SPD 490B IEP Performance Template

Individualized Education Program (IEP) Performance
Template
© 2019. Grand Canyon University. All Rights Reserved.

Table of Contents
Table of Contents......................................................................................................2
Standard 1: Contextual Factors: School and Community Demographics, Classroom
Demographics, Building Trust Relationships, and Classroom Management............3
Standard 2: Individualized Education Plan – Part 1..................................................4
Standard 3: Individualized Education Plan - Part 2.................................................11
Standard 4: Preparation for IEP Meeting................................................................16
Standard 5: Implementation, Communication, and Progress Reporting.................18
Standard 6: Revised IEP..........................................................................................20
Standard 7: Reflection of the IEP Process...............................................................21
© 2019. Grand Canyon University. All Rights Reserved. Page 2 of 23

Standard 1: Contextual Factors: School and Community Demographics,
Classroom Demographics, Building Trust Relationships, and Classroom
Management
The IEP Performance Standards is the process for preparing and implementing the IEP
process. This template will be used to address specific standards and go through the process
of creating an IEP for a student in your placement.
Part I: Community, District, School, and Classroom Factors

Complete this portion of the IPE Template document using the following link:
Standard 1, Part I
After completing the e-doc portion, submit the PDF you receive into the digital classroom.
Part II: Demographic, Environment, and Academic Factors

Complete this portion of the IEP Template document using the following link:
Standard 1, Part II
After completing the e-doc portion, submit the PDF you receive into the digital classroom.
In order to submit this assignment, you must:

1. Complete each section of Standard 1.
Note: Closing your internet browser before the signing process is completed will result in
a loss of your work. If you will be completing this document in multiple sittings, it is
highly recommended to save and back up your work on another document. When you
are ready to make your final submission, copy and paste your responses into this
document. The data from this electronic document will not be saved until you complete
the signing process.
2. Complete the signing process by entering your name, selecting “Click to Sign,” and
entering your email address.
 An initial email will be sent to you to confirm your email address.
 A completed copy of the document will be emailed to you within minutes of
confirming your email address.
3. After completing the e-doc portion, submit the PDF you receive into the digital
classroom.

Standard 2: Individualized Education Plan – Part 1
Base the IEP on the student you are following throughout your student teaching placement.
All identifiable student information should be replaced with pseudonyms for confidentiality. In
addition, some information has been marked "Do not complete"’ due to confidentiality
concerns.
The present level of academic achievement and functional performance (PLAAFP) will guide
the development of the IEP. Teachers must describe student strengths, interests, and needs
within the PLAAFP. Assessment scores and a description of how the student is performing in
relationship to typically developing peers will provide the rationale for the development of
IEP goals, services, testing accommodations, and supplementary aides and services. It is
important that all sections of the IEP align with the PLAAFP.
Special Education Department

Individualized Education Program (IEP)
Student Name: Student Data/Cover Sheet (Form A-1) IEP Meeting Date:
Katie Stone 04/22/23
Demographic Information
Student Number: Student (Pseudo) Birthdate: Gender: Grade:

12898708 Name: 06/07/2008 F 7
Katie Stone
Student Address: Home Phone:

3500 West Camelback Road Do not complete
City, State, Zip:
Phoenix, Arizona 85017
Parent 1 (Pseudo) Name: Parent 1 Relationship:
Kristen Stone Mother
Parent 1 Address: Home Phone:
Do not complete. Do not complete.
City, State, Zip: Work Phone:
Parent 1 Email:
Do not complete.
Parent 2 (Pseudo) Name: Parent 2 Relationship:
Joe Stone Father
Parent 2 Address: Home Phone:
City, State, Zip: Work Phone:
Parent 2 Email:
Do not complete.
Primary Language of Home: Primary Language Survey Date: Language of Instruction:
English Primary Language Survey Results: English

