INDIVIDUALIZED EDUCATION PLAN (IEP)

Overview – This IEP has been designed in accordance with the World Health Organisation International Classification of Functioning Disability and Health. In
accordance with this approach Disability is defined as an impairment in interaction with a wide range of environmental barriers. In this IEP, teachers are asked to
identify the learner’s impairment in combination with their school environment. The learning barriers should be documented alongside accommodations designed
to remove the participation barriers and improve educational success.

SECTION A: PERSONAL INFORMATION

LEARNER/PARENT INFORMATION: DIFFICULTIES (select most relevant): MEETING INFORMATION

DATE OF MEETING _____________
Learner ____________________________ Sex ______ ___ Difficulty in Seeing DATE OF LAST IEP ______________
Birth Date __________Grade/Level
_________ LRN_________ PURPOSE OF MEETING :
Current School ____________________________________ ___ Difficulty in Hearing ___ Interim IEP**
Address of School __________________________________ ___ Initial IEP
Mother Tongue Spoken______________________________ ___ Term IEP
___ Difficulty in Communicating
Address _________________________________________ ___ IEP Following 3-Yr Reevaluation**
Learner’sPhone(if there is)__________________________ ___ Revision to IEP Date_________
___ Difficulty in Moving/Walking
Parent/Guardian/Caregiver ___________________________ ___ Exit/Graduation_____________
Work & Workplace__________________________________ ___ IEP Revision Without a Meeting:
Landline/Mobile/Cell Phone No.__________Email________ ___ Difficulty in Concentrating/Paying At the request of ___Parent
Mother Tongue Spoken _____________________________ Attention ___School
Interpreter or Other Accommodations Needed _ IEP Review Date ________________
_______________________________________________ ___ Difficulty in Remembering/ COMMENTS:
Understanding
______________________________
___ Others (please specify)

____ Medical diagnosis (if yes, please attach)

_______________

1
 IEP TEAM MEMBERS IN ATTENDANCE

School
Parent/Guardian/Caregiver___________________________________________ Psychologist**_______________________________________________________
*Learner____________________________________________________________ Guidance Counselor /Designate_________________________________________
Principal/School Head_________________________________________________ School Nurse
Other (name and role) ________________________________________________ _______________________________________________________________
Special Education Teacher
_______________________________________________ Therapist/Pathologist/Specialist_________________________________________
**Regular Education /Receiving Teacher _____________ Other (name and role) Speech/Language Interpreter __________________________________________
*Learner must be invited when transition is discussed.
**The IEP team must include at least one regular education teacher of the learner (if the learner is or may be participating in the regular education environment)

_______________________________________________
Signature over Printed Name of Parent/Guardian/Caregiver:

AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, LEARNER MUST BE INFORMED OF THEIR RIGHTS UNDER THE LAW AND ADVISED THAT THESE
RIGHTS WILL BE ENJOYED AT AGE 18.

____ Not Applicable (learner will not be 18 within one year

____ The learner has been informed of his/her rights under law and advised of the transfer of rights at age 18

Distribution: __ Learner’s Folder

__ Parent/Guardian/Caregiver Ed Special Education/Receiving Teacher)

LEARNER: __________________________________________________________________________________
DATE: _________________________

2
I. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Results of initial or most recent evaluation and results of school and division assessments:

Description of academic, developmental and/or functional strengths:

Description of academic, developmental and/or functional needs:

Parental concerns regarding their child’s education:

Impact of the disability on involvement and progress in the general education curriculum (for preschool, how the disability affects participation in
appropriate activities):

3
II. CONSIDERATION OF SPECIAL FACTORS
a) Does the learner have difficulty relating with people which impedes his/her learning or the learning of others?  No  Yes
b) If yes, consider the appropriateness of developing a Behavior Intervention Plan.

Behavior Intervention Plan developed?  No  Yes

Refer to Behavior Intervention Plan for additional information.

Does the learner have difficulty in Moving/Walking?

 No  Yes
If yes, consider the mobility needs as related to the IEP and describe below.

Does the learner have difficulty in seeing or with blindness/visual impairment?  No  Yes
If yes, provide for instruction in Braille and the use of Braille, unless the IEP Team determines that instruction in Braille is not appropriate for the learner after an
evaluation of the learner’s reading and writing skills, needs, and appropriate reading and writing media, including evaluation of future needs for instruction in Braille
or the use of Braille. Describe below.

Does the learner have difficulty in communicating?  No  Yes

If yes, consider the communication needs and describe below.

Does the learner have difficulty in concentrating/paying attention?  No  Yes

If yes, consider the attention span needs and describe below.

Does the learner have difficulty in remembering/understanding?  No  Yes

If yes, consider the understanding needs and describe below.

