawing a person, he is able to draw the head, eyes, and
legs but does not include the mouth, arms, hair, nose, or any other part of the body. He is able to print
the first letter of his first name but not his entire name or his last name. He can only write the
numeral 1 and cannot print any uppercase letters in sequence from memory.

Adaptive Skills: When assessed for adaptive skills using the Brigance, Ken performed at an age
equivalent of 4 years and 6 months. He received a raw score of 38/48 and a composite score of 99. He
is able to eat on mostly on his own. He can ask for food when hungry and cold a cup with one hand and
drink. He inserts a spoon in his mouth with little or no spilling and without turning it upside down.
Where dressing and undressing are concerned, he can dress completely unsupervised except when his
clothes have many fasteners, such as zippers and buttons. He is also unable to tie his shoes. For
toileting and Bathing, he has bladder and bowel control and can wipe himself and flush the toilet. He
recognizes and acts on his toileting needs but cannot bathe himself without assistance. In the area of
personal information, he knows his first and last name as well as his own age. He doesn’t know his
birthday or telephone number, but he does know his street address. He does not know his complete
mailing address or his year of birth.

Present Level Related to Current Post-Secondary Transition Goals:

Page 7 of 26 April 2014
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

Transition services are not applicable at this time.

Parental Concerns for Enhancing the Education of the Student:

The parents would both like Ken’s speech to improve and for him to know his letters, as well as to begin
sight words in order to improve his communication skills and increase his independence. They also want
him to continue to get along with his peers and share with others besides his siblings.

How the Student’s Disability Affects Involvement in the General Education Curriculum:
Ken is performing both academically and functionally at an age equivalent of 4 years and 2 months.
This is slightly above his actual age of 4 years and 1 month. Whereas he really exceeds in some areas,
there are other areas such as receptive language, fine motor development, and Literacy where he is
below his developmental level and could see negative impacts on his participation in the general
education curriculum.

Strengths (per information above):

-Ken is above his developmental level in expressive language.
-Ken is well above his developmental level in social and emotional development.
-Ken is also above his developmental level in gross motor development.
-Ken gets along very well with other students as well as adults.
-Ken is intrinsically motivated and does not need to work for external rewards, he wants to do well and
please others.

Academic, Developmental, and Functional Needs Related to Student’s Disability:

Adaptive Skills:
The adaptive skills portion of the Brigance indicates that Ken doesn’t know crucial personal information
like his birthday or telephone number. He needs to correctly answer personal information questions so
that in the event he gets lost, he is able to tell people who to call or where he lives. He also needs to
improve his fine motor skills, especially writing and holding a pencil. Support is needed in this area so
he can further develop in language and communication.

Language Development:
The Brigance results indicated that Ken is below his developmental in receptive language. He needs to
be able to identify his colors in order to participate more effectively in class activities where these
concepts need to be generalized. He also needs improvement in understanding verbal concepts such as
the difference from “away from” and “toward.” These improvements can help Ken communicate
better and participate better in class activities.

Academic/Cognitive Development:
The Brigance results indicate that Ken’s literacy scores are below level and he needs additional support
in this domain. He needs to be able to identify the letters of the alphabet and increase his phonological
awareness in order to not struggle with reading in the future. Increased support in this area will allow
Ken to be able to read more efficiently and comprehend text.
Page 8 of 26 April 2014
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

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

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
Page 9 of 26 April 2014
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

Page 10 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

Independent Living Goal, if appropriate:

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

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
Science
Reading
Writing
ELA*
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

Page 11 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

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

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
Literature
Biology

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

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

PASA (Administered in grades 3-8, 11 for Reading and Math; Grades 4, 8, 11 for Science)
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):
Student is in preschool and therefore does not take this exam yet.

Explain why the PASA is appropriate:

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)

Page 12 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

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
Reading
Writing
Speaking

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

Student will participate in the Alternate ACCESS for ELLs.

Explain why the student cannot participate in the ACCESS for ELLs:

Explain why the Alternate ACCESS for ELLs is appropriate:

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

Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking

Local Assessments

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

Student will participate in local assessments without accommodations; OR

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

Page 13 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

The student will take a local alternate assessment.

Explain why the student cannot participate in the local regular assessment:

Explain why the local alternate assessment is appropriate:

Page 14 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

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 pencil to write with, Ken will be Twice a week, the special Progress will be reported to
able to correctly print the numerals 1-10 with education teacher will parents quarterly with
100% accuracy on 4 out of 5 trials, by the end of work one on one with Ken report cards.
the current IEP period. to practice writing the
numerals and record the
frequency in which he
correctly writes out a
numeral. This data will be
graphed and used to
inform which numerals
Ken needs more help with
and which have been
mastered. Every three
weeks this will be paused
in order to allow Ken to
write as many numerals
on his own as he can until
he completes all numerals
in 4 of 5 trials.
When presented with flashcards of uppercase Once a week, the special Progress will be reported to
letters, Ken will be able to correctly identify all education teacher will parents quarterly with
26 letters on 4 of 5 trials by the end of the IEP extend Ken’s writing report cards.
period. lessons to work on his
letter naming. He will
start with 5 letters with
Ken every session and
move on one letter for
every letter mastered. At
the start of each session,
Page 15 of 26 April 2014
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

the special education

teacher will ask Ken to
name as many letters as
he can in order and graph
the frequency of correctly
named letters. These
trials will be the start of
the trials and this
instruction will continue
once Ken has named all of
the letters of the
alphabet on 4 out of 5
trials.
When verbally asked personal information Ken’s classroom teacher Progress will be reported to
questions (birthdate, address, telephone number), will talk to him every day parents quarterly with
Ken will be able to correctly answer each question about his personal report cards.
within 10 seconds of it being asked with 100% information and ask him
accuracy by the end of the IEP period. directed questions for
practice. This will be
informal practice. Once a
week, Ken’s teacher will
ask him to sit down with
her at the end of the day
and she will ask him the
same personal information
questions in a formal
setting and record his
answers. Progress will be
shown over time on a
graph recording frequency
of correctly answered
items per session.

