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IEP (annotated)

Students name: Amanda Evans

INDIVIDUALIZED EDUCATION PROGRAM (IEP) (ANNOTATED)


********************************************* School Age

Student's Name: Tyler Jones

IEP Team Meeting Date: 5/4/2021

IEP Implementation Date (Projected Date when Services and Programs Will Begin): 5/5/2021

Anticipated Duration of Services and Programs: 1 calendar year (5/5/2021-5/4/2022)

Date of Birth: 3/21/2005

Age: 16

Grade: 10

Anticipated Year of Graduation: 2023

Local Education Agency (LEA): Annville-Cleona High School

Parent/Guardian/Surrogate Name: Jackie and William Jones

County of Residence: Lebanon

Address: 234 S White Oak St., Annville, PA 17003 Phone:(Home): (717)345-9487


(Work): N/A

Other Information: N/A

The LEA and parent have agreed to make the following changes to the IEP without convening an IEP
meeting, as documented by:

Date of Revision Participants/ Roles IEP section(s) amended

IEP TEAM/SIGNATURES

The Individualized Education Program Team makes the decisions about the student’s program and
placement. The student’s parent(s), the student’s special education teacher, and a representative from
the local education agency are required members of this team. Signature on this IEP documents
attendance, not agreement.

Role Printed name signature


Parent/ guardian/ surrogate Jackie Jones Jackie Jones
Parent/ guardian/ surrogate William Jones William Jones
Student* Tyler Jones Tyler Jones
Regular education teacher** Madi Reynolds Madi Reynolds
IEP (annotated)
Students name: Amanda Evans

Special education teacher Amanda Evans Amanda Evans


Local ed agency rep Bettie Bertram Bettie Bertram
Career/tech ed rep***
Community agency rep***
Teacher of the gifted****

* The IEP team must invite the student if transition services are being planned or if the parents choose
to have the student participate.

** If the student is, or may be, participating in the regular education environment

*** As determined by the LEA as needed for transition services

**** A teacher of the gifted is required when writing an IEP for a student with a disability who also is
gifted. One individual listed above must be able to interpret the instructional implications of any
evaluation results.

Written input received from the following members:

Transfer of Rights at Age of Majority

For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches
21 years of age. Likewise, for purposes of the Individuals with Disabilities Education Act, the age of
majority is reached for students with disabilities when they reach 21 years of age.

PROCEDURAL SAFEGUARDS NOTICE

I have received a copy of the Procedural Safeguards Notice during this school year. The school has
informed me whom I may contact if I need more information. The Procedural Safeguards Notice
provides information about your rights, including the process for disagreeing with the IEP.

Signature: Jackie Jones, William Jones

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical
Assistance programs)

I understand that the school may charge the School-Based Access Program (“SBAP”)—or any program
that replaces or supplements the SBAP—the cost of certain special education and related services
described in my child’s IEP. To make these charges to the SBAP, the school will release to the
administrator of that program the name, age, and address of my child, verification of Medicaid eligibility
for my child, a copy of my child’s IEP, a description of the services provided and the times and dates
during which such services were provided to my child, and the identity of the provider of such services. I
understand that such information will not be disclosed, and such charges will not be made, unless I
IEP (annotated)
Students name: Amanda Evans

consent to the disclosure. I acknowledge that I have provided written consent to disclose such
information.

I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw
my consent in writing, or orally if I am unable to write, at any time. My refusal to consent or my
withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my
family, any service or program to which my child is entitled under the Individuals with Disabilities
Education Act (“IDEA”) or that is necessary to enable my child to receive a free appropriate public
education as described in my child’s IEP.

I understand that the school cannot—

Require me or my family to sign up for or enroll in any public benefits or insurance program, such as
Medicaid, as a condition of receiving a free appropriate public education for my child;

Require me or my family to incur any expense for the provision of a free appropriate public education to
my child, including co-payments and deductibles, unless it agrees to pay such expenses on my or my
family’s behalf;

Cause a decrease in available lifetime coverage or any other insured benefit;

Cause me or my family to pay for services that would otherwise be covered by a public benefits or
insurance program and that are required for my child outside the time that he or she is in school;

Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related
expenditures

1. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY
FACTORS CHECKED AS “YES” MUST BE ADDRESSED IN THE IEP.
Is the student blind or visually impaired?
o Yes – The IEP must include a description of the instruction in Braille and the use of
Braille unless the IEP team determines, after an evaluation of the student’s reading and
writing skills, needs, and appropriate reading and writing media (including an evaluation
of the student’s future needs for instruction in Braille or the use of Braille), that
instruction in Braille or the use of Braille is not appropriate for the student.
o No
Is the student deaf or hard of hearing?
o Yes – The IEP must include a communication plan to address the following: language
and communication needs; opportunities for direct communications with peers and
professional personnel in the student’s language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the student’s
language and communication mode; and assistive technology devices and services.
Indicate in which section of the IEP these considerations are addressed. A
Communication Plan is available at: www.pattan.net
o No

Does the student have communication needs?


IEP (annotated)
Students name: Amanda Evans

o Yes – Student needs must be addressed in the IEP (i.e., present levels, specially designed
instruction (SDI), annuals goals, etc.)
o No

Does the student need assistive technology devices and/or services?

o Yes – Student needs must be addressed in the IEP (i.e., present levels, specially designed
instruction, annual goals, etc)
o No

Does the student have limited English proficiency?

o Yes – The IEP team must address the student’s language needs and how those needs
relate to the IEP.
o No

Does the student exhibit behaviors that impede his/her learning or that of others?

o Yes – The IEP team must develop a Positive Behavior Support Plan that is based on a
functional assessment of behavior and that utilizes positive behavior techniques. Results
of the functional assessment of behavior may be listed in the Present Levels section of
the IEP with a clear measurable plan to address the behavior in the Goals and Specially
Designed Instruction sections of the IEP or in the Positive Behavior Support Plan if this is
a separate document that is attached to the IEP. A Positive Behavior Support Plan and a
Functional Behavioral Assessment form are available at www.pattan.net
o No

Other (specify):

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:

§ Present levels of academic achievement (e.g., most recent evaluation of the student, results
of formative assessments, curriculum-based assessments, transition assessments, progress
toward current goals)

Tyler has received services for Specific Learning Disabilities since he was in third grade. His
primary difficulties are in the areas of reading and written expression. Tyler's 9th-grade CSAP
scores are 587 in reading (partially proficient- range of scores are 585-641), 430 in writing
(unsatisfactory- range of scores are 260-435), and 610 in math (proficient- range of scores are
602-651). Tyler also completed the College in Colorado Learn About Yourself Interest Profiler
and Career Cluster Assessment. His highest ranking on the Interest Profiler was realistic: a do-
er who enjoys hands-on activities and prefers concrete problems. Using tools comes naturally.
His second-highest ranking was conventional: organizer who enjoys step-by-step work tasks
and is detail-oriented. His highest Career Cluster score was architecture and construction.
IEP (annotated)
Students name: Amanda Evans

Currently, Tyler's overall reading ability is measured at the 6th-grade level. He scored 660L on
the SRI (Scholastic Reading Inventory) at the end of 9th grade and scored 670L on the SRI in
October of his 10th-grade year. He has particular difficulties with decoding and word
recognition. His fluency is several years below grade level. Surprisingly, his overall reading
comprehension represents the highest achievement he has in the general area of reading.
Also, his oral vocabulary is close to grade level.

Tyler's written expression is even lower than his reading. He writes at around the 4th-grade
level. His handwriting is labored; his spelling is also around the 4th-grade level. He has
difficulty writing a strong paragraph, much less a whole essay. Working on the computer has
alleviated some of his fear of writing as he has learned to depend on spell and grammar
checks, but his overall understanding of the organizational structure, sentence structure, and
semantics is quite limited. Tyler's best efforts at writing, in his general education English
courses, were in the area of poetry where he could use brevity and a strong vocabulary to his
benefit.

Mathematics comes more easily to Tyler. He has passed Algebra I with a C and is currently in
geometry where he is receiving mostly Bs. He does well with computational skills when he is
allowed time to complete the problems. He struggles with word problems and with
completing forms asking for mathematical computation. He likes math and considers it a
strength.

§ Present levels of functional performance (e.g., behavior results from a functional behavior
assessment, results of ecological assessments, progress toward current goals)

Tyler is a student with emotional disorders.  He suffers from anxiety and oppositional defiant
disorder.  His educational team believes they are connected.  He has been known to tell off his
teachers.  He will also get rude with his peers.  