Home District: La Grande Service Coordinator: Kathy Benson
Attendance District: La Grande
Home School: La Grande Middle School Attending School: La Grande Middle School
Vision Screened On: Results: Hearing Screened On: Results:
08/2021 No correction required 11/2021 No hearing issues
Meeting Date: Anticipated Duration of IEP: Re-evaluation Due: 04/07/2024
4/22/2023 From: 3:05pm To: 3:45pm Current Evaluation:
Special Education Primary Category 1: 90-Specific Learning Disability
Special Education Eligibility Category 2:
For Students with SLD only, the following area(s) of eligibility was/were previously determined:
Katie was referred for an eligibility assessment by her 3rd grade teacher at Greenwood Elementary. Data
from progress monitoring, classroom observations and standardized and cognitive assessments determined
that Katie was deficit in the areas of math, reading and writing. Katie demonstrated to be weak in reading
in the areas of basic reading skills, reading comprehension, reading fluency and broad reading. Deficits in
math included calculations, math reasoning, and broad math. Additionally, Katie was deficit in written
language, and basic writing skills.
Level of Services: (A) Specially designed instruction in the general education class 100%. Instruction will be
provided by the general education teacher in consult with the special education teacher.
Type of Meeting: Annual IEP review
Date Meeting Notice Sent to the Date Procedural Safeguards given to the
Parent(s): 03/10/2023 Parent(s): 03/22/2023

This page will not need to be completed because it is a signature page.
Student (Pseudo) Name: Student Data/Cover Sheet (Form A-2) IEP Meeting Date:
Student ID: 12898708 DOB: 06/07/2008
The following persons participated in the conference and/or the development of the IEP. Additionally, parents have
been given a copy of their rights regarding the student’s placement in special education and understand that they
have the right to request a review of their child’s IEP at any time.
Position/Relation to Student Participant Date (MM/DD/YY)
If during the IEP year the student turns 16, if the student is not present at the IEP meeting, the service coordinator
must review the IEP with the student and obtain the student’s signature and the date of this review.

Student (Pseudo) Name: Student Data/Cover Sheet (Form B) IEP Meeting Date:
Student ID:12898708 DOB:06/07/2008
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

(PLAAFP)
Section 1: Current IEP Information
Summarize special education services the student is receiving:

Katie is receiving specially designed instructions in the areas of math, English (reading and
writing) in the general education setting to help her progress in meeting her IEP annual
goals and to advance in the general education curriculum.
Section 2: Evaluation Information
Areas of Eligibility:
Special Education Primary Category: 90- Specific Learning Disability

For students with SLD only, the following area(s) of eligibility was previously determined:
Katie was referred for an eligibility assessment by her 3rd grade teacher at Greenwood Elementary. Data
from progress monitoring, classroom observations and standardized and cognitive assessments
determined that Katie was deficit in the areas of math, reading and writing. Katie demonstrated to be
weak in reading in the areas of basic reading skills, reading comprehension, reading fluency and broad
reading. Deficits in math included calculations, math reasoning, and broad math. Additionally, Katie was
deficit in written language, and basic writing skills.
State and District Assessment Scores:
State:
Statewide Standardized Assessments are given to students in grades 3-8 to measure progress in the areas
of ELA, Math, Science, and Social Studies. Students performance scores range from a level 1 through
level 4. Level 1 being minimally proficient, level 2 as partially proficient, level 3 as proficient, and level
4 as being proficient for grade level. Katie’s most recent scores were taken when she was in the 6 th grade
with the following results:
ELA- Level 2 in reading for information. Level 2 in reading for literature, and Level 1 for reading for
writing. The overall score was a level 2.
Math- Level 1 in ratio and proportional reasoning. Level 1 in the number system. Level 2 in the
expression and equations, and a level 1 in geometry, statistics, and probability. The overall score was a
level 1.

