Student Name: Hans Asperger Meeting Date: 1/07/15

__________________SCHOOL SYSTEM
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
IEP Meeting Date: 1/07/15 Purpose of IEP Meeting : Initial  Annual Review  Amendment

Student Name: Hans Asperger Date of Birth: GTID#
Eligibility Category(s): Speech Impairment in receptive language and Most Recent Eligibility Date(s): Hans received a re-evaluation on 12/10/14
Autism
School: Grade: 7th School Year: 2015
Parent(s):
Address: Email:
Phone (home): (work): (cell phone):

TEAM MEMBERS IN ATTENDANCE

REQUIRED MEMBERS ADDITIONAL MEMBERS
Parent: Name/Title:

Parent: Name/Title:

Local Education Agency Representative (LEA): Name/Title:

Special Education Teacher: Name/Title:

Regular Education Teacher: Name/Title:

Student (age 18 or if transition is being discussed): Name/Title:

Agency representative (responsible for transition services): Name/Title:

I. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Results of initial or most recent evaluation and results of state and district assessments:
Hans received a re-evaluation on 12/10/14 as a student with a Speech Impairment in receptive language. He continued to meet
special education eligibility criteria.
His scores on the subtests assessing listening comprehension and interpreting spoken language fell into the below average range.
Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II) is a brief, individually administered assessment of intelligence.

The WASI-II subtest scores are T scores with a mean of 50 and a standard deviation of 10. WASI-II index and IQ scores are standard
scores with a mean of 100 and a standard deviation of 15. 

Subtests:
Hans attained high scores on the WASI-II subtests that tend to be most sensitive to inattention and impulsive responding.
Similarities T score = 27; PR = 1 – below average

Indices:
Verbal Comprehension Index: SS = 73; PR = 4 – below average
FULL SCALE IQ: SS = 103; PR = 58% of individuals in the normative population scored equal to or less than Hans.
Two of Hans’s teachers completed the Conners-3
Hans had elevated scores on the scales assessing inattention, hyperactivity/ impulsivity, and problems in learning and executive
functioning.
The Autism Diagnostic Observation Schedule – Second Edition (ADOS-2) is a standardized assessment of communication, social
interaction, and play or imaginative use of materials to diagnose a child with Autism Spectrum Disorder. The ADOS-2 uses ratings
that range from 0 (no abnormality) to 2 (markedly abnormal), based upon the comparison of social affect and restricted/repetitive
score relative to a cited cut-off score.
Hans’s results indicated that reciprocal social communication skills were less developed than most students his age due to unusual
visual behavior squinting and tendency to miss “big picture” information while focusing on specific details.

The Gilliam Autism Rating Scale – Third Edition (GARS-3) is a teacher/parent rating scale. Hans’s parents’ responses which resulted in
an Autism Index score of 63 (<1st percentile rank), which fell in the range associated with a possible autism spectrum disorder. The
teacher’s responses yielded an Autism Index score of 86 (18 th percentile rank) suggested the likelihood of autism spectrum disorder.

Georgia Department of Education

Model Form July 2011
Student Name: Hans Asperger Meeting Date: 1/07/15

The Childhood Autism Rating Scale, Second Edition – High-Functioning Version (CARS2-HF) is a rating scale used to assess children who
have been referred because of possible Autism Spectrum Disorders or other Pervasive Developmental Disorders.
A child with mild-to-moderate symptoms of autism spectrum disorder is expected to attain a T-score between 42 and 50, and Hans’s
results were a Total Raw Score of 32.5 (T-score = 49), showing that Hans is “mildly to moderately” impaired in 8 of the 15 CARS2-HF
categories: Social-Emotional Understanding, Emotional Expression and Regulation of Emotions, Object Use in Play, Verbal
Communication, Nonverbal Communication, Thinking/ Cognitive Integration Skills, Intellectual Response, and General Impressions.
Hans is also “mildly” impaired in 3 out of 15 categories: Relating to People, Adaptation to Change/ Restricted Interests, and Visual
Response.