Does the learner have difficulty in hearing or Is the learner deaf or hard of hearing?  No  Yes
If yes, consider and describe the learner’s language and communication needs, opportunities for direct communication with peers and professional personnel in the
learner’s language and communication mode, academic level and full range of needs, including opportunities for direct instruction in the learner’s language and
communication mode. Describe communication needs below.

Does the learner need assistive technology devices or services?  No  Yes

If yes, describe the type of assistive technology and how it is used. If no, describe how the learner’s needs are being met in deficit areas.

Does the learner require alternative format for instructional materials?  No  Yes
If yes, specify format(s) of materials required below.

 Braille  Large type  Auditory  Electronic text

4
5
 SECTION B: DIFFICULTIES, BARRIERS AND ENABLING SUPPORTS

DIFFICULTY (enter all ENVIRONMENTAL BARRIERS (describe ENVIRONMENTAL FACILITATORS ACCOMMODATIONS (list
areas of difficulty) each factor restricting participation) (describe each factor enabling participation in items, staff resources and
response to barriers) infrastructure changes required
to enable participation)

Sample
DIFFICULTY (enter all ENVIRONMENTAL BARRIERS (describe ENVIRONMENTAL FACILITATORS ACCOMMODATIONS (list
areas of difficulty) each factor restricting participation) (describe each factor enabling participation in items, staff resources and
response to barriers) infrastructure changes
required to enable
participation)

Difficulty seeing 1. Printed text books (.4) 1. Braille text books (+4) All text books to be transcribed
into Braille

2. Printed exam papers (.4) 2. Braille exam paper and use of computer All exam papers to be
with screen reader (+4) transcribed into Braille
School desktop computer with
screen reader
Separate exam room
Exam supervisor

6
 3. Writing with pen / pencil and paper (.4) 3. Laptop computer with screen reader (+4) Laptop computer
Screen reader
Headphones
Adaptive technology training

Difficulty 1. Travelling between home and school (.3) 1. Buddy to provide sighted guide each day to School Buddy
moving/walking and from school.

2. Unmarked paths on school grounds. 2a. Tactile indicators on school grounds Tactile indicators
2b. Orientation and Mobility training to support Orientation and Mobility training
independent movement.

3. Team Sport (.4) 3. Provision of modified team sport activities School buddy
and classmate training to support participation
(+4)

Selection of Barriers and Qualifiers for Environmental Barriers and Facilitators (taken from ICF)

DIFFICULTIES (select all relevant categories) Qualifier for Environmental Barriers Qualifier for Environmental Facilitators
• Seeing .0 No barrier +1 Mild facilitator
• Hearing .1 Mild barrier +2 Moderate facilitator
• Communicating .2 Moderate barrier +3 Substantial facilitator
• Moving/Walking .3 Severe barrier +4 Complete facilitator
• Concentrating/Paying Attention .4 Complete barrier +8 Facilitator, not specified
• Remembering/Understanding .8 Barrier, not specified +9 Not applicable
.9 Not applicable

7
 SECTION C: STUDENT GOALS

To support identification of learner goals, also confirm:

• What opportunities are available at the school to support learner goals?
• What are the student interest areas?
• What disability-specific skills does the learner need to develop to support their participation / attainment of goals?

Goals (eg – Skills to improve participation in education or daily living skills. Goals should be SMART (Strategic, Measurable, Achievable, Realistic and Time-
bound)

INTEREST GOAL INTERVENTIONS TIMELINE INDIVIDUALS REMARKS PROGRESS / NEXT

RESPONSIBLE STEPS

Sample

INTEREST GOAL INTERVENTION TIMELINE INDIVIDUALS REMARKS PROGRESS / NEXT

RESPONSIBLE STEPS
Independent Independent Weekly mobility training 3 months
mobility travel from
home to
school
Reading Reading Braille training 6 months
Braille

8
SECTION D: STUDENT TRANSITION

This section is for learners exiting the school environment and transitioning into work.

INTEREST WORK OPPORTUNITIES INTERVENTIONS / INDIVIDUALS REMARKS

TRANSITION SKILLS RESPONSIBLE

IEP IMPLEMENTATION

___As the parent, I agree with the components of this IEP, I understand that its provisions will be implemented as soon as possible after the IEP
goes into effect.

___As the parent, I disagree will or part of this IEP. I understand that the School must provide me with written notice of any intent to implement
this IEP. If I wish to prevent the implementation of this IEP, I must submit a written request for a due process hearing to the school principal.

___________________________

Parent’s Signature

______________________________
_______________________ _______________________
Regular/Receiving Teacher(if LSEN is in
Special Education Teacher Principal/School Head
inclusion)

_______________________ _______________________ _______________________

Learner (if applicable) Guidance Counselor/SPED Coordinator Psychologist/Other Specialist

9
10