Confidential Student Information

SCHOOL-AGE Individualized Education Program (IEP)

School District Street Address City, State, And Zip Code Telephone Number Student Name: Jose Perez Disability Classification: Autism Street: 20 Chestnut St. City: Rutherford Zip: 07070 Student ID#: 123-45-6789 Current Instructional Grade/Grade Equivalent: 2nd Racial/Ethnic Group of Student: Hispanic Telephone: (201) 555-6475 County of Residence: Bergen Male Female Date of Birth: 9/24/ 1999

Age: 7

Native Language of Student: Spanish Interpreter for Student Needed: Yes If yes, specify language: Spanish No

Medical Alerts: Seizures

Surrogate Parent Needed: Yes

No

Other Information: Jose will have seizures when he feels overwhelmed or anxious

Date of initial referral:

/ / / / /

Date initial consent for evaluation received:

Date of IEP meeting to determine initial eligibility:

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Date of Committee on Special Education (CSE) Meeting to Develop this IEP: 5/10/07 Type of Meeting: Initial _______________

Requested Review

Annual Review

Reevaluation

Date IEP is to be Implemented: 9/6/07 Projected Date of Next Review: 5/10/08 Projected Date of Reevaluation Meeting: 5/10/10

PRESENT LEVELS

OF

ACADEMIC ACHIEVEMENT, FUNCTIONAL PERFORMANCE INDIVIDUAL NEEDS

AND

Current functioning and individual needs in consideration of: the results of the initial or most recent evaluation, the students strengths, the concerns of the parents, the results of the students performance on any State or districtwide assessment programs; the students needs related to communication, behavior, use of Braille, assistive technology, limited English proficiency; how the students disability affects involvement and progress in the general education curriculum; and the students needs as they relate to transition from school to post-school activities for students beginning with the first IEP to be in effect when the student turns age 15 (and younger if deemed appropriate). TRANSCRIPT INFORMATION SECONDARY STUDENTS ONLY Diploma Credits Earned: Commencement-level State Tests Passed: Expected Date of High School Completion: Projected # years to graduate: Expected Diploma: / /

ACADEMIC ACHIEVEMENT, FUNCTIONAL PERFORMANCE AND LEARNING CHARACTERISTICS: Current levels of knowledge and development in subject and skill areas, including activities of daily living, level of intellectual functioning, adaptive behavior, expected rate of progress in acquiring skills and information and learning style. Jose easily understands straightforward cause-and-effect relationships and questions that have a definite answer. He also does not present a significant cognitive delay or language delay. Jose is also able to remember things that were said a week ago. Jose processes verbal information in a very concrete or literal manner. Finally, Jose has difficulty understanding idiomatic expressions and using correct tenses and plurals.

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SOCIAL DEVELOPMENT: The degree and quality of the students relationships with peers and adults, feelings about self and social adjustment to school and community environments. When in social situations, Jose will interact with his peers if the peer initiates the interaction. He also interacts well with his teacher as well as other adults. Jose does not make eye contact, with peers or adults. He does not initiate interactions with peers. Finally, Jose has great difficulty understanding the subtleties of humor.

PHYSICAL DEVELOPMENT: The degree or quality of the students motor and sensory development, health, vitality and physical skills or limitations that pertain to the learning process. Jose has good fine motor skills. He can use scissors, hold a pencil and manipulate other small objects. Jose is also able to run, jump, and other physical activities. Finally, Jose is uncoordinated in many activities (i.e. jump roping, throwing a ball) and is not motivated to participate in physical activities.

MANAGEMENT NEEDS: The nature of and degree to which environmental modifications and human or material resources are required to enable the student to benefit from instruction. Management needs are determined in accordance with the factors identified in the areas of academic achievement, functional performance and learning characteristics, social development and physical development. Jose presents with overresponsiveness to sensory stimuli. Jose will cover his ears and start to walk in circles when he hears the fire alarm sound It helps when teacher knows when a fire alarm will happen so Jose can put on his earphones. Jose gags at the smell of eggs benefits from bringing lunch from home and eating in the classroom when any type of eggs are being served.