Hans’s pattern of behavior appeared consistent with Autism Spectrum Disorder according to the Diagnostic and Statistical Manual of
Mental Disorders – 5th Edition (DSM-5).
Adaptive Behavior Assessment System – 2nd Edition (ABAS-II) – Teacher Form
Hans’s current 3rd-grade teacher completed the ABAS-II, and her ratings resulted in scores that fell into the deficient range in three
areas: social, self-direction, and leisure, because a score of 4 or lower is considered a deficiency.
Leisure Scaled Score = 4
Self-Direction Scaled Score = 2
Social Scaled Score = 2
Description of academic, developmental and/or functional strengths:
 Hans’s teachers identified that he has strength in creativity and his artistic ability.
 Hans’s teacher reported that his cognitive abilities in nonverbal reasoning and problem-solving skills were superior.
Hans’s teacher reported that he entered school with sufficient school readiness skills and adequate support in the home for the
development of academic skills.
Hans’s Emotional Disturbance Examination results reported that the demonstration of adequate orientation to person, place, and
time.
Description of academic, developmental and/or functional needs:
Hans’s teachers reported that he demonstrated significant inattention and hyperactivity/ impulsivity.
Hans’s teacher reported that he was likely to become angry when he experienced changes in his routine.
Hans’s teacher reported that he exhibited poor social skills in group and one-on-one settings with his peers, because he did not try to
make friends with other students, nor did he seem to understand why a peer might not wish to interact with him when he behaved in
an unusual manner due to little social communication, seeming indifferent to others’ attention, and not understanding humor/slang.
Hans’s teacher reported unusual motor behaviors (e.g., flapping hands or fingers, making rapid movements while moving from place
to place) and reported that Hans often behaved in a compulsive manner.
Parental concerns regarding their child’s education:
Hans’s parents reported that Hans often failed to predict probable consequences in social events and tended to talk about a single
subject excessively (e.g., video games).
Hans’s parents noted that he had heightened emotional responses to changes in routine, not being allowed to do something, and to
frustration.
Hans’s mother reported contrasting data to the CAB-P assessment, indicating that Hans did not demonstrate inattentive or
hyperactive/ impulsive behavior at home as the assessment said he did.
Hans’s parents reported that Hans often became frustrated by schoolwork, suggesting that the depressed feelings he demonstrated in
the classroom were a reaction to academic demands.
Impact of the disability on involvement and progress in the general education curriculum (for preschool, how the disability affects participation in appropriate
activities):
Hans’s teacher reported that his weaknesses in listening comprehension and interpreting spoken language negatively affected his
ability to listen, remember details, infer and predict, use critical thinking strategies, and increase vocabulary skills.
Hans’s 3rd-grade teacher reported that, in the classroom setting, Hans very often demonstrated inattentive, distractible, overly active,
and impulsive behavior, which caused difficulty with initiation and completion of difficult tasks and schoolwork.
Hans’s current teacher reported that “His behavior impedes his ability to get class instruction and apply it.”
Hans’s teacher reported that he was prone to forget things that he had already learned, and if Hans offered an incorrect answer, he
tended to become very angry and shut down.

Page 1 of 7
II. CONSIDERATION OF SPECIAL FACTORS
Georgia Department of Education
Model Form July 2011
Student Name: Hans Asperger Meeting Date: 1/07/15

a) Does the student have behavior which impedes his/her learning or the learning of others?  Yes  No
If yes, consider the appropriateness of developing a Behavior Intervention Plan.
Behavior Intervention Plan developed?  Yes  No
Refer to Behavior Intervention Plan for additional information.

b) Does the student have Limited English proficiency?  Yes  No

If yes, consider the language needs as related to the IEP and describe below.

c) Does the student have blindness/visual impairment?  Yes  No

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 student
after an evaluation of the student’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.

d) Does the student have communication needs?  Yes  No

If yes, consider the communication needs and describe below.

e) Is the student deaf or hard of hearing?  Yes  No

If yes, consider and describe the student’s language and communication needs, opportunities for direct communication with peers and professional personnel
in the student’s language and communication mode, academic level and full range of needs, including opportunities for direct instruction in the student’s
language and communication mode. Describe communication needs below.

f) Does the student need assistive technology devices or services?  Yes  No

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

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

 Braille  Large type  Auditory  Electronic text

III. TRANSITION SERVICE PLAN

A transition service plan must be completed no later than entry into 9th grade or by age 16, whichever comes first, or younger, if determined appropriate by the IEP
team and updated annually. If transition service plan is developed, attach to the IEP.

Page 2 of 7

Georgia Department of Education

Model Form July 2011
Student Name: Hans Asperger Meeting Date: 1/07/15

IV. MEASURABLE ANNUAL GOALS

Progress At Reporting Period
Measurable Annual Goals: Academic and/or functional goals designed to meet the child’s
needs that result from the disability to enable the child to be involved in and make progress in the Method of
Criteria for Mastery
general education curriculum or to meet each of the child’s other educational needs that result Evaluation
from the disability.
1 2 3 4
(9 weeks) (18 weeks) (27 weeks) (36 weeks)

1. Through various social interventions, Hans will develop and 4 out of 5 trials Data collection 1 out of 5 trials 2 out of 5 trials 3 out of 5 trials 4 out of 5 trials
maintain age-appropriate relationships with his peers and teachers
by relating to his peers and interacting in typical ways.