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

Short term objectives / Benchmarks

N/A

Page 16 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

Page 17 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

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
SDI for Goal 1:
The special education
teacher will provide direct
and explicit individual
instruction on how to
Special Education
correctly write each 2 times per week 11/26/20 11/26/20-11/25/21
Classroom
numeral from 1-10. Each
numeral will be taught to
mastery before beginning
training on the next
numeral.
SDI for Goal 1:
Following the explicit
instruction, the special
education instructor will
prompt Ken to write as
many numerals as he can on Special Education
2 times per week 11/26/20 11/26/20-11/25/21
his own. This prompting Classroom
will be most to least
intrusive prompting and
faded as Ken writes the
numerals with increasing
independence.
SDI for Goal 2:
Following Ken’s fine motor
skill work in writing, the
special education teacher Special Education
1 time per week 11/26/20 11/26/20-11/25/21
will work with him using Classroom
flashcards to practice letter
naming fluency. The
instructor will start with
Page 18 of 26 April 2014
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

the first five letters of the

alphabet and move on to
new letters as a letter is
mastered.
SDI for Goal 2:
The special education
teacher will work with the
student following the
flashcard exercises on
Special Education
saying the names of the 1 time per week 11/26/20 11/26/20-11/25/21
Classroom
letters of the alphabet from
rote in order to reinforce
the verbal names he learns
during the intervention
sessions.
SDI for Goal 3:
The general education
teacher will work with the
student everyday
informally. Teacher will
talk to student about the
personal information items General Education
Everyday 11/26/20 11/26/20-11/25/21
he needs to improve his Classroom
knowledge on. Teacher
will alternate between
telling student this
information, asking it of
him, and showing it to him
on paper.
SDI for Goal 3:
At the end of every week
on a Friday, the teacher
will sit with the student
General Education
and ask him to tell him 1 time per week 11/26/20 11/26/20-11/25/21
Classroom
where he lives, what his
phone number is, and what
his birthdate is. This will
occur once a week.

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

Page 19 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

Service Location Frequency Projected Beginning Date Anticipated Duration

Once a week before first
session of the week with
Occupational Therapy Special Education Room 11/26/20 11/26/20/11/25/21
the special education
teacher.

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
Occupational
therapist will do the
short lesson with
Ken in front of the
Special Education Special Education
special education Once a week 11/26/20 11/26/20-11/25/21
Teacher Room
teacher so teacher
can maintain this
throughout his
sessions.

Page 20 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

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
Support Service
Support Service

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

Student IS eligible for ESY based on the following information or data reviewed by the IEP team:

OR

x 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:

Ken will be evaluated for ESY services during spring break of the 2020-2021 school year. Regression and recoupment data will be
taken 10 days prior to the break and then 10 days after Ken returns to school. This data will be analyzed to determine whether or
not there is an interruption to Ken’s progress towards his IEP goals that is due to extended time out of the classroom. After this
data has been analyzed, a decision will be made about an ESY placement going into the summer of 2021.

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

If the IEP team has determined ESY is appropriate, complete the following:

ESY Service to be Provided Location Frequency Projected Beginning Date Anticipated Duration

Page 21 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

Page 22 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Ken Harris

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.

It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public
or private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal
of students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education
in general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily.

 What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary
aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general
education class.

 What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?

 What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the
class, even with supplementary aids and services?

 To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:
Ken is performing both academically and functionally at the age equivalent of 4 years and 2 months.
There is not a notable disparity between this level and his actual age, therefore Ken’s participation
with students without disabilities will be to the maximum extent possible in the least restrictive
environment. He will be able to participate fully, aside from his weekly pull out sessions with the
special education teacher.

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Ken is performing both academically and functionally at the age equivalent of 4 years and 2 months.
There is not a notable disparity between this level and his actual age, therefore Ken’s participation
with students without disabilities will be to the maximum extent possible in the least restrictive
environment. He will be able to participate fully, aside from his weekly pull out sessions with the
special education teacher.

Page 23 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

B. Type of Support

1. Amount of special education supports

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

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

x Life Skills Support

Multiple Disabilities Support

Physical Support

x Speech and Language Support

Page 24 of 26 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

C. Location of student’s program

Name of School District where the IEP will be implemented: Steubenville City Schools

Name of School Building where the IEP will be implemented: Pugliese West Elementary School

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 25 of 26 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
spends in the regular time student spends inside the
school day) x 100 = %
classroom per day regular classroom: Using the calculation result – select the appropriate percentage category
(including lunch, recess
& study periods) (Column 1 ÷ Column 2) x
100 = %
5 6 5 ÷ 6 x 100 = 83% 83% of the day INSIDE the Regular Classroom 80% or More of the Day
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.
Page 26 of 26 April 2014