Science-Katie did not have to take this, as it was not offered at this grade level.
District:
The district assessments use iReady for grades K-8. The assessment system only measures the content
areas of math and reading. Students are tested 3 times a year. The assessments are used for leveled
performance standards in the classroom and can be used for placements or progress monitoring. In this
system calculates the difficulty of questions and number of correct responses. The data provides
measurements of the population across the district, as well as comparing and ranking students nationally.
The system offers grade equivalencies to determine if the student is performing at, below or above grade
level. Katie received the following scores in iReady on the date of 09/26/2022.
Reading-percentile rank 23rd. Grade equivalent 1.3. Katie improved 124 points from previous test.
Math- percentile rank 13th. Grade equivalent 1.6. Katie improved 64 points from previous test.
Section 3: Present Level of Academic Achievement and Functional Performance
A. Cognitive (academic performance in content areas, e.g., ELA/Reading/Writing, Math, Science, Social
Studies, Technology and Fine Arts, as applicable)
ELA/Reading/Writing- Katie’s current scores for writing samples indicate that she is at a grade level
ability of 1.6 in written language. Katie struggles with linear structure in her writing and
conventions. Katie’s reading fluency is at the 1.2 grade level and reading comprehension is at the
grade level of 1.4.
Math- Katie’s scores in math calculations indicates that she is at a 1.5 grade level and in math
reasoning and broad math she came in at 1.2 grade level. Katie is struggling with multiplication and
division facts, as well as understanding fractions. Her accuracy in 2-minute drills for multiplication
average about 20%. Katie has difficulty with story problems and finding key information.
B. Physical (gross motor, fine motor, vision, and hearing)

Katie does not exhibit any difficulties in the areas of gross motor, fine motor, vision or hearing.
C. Oral Language and Communication

Katie does not exhibit any communication needs.
D. Social and Emotional Behavior

Katie does not exhibit any social or emotional needs.
E. Adaptive
Katie does not use adaptive technology.
Current Classroom-Based Data:
Family’s Input on Student’s Current Performance:

Katie’s family expressed their concerns at the low turn in rate on assignments and that Katie gets
confused on the directions or instructions for assignments. Her mother also expressed that they are
concerned that she is falling behind in all of her classes and that she will have a hard time catching up.
Both parents are discouraged at any progress and see little growth.
Summary of Work Habits:

Katie has an attendance rate of 98% and has had no referrals for behaviors. Katie uses her planner to try
to stay organized but has difficulty turning in assignments on time or at all. Katie’s teachers explain that
Katie gets easily confused but rarely asks for help.
Section 4: Summary of Educational Needs and General Accommodations

Student (Pseudo) Name: Considerations Form (Form C) IEP Meeting Date:
Student ID 12898708 DOB : 06/07/2008
ADDITIONAL DOCUMENTATION/CONSIDERATION OF SPECIAL FACTORS
Considered
Not Needed Included
Individual Transition Plan ☒ ☐

Statement of Transfer of Parental Rights at Age of Majority ☒ ☐
Statement of Positive Behavior Interventions, Strategies, and Supports ☒ ☐
Considered for a Student Whose Behavior Impedes his or her Learning,
or That of Others
Statement of Language Needs in the Case of a Child with Limited ☒ ☐

English Proficiency
Statement of Provisions of Instruction in Braille and User of Braille for ☒ ☐

a Visually Impaired Child
Statement of the Language of Needs, Opportunities for Direct ☒ ☐

Communication with Peers in the Child’s Language, and
Communication Mode
Statement of Required Assistive Technology Devices and Services ☒ ☐

Statement of Communication Needs for a Child with a Disability ☒ ☐

Student (Pseudo) Name: Accommodations (Form F) IEP Meeting Date:
Student ID: 12898708 DOB: 06/07/2008

ASSESSMENTS
(Rationales for the accommodations that are being chosen specific to assessments.)
Rationale: Katie advocated that she would like to use a separate setting for taking tests. She stated that
she feels less distracted and concentrates better. The team agreed that Katie would also benefit from
using a multiplication chart for computations and text to speech applications to help meet her learning
needs.
State Assessments
Standard Accommodation(s):
ELA- embedded supports, text to speech, separate setting
Math- multiplication chart, embedded supports, text to speech, separate setting.
District Assessments
Standard Accommodation(s):
ELA- embedded supports, text to speech, extended time, separate setting spell checker, graphic organizer.
Math- embedded supports, text to speech, extended time, separate setting, multiplication chart,
calculator, graphic organizers.
CURRENT STATE STANDARDIZED TEST (i.e., AIMS, PSSA) RESULTS
Testing Area Test Results Grade Semester Year