2. Using self-regulation strategies such as taking deep breaths,

counting to ten, closing his eyes for a few seconds, and/or taking a
walk to get a drink of water, Hans will gain the self-control to react
appropriately to academic demands and changes in his routine.

3. Through the strategic utilization of prompting, to initiate and Less than 5 prompts per Data collection
school day for 4 weeks.
complete his assignments, Hans will gain the responsibility to self-
direct in the independent completion of his assignments.

stem from impairments in executive functions and deficits in adaptive

behavior

4.
address assessed weaknesses in adaptive behavior in the areas of

inferential and critical thinking skills.

REPORT OF STUDENT PROGRESS

When will the parents be informed of the child’s progress toward meeting the annual goals?
Progress will be reported to parents every 9 weeks.

Georgia Department of Education

Model Form July 2011
Student Name: Hans Asperger Meeting Date: 1/07/15

Page 3 of 7
V. MEASURABLE ANNUAL GOALS & SHORT-TERM OBJECTIVES/BENCHMARKS
Academic and/or functional goals designed to meet the child’s needs that result from the disability to enable the child to be involved in and make progress in the general education curriculum or to meet each of the
child’s other educational needs that result from the disability.

MEASURABLE ANNUAL GOAL: Social Skills

___________________________________________________________________________________________________________________________________________

Progress At Reporting Period

Short term objectives/benchmarks: Measurable, intermediate steps or targeted sub-skills to Method of
Criteria for Mastery
enable student to reach annual goals. Evaluation
1 2 3 4
(9 weeks) (18 weeks) (27 weeks) (36 weeks)

To assist in the development of age-appropriate peer Data collection

through
interactions, Hans will act out social scenarios using play items. observation

Maintaining eye Observation of Maintaining Maintaining Maintaining Maintaining

Hans’s teachers will rehearse having reciprocal conversations conversations
contact for 80% of a eye contact eye contact eye contact eye contact
with him by engaging him with questions that provoke
conversation for 20% of for 40% of for 60% of for 80% of
meaningful responses to encourage him to be more a a a a
comfortable with conversing with his peers beyond class conversatio conversatio conversatio conversatio
assignments. n n n n
Hans’s teachers will model appropriate behavior for him and with
encourage him to practice social skills opportuniti
If Hans appears to be having trouble entering a group of peers es for
or interacting during a class assignments feedback

Georgia Department of Education

Model Form July 2011
Student Name: Hans Asperger Meeting Date: 1/07/15

Hans identified a few classmates as friends, but he could not

identify the qualities that differentiated being a friend from being
just a classmate.
- Although Hans had difficulty relating to peers in his class per
teacher report, Hans did not acknowledge any difficulty or seem
aware of any behaviors that might be frustrating or annoying to
others.

stem from impairments in executive functions and deficits in adaptive

behavior (especially in the areas of social and self-direction).

REPORT OF STUDENT PROGRESS

When will the parents be informed of the child’s progress toward meeting the annual goals?
Progress will be reported to parents every 9 weeks when progress reports are released.

Page 4 of 7

Georgia Department of Education

Model Form July 2011
Student Name: Hans Asperger Meeting Date: 1/07/15

VI. STUDENT SUPPORTS

To advance appropriately toward attaining annual goals; to be involved and progress in the general curriculum; to be educated and participate with other children
in academic, nonacademic, and extracurricular activities, the following accommodations, supplemental aids and services and/or supports for school personnel will
be provided:
Instructional Accommodations
Hans will be provided with preferential seating within close proximity of the teacher/instructor.
Hans’s independent work skills will be supported by following a consistent routine to the greatest extent possible.
Hans will be allowed to stand while working, move around his desk area, and utilize a dynamic seat cushion.
 Hans will be provided with regular prompting and attention-getting cues to stay on task, especially during independent work time.
Hans will be provided with regular movement breaks of 2-5 minutes to stand up from his seat and walk around the classroom to
assist Hans in organizing his learning.
Classroom Testing Accommodations
Hans will be provided with regular movement breaks of 2-5 minutes to stand up from his seat and walk around the classroom
and/or hallway while being monitored by a teacher.
Hans will test in a distraction reduced environment to the greatest extent possible while testing.
Hans will be given time and a half on assessments to formulate thoughts and respond to questions.
For classroom given tests, Hans’s test will be broken down into smaller parts so that he will be encouraged to work on one part at a
time.
Hans will be provided with preferential seating within close proximity of the teacher/instructor.
Supplemental Aids and Services
Hans will be allowed to access the Learning Center where he can receive teaching and assistance/support with independent work.
Hans will be given the opportunity to stay after school to complete his homework with a school tutor who works with him in both a
small group setting and individually.
Hans will be provided with organizational tools such as a step-by-step checklist and problem-solving strategies to promote
retention of concepts learned.
 Hans will receive small group instruction and get pulled out into a resource room for 15 minutes during each class period.
Hans will receive support from
Supports for School Personnel
Hans’s teachers and paraprofessionals will attend a teacher training session for social services to develop a deeper understanding
of how to serve students with Autism Spectrum Disorder.
Hans’s teachers will hold a monthly parent-teacher conference in-person or over the phone to discuss progress at home and
determine how teachers and parents can provide consistency for Hans at school and home.