§ Present levels related to current post secondary transition goals if the student's age is 14 or
younger if determined appropriate by the IEP team. (e.g., results of formative assessments,
curriculum-based assessments, progress toward current goals)

For several years, Tyler has worked alongside his father in the summers at construction sites.
He has done everything from hauling trash to being the "gofer" for the workers. Last year, he
spent time in the trailer "office" that was set up at the site. His mother encouraged him to
help her with the books, billing, and other paperwork issues. Tyler dutifully complied but he
really wanted to be out at the site. This next summer, his dad will let him help with pouring
cement and foundation work (as much as OSHA will allow). Tyler is really excited about this
possibility.

Tyler's biggest dream in life is to become a partner with his parents in their business and
eventually take over as the owner of the business. He has even approached his 13-year-old
sister with the idea that they would take it over together. He is enthusiastic about sharing his
dreams with his teachers and friends. There is no job too small at the site that he will not try,
just to get the experience he senses he will need in order to become the business person he
wants to be.
IEP (annotated)
Students name: Amanda Evans

§ Parental concerns for enhancing the education of the student

N/A

§ How the student’s disability affects involvement and progress in the general education
curriculum

N/A

§ Strengths

Math

Bright and engaging

Quick sense of humor

Using tools

Detail-oriented

Organized

Reading comprehension

Strong vocabulary

§ Academic, developmental, and functional needs related to student's disability

Shy

Reading

Written expression

Decoding and word recognition

Handwriting

Spelling

Grammar

III. TRANSITION SERVICES – This is required for students age 14 or younger if determined appropriate by
the IEP team. If the student does not attend the IEP meeting, the school must take other steps to ensure
that the student’s preferences and interests are considered. Transition services are a coordinated set of
activities for a student with a disability that is designed to be within a results oriented process, that is
focused on improving the academic and functional achievement of the student with a disability to
facilitate the student’s movement from school to post school activities, including postsecondary
education, vocational education, integrated employment (including supported employment), continuing
and adult education, adult services, independent living, or community participation that is based on the
individual student’s needs taking into account the student’s strengths, preferences, and interests.
IEP (annotated)
Students name: Amanda Evans

POST SCHOOL GOALS: Based on age appropriate assessment, define and project the appropriate
measurable postsecondary goals that address education and training, employment, and as needed,
independent living. Under each area, list the services/activities and courses of study that support that
goal. Include for each service/activity the location, frequency, projected beginning date, anticipated
duration, and person/agency responsible.

For students in Career and Technology Centers, CIP Code:

Postsecondary Education and Training Goal(s):  Measurable Annual Goal


Work with his father to pour concrete and do foundation work. Yes/No 
(Document in Section V)

Courses of Study: N/A

Service/Activity  Location  Frequency  Projected  Anticipated  Person(s)/ Agency  


Beginning  Duration Responsible
Date

Employment Goal(s):  Measurable Annual


Become a partner with his parents in their business Goal Yes/No 
Eventually take over as owner of the business with his younger (Document in Section V)
sister
He wants to actively work on the construction site
Courses of Study: Construction

Service/Activity  Location  Frequency  Projected  Anticipated  Person(s)/ 


Beginning  Duration Agency  
Date Responsible

Independent Living Goal(s), if appropriate:  Measurable


N/A, if he is working for his parents he will most likely be living with Annual Goal
them as well Yes/No 
(Document in Section
V)
IEP (annotated)
Students name: Amanda Evans

Courses of Study:

Service/Activity  Location  Frequency  Projected  Anticipated  Person(s)/ 


Beginning   Duration Agency  
Date Responsible

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Instructions for IEP Teams:

Please select the appropriate assessment option. Information on available testing accommodations may
be found in the Accommodations Guidelines available on www.education.state.pa.us.

State Assessments

Not Assessed

No state assessment is administered at this student’s grade level.


PSSA (Math available in grades 3-8; Science available in grades 4 and 8; Reading available in grades 3-8;
Writing available in grades 5 and 8; and ELA*)

Tested subject Without With accommodations Accommodations to be


accommodations provided
Math
Science
Reading
Writing
ELA*
*ELA will replace the Reading and Writing PSSAs in 2014-2015 for grades 3-8.