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AND OLDER) For students beginning with the first IEP to be in effect when the student turns age 15 (and younger if deemed appropriate), identify the appropriate measurable postsecondary goals based upon age appropriate transition assessments relating to training, education, employment and, when appropriate, independent living skills. Training: Education: Employment: Independent Living Skills (when appropriate):

MEASURABLE POST-SECONDARY GOALS (AGES 15

MEASURABLE ANNUAL GOALS

* For students with severe disabilities who would meet the eligibility criteria to take the New York
State Alternate Assessment, the IEP must also include short-term instructional objectives and benchmarks for each annual goal. Annual Goal: What the student will be expected to be able to do by the end of the year in which the IEP is in effect. Evaluative Criteria: How well and over what period of time the student must demonstrate performance in order to consider the annual goal to have been met. Procedures to Evaluate Goal: The method that will be used to measure progress and determine if the student has met the annual goal. Evaluation Schedule: The dates or intervals of time by which evaluation procedures will be used to measure the students progress. ANNUAL GOAL: Jose will make eye contact while being spoken to. Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule: 9/10 times over a two week period charting By end of quarter

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ANNUAL GOAL: Jose will participate in physical activities for 10 minutes. Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule: Daily for two weeks charting Once a month

ANNUAL GOAL: Jose will initiate vocal social interactions with peers. Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule: 9/10 TIMES charting Every three weeks

ANNUAL GOAL: Jose will use correct tenses when writing sentences. Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule: With 100% accuracy Work sample At end of the term

ANNUAL GOAL: When given free time, Jose will choose a novel activity. Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule: 9/10 times chart End of quarter

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ANNUAL GOAL: Jose will become coordinated when throwing a ball. Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule: 9/10 times chart End of second quarter

(Add additional annual goals as appropriate)

RECOMMENDED SPECIAL EDUCATION PROGRAMS

SPECIAL EDUCATION PROGRAM/SERVICES Frequency Duration

AND

SERVICES
Initiation Date / / / / / / / / / /

Location

RELATED SERVICES Frequency Duration Location Initiation Date

/ / / PROGRAM MODIFICATIONS/ACCOMMODATIONS/SUPPLEMENTARY AIDS AND SERVICES Frequency Duration Location

/ / /

Initiation Date / / / / / / / / / /

ASSISTIVE TECHNOLOGY DEVICES/SERVICES Frequency Duration Location Initiation Date / / / / / /

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SUPPORTS FOR SCHOOL PERSONNEL ON BEHALF OF STUDENT Frequency Duration Location Initiation Date / / / /

SPECIAL TRANSPORTATION NEEDS: NONE Student has special transportation needs as recommended below: Special seating - Specify: Vehicle and/or equipment needs - Specify: Adult Supervision - Specify: Type of transportation Specify: Other Accommodations Specify: OTHER:

TESTING ACCOMMODATIONS:
The following individual appropriate accommodations are necessary to measure the academic achievement and functional performance of the student on State and districtwide assessments. Recommended testing accommodations will be used consistently: in the students education program, in the administration of districtwide assessments of student achievement, consistent with school district policy, and in the administration of State assessments of student achievement, consistent with State Education Department policy. TESTING ACCOMMODATION CONDITIONS SPECIFICATIONS More time taking tests

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PARTICIPATION IN STATE ASSESSMENTS The student will participate in the same State assessments that are administered to general education students. Graded: The student will take the State assessment with his/her grade level peers. Ungraded: The student will take the State assessment based on chronological age because his/her instructional levels in English and mathematics are three or more years below the grade-level coursework of the students nondisabled peers. The student will participate in the New York State Alternate Assessment (NYSAA) for Students with Severe Disabilities. Explain why the State assessment(s) administered to general education students is not appropriate for the student and why the alternate assessment selected is appropriate for the student: ____________ PARTICIPATION IN DISTRICTWIDE ASSESSMENTS The student will participate in the same districtwide assessments that are administered to general education students. The student will participate in the following alternate assessment for districtwide assessments: _______________ Explain why the districtwide assessment(s) administered to general education students is not appropriate for the student and why the alternate assessment selected is appropriate for the student: ____________

REMOVAL

FROM THE GENERAL EDUCATIONAL ENVIRONMENT occurs only when the nature or

severity of the disability is such that, even with the use of supplementary aids and services, education cannot be satisfactorily achieved. Explanation of the extent, if any, to which the student will not participate in general education programs, including extra curricular and other nonacademic activities: Jose will attend a resource room during Language Arts The student will not participate in the general education physical education program, but will participate in specially designed or adapted physical education. LANGUAGE OTHER THAN ENGLISH EXEMPTION No Yes, the students disability adversely affects the ability to learn a language, and the student is excused from the language other than English requirement.