Reading Level 2 1.2 2nd 2022
Writing Level 2 1.3 2nd 2022
Math Level 1 1.0 2nd 2022
Science N/A
LEAST RESTRICTIVE ENVIRONMENT (LRE)

Provide an explanation of the extent, if any, to which the student will NOT participate with non-
disabled students in the general curricular, extracurricular, nonacademic activities, and program

options. §300.347(a) (4): Katie participates in the general education setting 100% and receives
specially designed instruction by the general education teacher. Katie will participate with non-
disabled students in the general education setting as well as any extracurricular activities and
non-academic activities.
Consider any potential harmful effects of this placement for the child or on the quality of
services that he or she needs §300.552 (a-b): Katie’s placement in the general education setting
with supports will help make reasonable progress for her.
Reason for different services at school: Katie’s learning disability may hinder her advancement
to grade level work. As a result, Katie will receive accommodations in the general education
setting. This includes testing in a separate setting, extra time to complete assignments and tests,
multiplication charts to enhance learning, clarifications in directions and assignments, and check
for comprehension. These accommodations will help Katie feel less frustrated in completing
tasks in the general education classroom.
OR, if the above LRE information does not apply to this student, explain why:

Standard 3: Individualized Education Plan - Part 2

Student (Pseudo) Name: Student Goals and Performance Objectives IEP Meeting Date:
Student ID: 12898708 Progress Report DOB: 06/07/2008
Skill Area: Math

Standard: Fluently divide multi-digit numbers (6.NS.2).
Annual Goal: In 12 months, Katie will demonstrate an increase of mathematical skills to grade
level 6 when dividing multi-digit numbers. Given a set of 10 problems, will successfully solve
the equations with 80% accuracy across 3 consecutive trials.
Baseline Level of Mastery: 80%

Service Provider(s) for this goal: General education and special education teachers.
Skill Area: Written Language

Standard: Produce clear and coherent writing in which the development and organization are appropriate
to task, purpose and audience (3.W.4).
Annual Goal: In 12 months Katie will demonstrate an increase in writing skills in the areas of
development and organization, when given a writing sample prompt so that on a minimal of
three grade level writing samples, Katie will score a 75% or better.
Baseline Level of Mastery: 75%

Service Provider(s) for this goal: General education and special education teachers.
Skill Area:
Standard:
Annual Goal:
Baseline Level of Mastery:

Service Provider(s) for this goal:

Skill Area:
Standard:
Annual Goal:
Baseline Level of Mastery:

Service Provider(s) for this goal:

Student (Pseudo) Name: Accommodations (Form E) IEP Meeting Date:
Student ID 12898708 DOB: 06/07/2008

ACCOMODATIONS
Date Given to General Education Teacher: 09/2022 Service Coordinator: Tami Goddard
Accommodations Type Location

Extra time 3 A
Text to speech 3 A
Multiplication chart 3 E, F. I
Calculator 3 E, F, I
Separate setting 3 A
LEGEND FOR TYPE AND LOCATION FIELDS

Type:
1 = Class work/assignments 2 = Assessments/tests 3 = Both class work/assignments/assessments
Location:
A = All Subjects B = Language Arts/English C = Reading D = Spelling E = Math
F = Science G = Social Studies H = Health I = Electives J = Physical Education
K = Lunch L = Transition / Vocation M = Library N = Title 1 O = Special/Exploratory
Family Communication
How will the family be informed of their child’s academic progress and the extent to which that progress
is sufficient to enable the child to achieve annual goals by the end of the year?
Families will be provided in writing, progress reports and other achievements once a month.
IEP Team Consideration for Extended School Year
Consideration for eligibility: Katie is not considered for extended school year. No regression is
demonstrated.
Eligible for ESY: No
Written explanation as to why ESY is or is not needed: The data taken does not support that Katie
experiences significant regression on her IEP goals or objectives.