VII.ASSESSMENT DETERMINATION FOR DISTRICT AND STATEWIDE ASSESSMENTS FOR GRADES K-12
a) The student will participate in the following regular required assessments (Each state mandated test and subtest must be considered individually
and documented below).
Specific Testing Accommodations (Accommodations used for assessment must be consistent with accommodations used for classroom instruction/testing and
specified in the IEP. Some accommodations used for instruction may not be allowed for statewide assessment. Refer to the GaDOE Student Assessment
Handbook for the only allowable accommodations. Conditional accommodations are only allowable for students who meet eligibility criteria.) All subtests must
be considered individually. If the CRCT-M is considered, the Participation Guidelines for the CRCT-M must be completed and attached.

Test Subtest Setting Timing/Scheduling Presentation Response None, Standard or Conditional

GA Milestone Reading/ELA Small Through the end of Read-Aloud N/A None

group/Resource the school day
Room

b) The student will participate in the Georgia Alternate Assessment (GAA)  Yes  No
If yes, provide a statement of why the child cannot participate in regular required assessment.

Georgia Department of Education

Model Form July 2011
Student Name: Hans Asperger Meeting Date: 1/07/15

VIII. SPECIAL EDUCATION: Instruction/Related Services in General Education

Classroom/Early Childhood Setting
Options Initiation of Anticipated
Content/Specialty
Considered Frequency Services Duration Provider Title
Area(s)
 (mm/dd/yy) (mm/dd/yy)
Consultative

Collaborative
x Daily (02/01/15) (02/01/16) General Reading/English
Education Language Arts,
Teacher and Mathematics,
Co-teaching
Special Social Studies,
Education Science
Teacher
Supportive Services

Related Services

IX. SPECIAL EDUCATION: Instruction/Related Services Outside of the General Education Classroom
Options Initiation of Anticipated
Content/Specialty
Considered Frequency Services Duration Provider Title
Area(s)
 (mm/dd/yy) (mm/dd/yy)
x 15 minutes daily (02/01/15) (02/01/16) Special Reading/English
Separate
Education Language Arts
Class/Resource Room
Teacher
Separate School

Home Instruction
Residential
Hospital/Homebound
x Supportive Services
x 2-3 days weekly for 1 hour (02/01/15) (02/01/16) Speech Receptive Language
Speech Pathology
Pathologist

Related Services

X. The explanation of the extent, if any, to which the child will not participate with peers without disabilities in the regular
class and/or in nonacademic and extracurricular activities:

Page 6 of 7

XI. EXTENDED SCHOOL YEAR

a) Are extended school year services necessary?  Yes  No
If yes, complete the section below.
b) Goals to be extended or modified:
Georgia Department of Education
Model Form July 2011
Student Name: Hans Asperger Meeting Date: 1/07/15

Initiation of Anticipated
Services Frequency Services Duration Provider Title Location
(mm/dd/yy) (mm/dd/yy)

XII. DOCUMENTATION OF NOTICE OF IEP MEETING

Date Method of Notification By Whom

1st Notification Invitation  Phone Call  In Person Reminder notice Other:

2nd Notification Invitation  Phone Call  In Person Reminder notice Other:

3rd Notification Invitation Phone Call  In Person Reminder notice Other:

XIII. PARENT PARTICIPATION IN THE IEP PROCESS

The following documents were provided to parent(s):
 Parental Rights in Special Education
 Individualized Education Program (IEP)
 Eligibility Report(s)
 Evaluation
 Other:________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
___

If parent did not attend the meeting, complete below:

On _____________the documents were:  Mailed  Given In Person  Sent via Student  Other______________

Page 7 of 7

Georgia Department of Education

Model Form July 2011