Keystone Exam (Available when student has completed the course/subject; and replaces the PSSA in
high school)

Tested subject Without With accommodations Accommodations to be


accommodations provided
Algebra 1 X
Literature X Audiobook/reader
provided
Biology X

PASA (Available in grades 3-8, and 11 for Reading and Math; Grades 4, 8, and 11 for Science)

Student will participate in the PASA


IEP (annotated)
Students name: Amanda Evans

Explain why the student cannot participate in the PSSA or the Keystone Exam for
Reading/Literature, Math/Algebra 1, Science/Biology, and Composition:

Explain why the PASA is appropriate:

Choose how the student’s performance on the PASA will be documented.

o Videotape (preferred method)


o Written narrative notes (requires prior approval in accordance with PDE
guidance)

Local Assessments

o Local assessment is not administered at this student’s grade level; OR


o Student will participate in local assessments without accommodations; OR
o Student will participate in local assessments with the following
accommodations;
o The student will take a local alternate assessment.

Explain why the student cannot participate in the local regular


assessment:

Explain why the local alternate assessment is appropriate:

V. GOALS AND OBJECTIVES including academic and functional goals: (Use as many copies of this page
as needed to plan appropriately. Specially designed instruction may be listed with each goal/objective or
listed in Section VI.)

Short term learning outcomes are required for students who are gifted. The short term learning
outcomes related to the student’s gifted program may be listed under Goals or Short Term Objectives.

MEASURABLE ANNUAL GOAL  Describe HOW the   Describe WHEN   Report of


Progress
Include: Condition, Name, Behavior, and student’s progress   periodic reports on 
Criteria (Refer to  annotated IEP for progress will be  
toward meeting
description of these components.)
this  goal will be provided to parents
measured

When Tyler is frustrated with his teacher, Tyler’s progress will Parents will be *Attached
he will ask to take a brain break, in 4 out of be monitored with given updates via below*
5 classes during a 4–5-week period. a weekly self- weekly progress
evaluation chart. reports sent home
through email.

By the end of the school year, Tyler will Tyler’s progress will Parents will be *Attached
manage conflicts with peers without being be monitored given bi-weekly below*
rude, independent of teacher support in 4 through teacher updates of
IEP (annotated)
Students name: Amanda Evans

out of 5 observed occurrences over a observations and observations and


three-month period as measured by performance bi- Tyler’s self-
observations and bi-weekly self- weekly self- evaluations
evaluations. evaluations. through email.
IEP (annotated)
Students name: Amanda Evans

SHORT TERM OBJECTIVES - Required for students with disabilities who take alternate assessments
aligned to alternate achievement standards (PASA). 

Short term objectives / Benchmarks

VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM
MODIFICATIONS, include as appropriate for nonacademic and extracurricular services and activities.

A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI) - (Specially


designed instruction may be listed with each goal.)
· SDI may be listed with each goal or as part of the table below
· Include modifications and SDI
· Include supplementary aids and services, as appropriate
· For a student who has a disability and is gifted, SDI also should include adaptations,
accommodations, or modifications to the regular education curriculum, as appropriate for a
student with a disability.
IEP (annotated)
Students name: Amanda Evans

Modifications and SDI Location Frequency Projected beginning Anticipated duration


date

Fidget tools All classrooms When needed. 5/5/21 Yearly


Guided Notes All classrooms When writing 5/5/21 Yearly

B. RELATED SERVICES - List the services that the student needs in order to benefit from or
access his/her special education program.

Service Location Frequency Projected beginning Anticipated duration


date

Counseling Guidance Office Once a week, 45 5/10/21 Annual


minutes
One-on-one ELA work Resource room Three times a week, 5/10/21 Annual
one hour

C. SUPPORTS FOR SCHOOL PERSONNEL - List the staff and supports needed to implement the
student’s IEP

School Personnel to receive Support Location Frequency Projected Anticipated


support beginning date duration

D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS


IDENTIFIED AS A STUDENT WITH A DISABILITY - Support services are required to assist a
gifted student to benefit from gifted education (e.g., psychological services, parent
counseling and education, counseling services, transportation to and from gifted programs
to classrooms in buildings operated by the school district).