Student (Pseudo) Name: Services and Environment (Form I) IEP Meeting Date:
Student ID: 12898708 DOB: 06/07/2008
SPECIAL EDUCATION SERVICES TO BE PROVIDED

Special education services necessary to meet special education goals and objectives during the school
calendar year.
The child is in need of specially designed instruction in the following areas:
Special Instructional
Education Setting/ Start Date Frequency Provider Duration/ End
Services Location Date
Math General 03/23/2023 40 minutes Classroom 03/21/2024
Education daily teacher
Written General 03/23/2023 10 minutes Classroom 03/21/2024
Language Education daily teacher
Clarification:
EDUCATIONALLY RELEVANT RELATED SERVICES
Clarification:
EDUCATIONALLY RELEVANT SUPPLEMENTARY AIDS/ASSISTIVE TECHNOLOGY and

SERVICES for STUDENTS
.
Text to General 03/23/203 Daily Classroom 03/21/2024
speech Education teacher
Notes General 03/23/2023 Daily Classroom 03/21/2024
Provided Education teacher
Extended General 03/23/2023 Daily Classroom 03/21/2023
time Education teacher
Clarification:
SUPPORTS FOR SCHOOL PERSONNEL

Consultation All school 03/23/2023 Quarterly LEA 03/21/2024
sites
Clarification:

Standard 4: Preparation for IEP Meeting
The IEP team must cover mandated topics during the IEP meeting. Topics that must be
addressed during the IEP include, but are not limited to, an introduction of team members,
clarifying the type of meeting (initial, review, amendment/addendum to current IEP), the
required components of the IEP, the procedural safeguards, and prior written notice.
IEP Meeting Planning

Required Participants/Roles: List the participants of an IEP meeting and their roles, including
whether or not the student is expected to participate.
Student: Katie will be invited to participate in her IEP, but it is not required.
Parents/Guardians: Parents or guardians offer details and insights on their child’s strengths,
interests and needs. Parents can also share history, cultural expectations and offer suggestions
or communicate concerns.
General Education Teacher: At least one of the students general education teachers must
attend the IEP meeting. The role of the general education teacher is to provide information
about the curriculum taught in the classroom, citing the areas of strengths and needs they see.
General education teachers also offer suggestions on how to modify the curriculum and
instruction to help meet the needs of the student. Additionally, general education teachers
often supplies important data.
Special Education Teacher: Is the main source of knowledge about the student. The role of
the special education teacher is to help to develop the modifications and accommodations for
the student and collect the data for progress in the goals.
Administrator: The role of an administrator in an IEP meeting is to help mitigate any

conflicts and to ensure that resources and services implemented in the IEP will be provided.
Specialists: These can include school nurses, speech services providers, occupational
therapists, physical therapists. These specialists provide expert knowledge in addressing
specific needs.
Required Agenda Outline: In 500-750 words, create an agenda for the IEP meeting. Discuss the
required topics you must address (i.e., introduction of team members, whether or not this is an initial or
review or an annual IEP, discussion of test results, present levels, goals, services, Least Restrictive

Environment (LRE) statement, Extended School Year (ESY) services, procedural safeguards, and prior
written notice.
Plan for Conflicts: Provide a description of ways you can involve parents in the development of
the IEP. Discuss whether you anticipate issues or conflicts that may arise during the meeting and your
plan on addressing those concerns.
Mock IEP Introduction Video

Now that you have outlined the IEP meeting agenda, you are prepared to conduct the meeting. In order
to prepare for running your first official IEP meeting, record yourself as if you were conducting the IEP
meeting. Your video should not exceed 15 minutes in length.
Focus your practice on the meeting introduction. Include the following components within your
recording:
 An introduction of all parties represented and their roles
 Reason for the meeting (initial IEP or IEP review)
 Meeting norms so all parties are heard and respected
 Review of the PLAAFP including the discussion of test results, present levels, goals, services,
Least Restrictive Environment (LRE) statement, Extended School Year (ESY) services,
procedural safeguards, and prior written notice (PWN).
Conclude your video by providing an explanation of how you would actively listen to and address the
needs of families and other stakeholders throughout the meeting.
After recording yourself, review and reflect upon the video below.
Mock IEP Introduction Video Link:

Video Recording Link: If you are submitting your video to OneDrive, note it here.
Reflection: In 250-500 words, reflect on your IEP meeting practice session. In what areas do you
feel you did well? In what areas would you like to have more guidance and coaching before conducting
your first official IEP on your own? What plan of action do you have for more coaching and guidance?