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COORDINATED SET

OF

TRANSITION ACTIVITIES (SCHOOL

TO

POST SCHOOL)

For students beginning with the first IEP to be in effect when the student turns age 15
(and younger if deemed appropriate) needed transition services/activities to facilitate the students movement from school to post-school activities. DATE COORDINATED SET OF TRANSITION SCHOOL ACTIVITY ACTIVITIES DISTRICT/AGENCY RESPONSIBLE / / Instruction / / Related Services / / Development of Employment/Other Post-School Adult Living Objectives / / Community Experience / / Acquisition of Daily Living Skills / / Functional Vocational Assessment

PLACEMENT RECOMMENDATION
10 Month Placement:
Extended School Year Eligible: Yes If yes: Provider: No Projected dates of services: Site: to

REPORTING PROGRESS

TO

PARENTS

Identify when periodic reports on the progress the student is making toward meeting the annual goals will be provided to the students parents: Weekly

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RECOMMENDATIONS UPON DECLASSIFICATION

Date Declassified: / /

IEP recommendations to continue upon declassification: Testing Accommodations Conditions Specifications

Continued Eligibility for Local Diploma (Safety Net): Yes Continued Language Other Than English Exemption: Yes

No No

DECLASSIFICATION SUPPORT SERVICES to be provided during the first year that a student moves from a special education program to a full-time general education program. Service Initiation Date / / / / / / Frequency Duration Ending / / / Date / / /

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PARENT INFORMATION
Students Name: Mothers/Guardians Name: Street: City: Zip: Fathers/Guardians Name: Street: City: Zip: Surrogate Parent Needed Surrogate Parents Name: Street: City: Zip: Telephone: County of Residence: Native Language of Parent/Guardian: Interpreter Needed for Meeting: Yes Telephone: County of Residence: Native Language of Parent/Guardian: Interpreter Needed for Meeting: Yes No No

Date Appointed: Telephone:

Native Language of Surrogate Parent: Interpreter Needed for Meeting: Yes No

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COMMITTEE PARTICIPANTS CSE Subcommittee

Name Professional Title Committee Member Role1

If the parent or another CSE member participated (with parent and school district agreement) through alternative means, indicate the manner in which he or she participated (e.g., video or telephone conference calls).

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SUPPLEMENTAL PAGE FOR ADDITIONAL ANNUAL GOALS

ANNUAL GOAL:

Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule:

ANNUAL GOAL:

Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule:

ANNUAL GOAL:

Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule:

ANNUAL GOAL:

Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule:

*** DUPLICATE AS NECESSARY***

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Confidential Student Information SUPPLEMENTAL PAGE IF INCLUDING SHORT-TERM INSTRUCTIONAL OBJECTIVES AND BENCHMARKS FOR EACH ANNUAL GOAL* * NOTE: FEDERAL AND STATE LAW AND REGULATIONS REQUIRE SHORT-TERM INSTRUCTIONAL OBJECTIVES AND BENCHMARKS IN IEPS ONLY FOR STUDENTS WITH SEVERE DISABILITIES WHO WOULD MEET THE ELIGIBILITY CRITERIA TO TAKE THE NEW YORK STATE ALTERNATE ASSESSMENT AND FOR ALL PRESCHOOL STUDENTS WITH DISABILITIES.
ANNUAL GOAL:

Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule:

INSTRUCTIONAL OBJECTIVES OR BENCHMARKS:

ANNUAL GOAL:

Evaluative Criteria: Procedures to Evaluate Goal: Evaluation Schedule:

INSTRUCTIONAL OBJECTIVES OR BENCHMARKS:

***DUPLICATE AS NECESSARY***

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