The document contains an Individualized Education Plan (IEP) form that collects student and parent contact information, identifies the student's eligibility category, notes when IEP meetings will take place, and lists required participants; it includes sections to describe the student's current academic and functional performance, strengths and concerns, and consideration of special factors; and the form provides space to list the student's annual IEP goals and progress reports.
The document contains an Individualized Education Plan (IEP) form that collects student and parent contact information, identifies the student's eligibility category, notes when IEP meetings will take place, and lists required participants; it includes sections to describe the student's current academic and functional performance, strengths and concerns, and consideration of special factors; and the form provides space to list the student's annual IEP goals and progress reports.
The document contains an Individualized Education Plan (IEP) form that collects student and parent contact information, identifies the student's eligibility category, notes when IEP meetings will take place, and lists required participants; it includes sections to describe the student's current academic and functional performance, strengths and concerns, and consideration of special factors; and the form provides space to list the student's annual IEP goals and progress reports.
The document contains an Individualized Education Plan (IEP) form that collects student and parent contact information, identifies the student's eligibility category, notes when IEP meetings will take place, and lists required participants; it includes sections to describe the student's current academic and functional performance, strengths and concerns, and consideration of special factors; and the form provides space to list the student's annual IEP goals and progress reports.
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INDIVIDUALIZED EDUCATION PLAN (IEP)
INFORMATION STUDENT/PARENT INFORMATION ELIGIBILITY CATEGORY MEETING INFORMATION ____ Autism (66) DATE OF MEETING ________________ Student ________________________ Sex Male________ ____ Deaf/Blind (79) DATE OF LAST IEP ________________ Birthdate ____________ Grade _______ Student ID# ____________ ____ Developmentally Delayed (59) PURPOSE OF MEETING: Student Primary Language ________________________________________ ____ Emotional Disturbance (63) ____ Interim IEP Student English Proficiency Code (optional) ____ Health Impairment (81) ____ Initial IEP _________________________________ ____ Annual IEP ____ Hearing Impairment/Deaf (77) Address __________________________ ____ IEP Following 3-Yr Reevaluation ____ Mental Retardation (70) Student Phone _________________________________________________ ____ Revision to IEP Date __________ Parent/Guardian/Surrogate ______________ ____ Orthopedic Impairment (82) ____ Specific Learning Disability (81) ____ Exit/Graduation ______________ Parent Phone (Home) _______________ Work __OFW________________ Mobile Phone/Cellphone No. _________________ Email ____ Speech/Language Impairment (58) ____ IEP Revision without a meeting: ______________________ ____ Traumatic Brain Injury (83) At the request of ____ Parent Primary Language Spoken at Home ____ _____________________________ ____ Visual Impairment/Blind (75) ____ School/District Interpreter or Other Accommodations Needed ____ Multiple Impairment (67) OTHER ADDENDUM MEETING ________________________________ Eligibility Date IEP Services will begin ___________ Emergency Contact/Phone Number ______________________ Anticipated ________________________________________ ANTICIPATED Duration of Services _____________ Current School _ ______________ District IEP Review Date __________________ 3-YR REEVALUATION COMMENTS: ___________________ _________________________________ _________________________________ _________________________________ IEP PARTICIPATION * Parent/Guardian/Surrogate __________________________________________________________ Speech/Language Therapist/Patholigist/Specialist ________________________________________________________ Student ___________________________________________________________________________ School Nurse __________________________________________________________________ Interprerer _________________________________________________________________________ * Special Education Teacher ___________________________________________________________ Other (Name and role) ___________________________________________________________ * Regular Education Teacher___________________________________________________________ Other (Name and role) ___________________________________________________________ School Psychologist _________________________________________________________________ Other (Name and role) ___________________________________________________________ * Required participation ** Student must invited when transition is discussed (beginning at age 14 or younger if appropriate) *** The IEP tem must include at least one year regular education teacher of the student (if the student is or may be participating in the regular education environment) PROCEDURAL SAFEGUARDS ___ I have received a statement of procedural safeguards under the individuals with Disabilities Education Act (IDEA) and these rights have been explained to me in my primary language. Parent Signature: __________________________________________________________ AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, STUDENTS MUST BE INFORMED OR THEIR RIGHTS UNDER IDEA AND ADVISED THAT THESE RIGHTS WILL TRANSFER TO THEM AT AGE 18. ____ Not Applicable (Student will not be 18 within one year ____ The student has been informed of his/her rights under IDEA and advised of the transfer of rights at age 18 Distribution: ____ Confidential Folder ____ Parent/Guardian/Surrogate ____ Special Education Teacher ____ Case Manager ____ Diagnostic Center Student: _____________________________ Date: _______________________________ PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE Consider results of the initial evaluation or most recent reevaluation, and the academic, developmental and functional needs of the student, which may include the following areas: academic achievement, language/communication skills, social/emotional/behavior skills, cognitive abilities, health, motor skills, adaptive skills, pre-vocational skills, vocational skills and other skills as appropriate. For students who are 16 or older, or will turn 16 when this IEP is in effect, also consider the results of age appropriate transition assessments related to training/education, employment and independent living skills (as appropriate). ASSESSMENT CONDUCTED ASSESSMENT RESULTS EFFECT ON STUDENT’S INVOLVEMENT AND PROGRESS IN GENERAL EDUCATION CURRICULUM OR, FOR EARLY CHILDHOOD STUDENTS, INVOLVEMENT IN DEVELOPMENTAL ACTIVITES Student: Date: STRENGTHS, CONCERNS, INTERESTS AND REFERENCES Page ___ of ___ STATEMENT OF THE STUDENT’S STRENGTH
STATEMENT OF PARENT’S EDUCATIONAL CONCERNS
STATEMENTS OF STUDENT’S PREFERENCES AND INTERESTS (required if transition services will be discussed, beginning at age 14 or younger if appropriate)
CONSIDERATION OF SPECIAL FACTORS
1. Does the students behavior impede the student’s learning or the learning of others? ____ No action needed ____ Yes, addressed in IEP 2. Does the student have limited English proficiency? If yes, team must consider language needs of the student as those needs relate to the student’s IEP. ____ No action needed ____ Yes, addressed in IEP 3. Is the student blind or visually impaired? If yes, team must evaluate reading and writing needs and provide for instruction in Braille unless determined not appropriate for the ____ No action needed ____ Yes, addressed in IEP student. 4. Is the student deaf or hard of hearing? ____ No action needed ____ Yes, addressed in IEP If yes, team must consider communication needs. 5. Does the student require assistive technology devices and services? ____ No action needed ____ Yes, addressed in IEP If yes, team must determine nature and extent of devices and services.
IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS AND BENCHMARKS OR SHORT-TERM OBJECTIVES
MEASURABLE ANNUAL GOAL (Including how progress toward the annual goal will be measured) PROGRESS REPORT 1. Satisfactory Progress being made (Continue) 2. Unsatisfactory Progress being made (need to review/revise) 3. Goal met (note date) Date Date Date Date
BENCHMARK OR SHORT-TERM OBJECTIVES
1.
2.
3.
MEASURABLE ANNUAL GOAL ((Including how progress toward the annual goal will be measured) PROGRESS REPORT 4. Satisfactory Progress being made (Continue) 5. Unsatisfactory Progress being made (need to review/revise) 6. Goal met (note date) Date Date Date Date BENCHMARK OR SHORT-TERM OBJECTIVES 1.
2.
3. Student : Date : METHOD FOR REPORTING PROGRESS Page ____ of ____
METHOD FOR REPORTING THE STUDENT’S PROGRESS TOWARD MEETING ANNUAL GOALS (Check all PROJECTED FREQUENCY OF REPORTS methods that will be used) ____ IEP Goals Pages ____ Report Card ____ Quarterly ____ Semester ____ Specialized Progress Report ____ Parent Conferences ____ Trimester ____ Other ____ Other: ___________________________________________________________________________________________
SPECIAL EDUCATION SERVICES
SPECIALLY DESIGNED INSTRUCTION BEGINNING AND ENDING FREQUENCY OF LOCATION OF
RATE SERVICES SERVICES
SUPPLEMENTARY AIDS AND SERVICES
Includes aids, services and other supports provided in regular education classes or other education-related settings to enable participation with nondisabled students MODIFICATION, ACCOMODATION OR SUPPORT FOR BEGINNING AND ENDING FREQUENCY OF LOCATION OF STUDENT OR PERSONNEL (Described below or select from RATE SERVICES SERVICES supplemental “Modifications, Accommodations and supports” Student : Date : RELATED SERVICES Page ____ of ____ RELATED SERVICES SERVICES TYPE AND/OR BEGINNING AND ENDING FREQUENCY OF SERVICES LOCATION OF SERVICES DESCRIPTION DATES ____ Speech/Language ____ Physical Therapy ____ Occupational Therapy ____ Transportation ____ Counseling ____ Psychological Services ____ Orientation and Mobility ____ Audiology ____ Medical Services for Diagnostic or Evaluation ____ Recreation Therapy ____ Parent Counseling & Training ____ Interpreting Services ____ Social Work Services ____ School Nurse Services Other EXTENDED SCHOOL YEAR SERVICES Does the student require extended school year services? ____ No ____ Yes If YES, IEP goals and benchmarks/short-term objectives and/or related services to be implemented in ESY must be identified If need for ESY is to be determined at a later date, indicate date by which IEP decision will be made:
PLACEMENT PLACEMENT CONSIDERATIONS PERCENTAGE OF TIME IN REGULAR EDUCATION ENVIRONMENT ___ ___ Rejected Regular class w/supplementary aides and services Selected ___ Rejected Regular class and SPED class (i.e. resource) combination ___ ___ Rejected Self-contained program Selected ___ Rejected Special school ___ ___ Rejected Residential Selected ___ Rejected Hospital ___ ___ Rejected Home Selected ___ Rejected Other ___ Selected ___ Selected ___ Selected ___ Selected JUSTIFICATION FOR PLACEMENT INVOLVING REMOVAL FROM REGULAR EDUCATION ENVIRONMENTS Explain why IEP goals and objectives cannot be implemented in regular education environments, including the reasons why the team rejected a less restrictive placement. Include an explanation of any harmful effects on the learning of this or other students which affected the placement selection.
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.