Standard 5: Implementation, Communication, and Progress Reporting
Accountability of Free Appropriate Public Education (FAPE) is mandated by the Individuals with
Disabilities Education Act of 2004 (IDEA). IEP teams must have a plan to document the provision of
services as written in the IEP. Appropriate and accurate data must also be collected to document
quarterly progression toward mastery of IEP goals. Teams must have a plan for on-going data
collection, communication, and presentation of data to the parents/guardians during quarterly
progress reports and annual IEP review meetings.
Accommodations Progress and Communication Plan

Complete the Accommodations Table below, demonstrating how you plan to ensure all
accommodations are being met in the general education setting (if applicable). If the student is not in a
general education classroom, indicate how the student will receive accommodations in content specific
areas based on his or her PLAAFP and IEP goals.
On the Accommodations Table, note the dates when you will obtain progress reports from the general
education teacher or related services staff so that you can gather data on progress (if applicable). If no
general education teachers are reporting, indicate the dates of your (special education teacher)
reporting.
In addition, use the Accommodations Table to gather data on the student’s progress for the first
Quarterly Progress Report.
NOTE: Only two dates are included on the Accommodations Table for the purpose of this assignment.
You may not gather data on both dates in the duration of your placement, but dates should be noted.
Accommodations Table
Goal 1:
Implemented Accommodations: Person(s) Responsible:
Quarterly Progress Report 1 Date:
Data Results:
Data Results:
Goal 2:
Implemented Accommodations: Person(s) Responsible:

Data Results:
Data Results:
Accommodations Summary:
In 100-150 words, summarize information from the Accommodations Table as well as data you have gathered
through teaching and observing the student. Address mastery of goals, progress towards mastery, and overall
service provision.
Communication Plan for General Education Teachers and Related Services Staff:
After completing the accommodations table and summary, in 150-250 words, describe a communication plan that
outlines how you plan to share the student’s progress information with the necessary faculty and staff. Address how
you and your colleagues will continue to monitor progress along the way, prior to receiving the quarterly
progression updates.

Standard 6: Revised IEP
IEP teams are expected to regularly analyze and document students’ progress on their IEP
goals throughout the year. This includes identifying when there are changes affecting the
student and presenting evidence of attempts to meet student needs when there is a lack of
progress. To address times when information, services, or goals need to be changed or added
to an existing IEP, the Individuals with Disabilities Education Act of 2004 (IDEA) describes
the regulations and procedures for changing an IEP using an amendment or addendum. An
amendment is used to change something already in the IEP. An addendum is used to add
something new to the IEP, such as goals, services, or accommodations.
After reflecting on your completed Standard 5 content, create a progress report addendum and/or
amendment (based on changes needed) to be added to the initial IEP, or describe why neither an
addendum nor amendment are not needed.
Data Collection and IEP Modifications

Stakeholders involved in special education must be aware of the student progress monitoring
process, keeping the goal of mastering IEP goals and presenting evidence of attempts to meet
said goals in mind. It is vital to keep a record of new information affecting student needs,
including a lack of progress when an IEP is in effect, using an IEP amendment or addendum.
An amendment is a change to the IEP and an addendum is the addition of goals or services and
accommodations to the IEP.
IEP Modification Need

After monitoring and gathering data, analyze how the student is performing on his or her IEP
goals and with the accommodations. Consider whether there is a need for an addendum and/or
an amendment for the student. If there is a need, in 50-100 words explain this need and the
approach to be taken (an amendment or an addendum). If there is no need at this time, simply
explain how the student is performing and progressing toward their IEP goals.
Family Communication Plan

In 50-100 words, discuss how you plan to communicate the student’s progress on his or her
IEP goals with the parents/guardians. (You may want to discuss this process with your mentor
so you have a method to use for future practice.)