Support service
Support service
Support service
E. EXTENDED SCHOOL YEAR (ESY) - The IEP team has considered and discussed ESY services,
and determined that:
o Student IS eligible for ESY based on the following information or data reviewed by
the IEP team:
OR
IEP (annotated)
Students name: Amanda Evans

o As of the date of this IEP, student is NOT eligible for ESY based on the following
information or data reviewed by the IEP team: The Annual Goals and, when
appropriate, Short Term Objectives from this IEP that are to be addressed in the
student’s ESY Program are: If the IEP team has determined ESY is appropriate,
complete the following.

ESY Service to be Location Frequency Projected beginning Anticipated duration


provided date

VII. EDUCATIONAL PLACEMENT

A. QUESTIONS FOR IEP TEAM: The following questions must be reviewed and discussed by the
IEP team prior to providing the explanations regarding participation with students without
disabilities
Explanation of the extent, if any, to which the student will not participate with students
without disabilities in the general education class:

Tyler will be out of the general education classroom once a week for 45 minutes during his
counseling session in the guidance counselor’s office. Tyler will also be out of the general
education classroom three times a week, for one hour each session, while working on ELA
independently with a teacher in a resource room.

Explanation of the extent, if any, to which the student will not participate with students
without disabilities in the education curriculum:

Tyler will not participate in the general education curriculum three times a week, for one
hour each session, while working on ELA independently with a teacher in a resource room.

B. Type of Support

1. Amount of special education supports


o Itinerant: Special education supports and services provided by special education
personnel for 20% or less of the school day
o Supplemental: Special education supports and services provided by special
education personnel for more than 20% of the day but less than 80% of the school
day
o Full-Time: Special education supports and services provided by special education
personnel for 80% or more of the school day
2. Type of special education supports
o Autistic Support
o Blind-Visually Impaired Support
IEP (annotated)
Students name: Amanda Evans

o Deaf and Hard of Hearing Support


o Emotional Support
o Learning Support
o Life Skills Support
o Multiple Disabilities Support
o Physical Support
o Speech and Language Support

C. Location of student’s program


Name of School District where the IEP will be implemented: Annville-Cleona
Name of School Building where the IEP will be implemented: Annville-Cleona High School
Is this school the student’s neighborhood school? (i.e., the school the student would attend
if he/she did not have an IEP)
o Yes
o No. If answer is “no”, select the reason why not:
o Special education supports and services required in the student’s IEP cannot
be provided in the neighborhood school
o Other. Please explain:

VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one
Educational Environment)

To calculate the percentage of time inside the regular classroom, divide the number of hours the
student spends inside the regular classroom by the total number of hours in the school day (including
lunch, recess, study periods). The result is then multiplied by 100.

SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers – Indicate the
Percentage of time INSIDE the regular classroom for this student:

Time spent outside the regular classroom receiving services unrelated to the student’s disability (e.g.,
time receiving ESL services) should be considered time inside the regular classroom. Educational time
spent in age appropriate community-based settings that include individuals with and without disabilities,
such as college campuses or vocational sites, should be counted as time spent inside the regular
classroom.

Total hours the student spends in the regular classroom per day: 6.5 hours

Total hours in a typical school day (including lunch, recess & study periods): 7.5 hours

(Hours inside regular classroom ÷ hours in school day) x 100 = % (Column 1 ÷ Column 2) x 100 = %

Section A: The percentage of time student spends inside the regular classroom: 86% of the day

Using the calculation result – select the appropriate percentage category


IEP (annotated)
Students name: Amanda Evans

o INSIDE the Regular Classroom 80% or More of the Day


o INSIDE the Regular Classroom 79-40% of the Day
o INSIDE the Regular Classroom Less Than 40% of the Day

SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for
more than 50% of the day – select and indicate the Name of School or Facility on the line
corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of
these locations, the IEP team must do the calculation in Section A)

o Approved Private School (Non Residential) _________________________


o Approved Private School (Residential) _________________________
o Other Private Facility (Non Residential) _________________________
o Other Private Facility (Residential) _________________________
o Other Public Facility (Residential) _________________________
o Other Public Facility (Non Residential) _________________________
o Hospital/Homebound _________________________
o Correctional Facility _________________________
o Out of State Facility _________________________
o Instruction Conducted in the Home _________________________

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