Standard 7: Reflection of the IEP Process
Reflection is an important part of professional practice. Professional special education
teachers plan and frequently reflect on their delivery of services, instruction, data collection
procedures, and individual student progress. Identification of practices that have worked, and
those that have not, can help the special education teacher adjust instruction and services to
better meet the needs of students.
Continued Learning
After completing the Individualized Education Program (IEP) Performance Template, reflect
upon three best practices you have learned from this student teaching experience in 50-150
words.
1.
2.
3.
Improved Practice
Based on your experience of developing and delivering your Individualized Education
Program (IEP) Performance Template, list three implications for your future teaching practices
in 50-150 words. Consider concepts you want to take with you into your own classroom, such
as how you will establish and maintain organization in order to facilitate the IEP process in
your classroom.
1.
2.
3.

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What are the main components of an IEP?

What are the main components of an IEP?

What is the purpose of the PLAAFP?

What is the purpose of the PLAAFP?

Individualized Education Program (IEP) Performance

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© 2019. Grand Canyon University. All Rights Reserved. Page 2 of 23

Part I: Community, District, School, and Classroom Factors

Part II: Demographic, Environment, and Academic Factors

In order to submit this assignment, you must:

© 2019. Grand Canyon University. All Rights Reserved. Page 3 of 23

Special Education Department

Student Number: Student (Pseudo) Birthdate: Gender: Grade:

Student Address: Home Phone:

© 2019. Grand Canyon University. All Rights Reserved. Page 4 of 23

Special Education Eligibility Category 2:

Special Education Eligibility Category 3:

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Student ID: 12898708 DOB: 06/07/2008

Position/Relation to Student Participant Date (MM/DD/YY)

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Student ID:12898708 DOB:06/07/2008

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Section 1: Current IEP Information

Summarize special education services the student is receiving:

Section 2: Evaluation Information

Special Education Primary Category: 90- Specific Learning Disability

State and District Assessment Scores:

© 2019. Grand Canyon University. All Rights Reserved. Page 7 of 23

Section 3: Present Level of Academic Achievement and Functional Performance

B. Physical (gross motor, fine motor, vision, and hearing)

C. Oral Language and Communication

D. Social and Emotional Behavior

Current Classroom-Based Data:

Family’s Input on Student’s Current Performance:

Summary of Work Habits:

© 2019. Grand Canyon University. All Rights Reserved. Page 8 of 23

Section 4: Summary of Educational Needs and General Accommodations

Special Education Department

Student ID 12898708 DOB : 06/07/2008

ADDITIONAL DOCUMENTATION/CONSIDERATION OF SPECIAL FACTORS

Individual Transition Plan ☒ ☐

Statement of Language Needs in the Case of a Child with Limited ☒ ☐

Statement of Provisions of Instruction in Braille and User of Braille for ☒ ☐

Statement of the Language of Needs, Opportunities for Direct ☒ ☐

Statement of Required Assistive Technology Devices and Services ☒ ☐

© 2019. Grand Canyon University. All Rights Reserved. Page 9 of 23

Student ID: 12898708 DOB: 06/07/2008

CURRENT STATE STANDARDIZED TEST (i.e., AIMS, PSSA) RESULTS

Testing Area Test Results Grade Semester Year

LEAST RESTRICTIVE ENVIRONMENT (LRE)

© 2019. Grand Canyon University. All Rights Reserved. Page 10 of 23

© 2019. Grand Canyon University. All Rights Reserved. Page 11 of 23

Special Education Department

Student ID: 12898708 Progress Report DOB: 06/07/2008

Skill Area: Math

Baseline Level of Mastery: 80%

Skill Area: Written Language

Baseline Level of Mastery: 75%

Baseline Level of Mastery: