INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student’s Name:

INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

Student’s Name: Luke Smith

IEP Team Meeting Date (mm/dd/yy): 2/12/2024
IEP Implementation Date (Projected Date when Services and Programs Will Begin): 2/13/2024
Anticipated Duration of Services and Programs: 2/11/2025
Date of Birth: 4/11/2016
Age: 8
Grade:
Anticipated Year of Graduation: 2034
Local Education Agency (LEA): Pennsbury School District
County of Residence:
Name and Address of Parent/Guardian/Surrogate: Phone (Home): 215-999-0987
Julia Hanes, Jeff Hanes Phone (Work):
123 Smith Drive
Yardley, Pennsylvania
19067-4819
Other Information:

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(s) Participants/Roles IEP Section(s) Amended

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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 Julia Smith
Parent/Guardian/Surrogate Jeff Smith
Student* Luke Smith
Regular Education Teacher** Kimberly Dryzga
Special Education Teacher Meghan Frederick
Local Ed Agency Rep Alida Fitzpatric
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 and other community 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

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

Signature of Parent/Guardian/Surrogate:

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 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.

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I. 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?

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.
x No

Is the student deaf or hard of hearing?

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. The
Communication Plan must be completed and is available at www.pattan.net

x No

Does the student have communication needs?

Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)

x No

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

Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)

x No

Does the student have limited English proficiency?

Yes The IEP team must address the student’s language needs and how those needs relate to the IEP.

x No

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

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)
o Reading
 Luke receives whole group reading instruction in the inclusion classroom using grade level curriculum. Luke also receives small
group reading instruction in the special education classroom (5 days per week, 30-minute sessions) using a supplemental online
program to support his needs in the area of reading. During small group reading lessons, Luke is working on letter/sound
identification, blending and segmenting cvc words, sight word identification, as well as reading comprehension. Luke benefits
from multiple prompts, eliminating choices, and repetition of lessons. Luke’s daily lesson average is 74%. At this time, he
needs a great amount of support in the area of reading, therefore it is recommended that Luke participates in a modified
spelling group to support his emerging skills. In the area of sight words, Luke is currently working on the pre-primer level and is
able to read 8/41 words.
 DRA-2 Level 3 (Instructional
 Below Grade Level – Mid Kindergarten
 Fall Acadience Reading Benchmark – 2nd Level
 Nonsense Word Fluency – Correct Words Read 13 (54 – Target for Beginning of 2 nd Grade)
 Nonsense Word Fluency – Correct Words Read 1 (13 – Target for Beginning of 2 nd Grade)
 Oral Reading Fluency – 2 words correct (52 – Target for Beginning of 2 nd Grade)
 Reading Growth Measure – 2nd Level
 236 – Below Level (Grade Equivalency: 0.6)
o Writing
 Luke participates in the general education curriculum for writing in an inclusion classroom. Writing is a non-preferred task for
Luke as it is difficult for him. During writing instruction, Luke frequently engages in behaviors such as putting his head down,
breaking pencils, scribbling on paper, and verbal disruptions (eg: growling). When Luke does write, his writing is illegible. This
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is a need being addressed in the classroom as well as during OT sessions. At this time, Luke requires intensive supports in the
area of writing. He benefits from sentence starters and fill in the blanks given a topic. When Luke is interested in the topic, he
is willing to brainstorm and come up with ideas 1:1 with a teacher or paraprofessional. It is recommended that Luke continues
to receive small, flex grouping with the special education teacher during writing instruction.
o Math
 Luke participates in the general education curriculum for math in an inclusion classroom. During whole group instruction, Luke
requires frequent redirection in order to focus on the teacher. At times, Luke will refuse to come to the carpet area for whole
group lessons and cries that the work is too challenging. He benefits from sitting by the teacher or paraprofessional so
information can be repeated for understanding as well as quantity adjustments during independent practice. Beginning of the
year math assessments reveal that Luke is performing well below grade level in math. In order to make progress and support
Luke’s behavioral needs, it is recommended that Luke begin receiving math instruction in a small group environment at his
instructional level.
 Math Seeds Placement Assessment
 Level 4 (Kindergarten level)
 Envisions Math Screener
 3 out of 22 points (14%)
 Envisions Assessments
 Topic 1: 8 out of 19 points (Modified)
 Fall Acadience Math Benchmark – 2nd Level
 Computation: 2 points (6 – Target for Beginning of 2nd Grade)
 Concepts and Application Skills: 0 points (14 – Target for Beginning of 2 nd grade)
 Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
o Luke is a new student at Eleanor Roosevelt. He is motivated by short-term breaks and rewards as well as 1:1 attention and positive
praise. Across the school setting, it has been observed that Luke needs to increase compliance (listening to teachers, following
directions) as well as self-control (maintaining a calm body, not breaking objects, or yelling). Currently, Luke uses a Daily Behavior
chart to help increase expected behaviors. Luke has the opportunity to exchange points for rewards two times a day, before recess and
at the end of the day. Luke’s previous behavior goal addressed unexpected behaviors during less structured times of the day such as
recess, lunch, bathroom, and specials. During the first month of school at ER, zero incidents have been reported. Based on this
information, it is recommended that Luke’s behavior goals be adjusted to meet his current needs. In addition, it is recommended that
Luke continue receiving social skills instruction (2x per week, 20 minutes per session).
o Behavior Charts
 First Marking Period:
 Listen and Follow Directions: 74%
 Safe and Calm Body: 82%
o Out of 22 points
 Second Marking Period:
 Listen and Follow Directions: 66%
 Safe and Calm Body: 76%
o Out of 24 points
o Occupational Therapy Summary
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 Luke receives occupational therapy services for 30 sessions per IEP year for 30 minutes per session to address fine and visual
motor skills. Luke also receives OT consultation services for 15 minutes per month to address sensory processing skills within
the classroom. Luke has been seen for 3 sessions so far this school year. He is able to participate in activities within the session
with use of a token reward system, however at times does not appear to need the reward system in OT sessions. The following
are Luke’s goals and progress made towards his goals.
 Goal 1: In order to improve fine motor and visual motor skills, Luke will produce an age-appropriate writing sample (up
to 2 sentences) from a near point source, on lined paper while maintaining 80% in the following handwriting areas:
o -Letter Formation
o -Letter Sizing
o -Baseline Adherence
o -Word Spacing
 Baseline: Letter formation: 75%, Letter Sizing: 65%, Baseline Adherence: 60%, Word Spacing: 75%
 Progress: With consistent verbal/visual prompting for letter sizing, line orientation and spacing between words, Luke is
able to copy a 9-word sentence with 94% legibility, 80% correct letter size, 82% correct line orientation and 100%
correct spacing between words (cues to use finger to space between words). When writing on his own and not copying,
Luke demonstrates difficulty with letter size, letter to line orientation, and use of capitalization. Many of his letters
are large and do not fall on the baseline. When prompted to write smaller and have his letters fall on the line, Luke is
able to comply. When motivated to produce his “best work”, he is able to write with improved legibility. Luke is
currently working on forming his letter (i) with a dot on top versus a circle as well as a period instead of a circle at the
end of sentences.
 Goal 2: In order to improve fine motor coordination, Luke will lace sneakers with minimal assistance in order to increase
independence in self-care tasks.
 Baseline - Moderate assistance with lacing
 Progress: Luke is able to complete the first step of shoe tying which is forming the knot. He is not sure the next steps,
however seems familiar with the process.
 Frequency of 30 sessions per IEP year (30 minute sessions) and OT consult once a month for 15 minutes remains appropriate at
this time.
 Present levels related to current postsecondary 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)
o Not applicable due to Luke’s age
 Parental concerns for enhancing the education of the student
o The Parental Concern form was sent to Luke’s parents on 9/26/23 but was not returned prior to the IEP Meeting. Below include
concerns addressed at the IEP Meeting:
 Mrs. Smith agrees that Luke works better when receiving small group instruction.
 The IEP team feels that the AM/PM rewards and break schedule has helped with compliance.
 Mrs. Smith shared that it is difficult to motivate Luke to do any work at home. Luke’s teachers shared that he seems to prefer
computer activities. Teachers shared how Luke can access these websites via Clever at home.
 How the student’s disability affects involvement and progress in the general education curriculum
o Due to Luke’s primary classification of Other Health Impairment and a secondary classification of Specific Learning Disability, he will
require the implementation of specially designed instruction in order to be successful and make progress in the general education
curriculum.
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 Strengths
o Academic
 Verbal Comprehension
 Working Memory
 Processing Speed
 Expected Listening Comprehension
 Visual Perception (Without a motor component)
o Functional
 Willing to work towards a short-term break or reward
 Academic, developmental, and functional needs related to student’s disability
o Academic
 Basic Reading Skills (Goal)
 Reading Fluency Skills (SDI)
 Reading Comprehension Skills (SDI)
 Written Expression (SDI)
 Math Calculation (Goal)
 Math Problem Solving (Goal)
o Functional
 Attention/Focus (SDI)
 Executive Functioning (SDI)
 Social Skills/Coping Skills (Goal)
 Self-Control/Non-compliance (Goal)

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.

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:

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Postsecondary Education and Training Goal:

Measurable Annual Goal
Yes/No
(Document in Section V)

Courses of Study:

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible

Employment Goal:
Measurable Annual Goal
Yes/No
(Document in Section V)
Courses of Study:

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible

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Independent Living Goal, if appropriate:

Measurable Annual Goal
Yes/No
(Document in Section V)

Courses of Study:

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration 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.pa.gov

State Assessments

Not Assessed
x No statewide assessment is administered at this student’s grade level.
x No English proficiency assessment administered because the student is not an English Learner.

PSSA (Math and English Language Arts (ELA) administered in grades 3-8; Science administered in grades 4 and 8)

Without With
Tested Subject Accommodation Accommodations Accommodations to be Provided
s
Math
Science
ELA

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Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11th grade)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1
Literature
Biology

Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam module.)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1
Literature
Biology

Validated Local Assessment (Available when selected as option by LEA)

Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1
Literature
Biology

PASA (Administered in grades 3-8, 11 for English Language Arts (ELA) and Math; Grades 4, 8, 11 for Science)

Student will participate in the PASA:

The IEP team must review each of Pennsylvania’s 6 eligibility criteria to determine participation in the PASA. The IEP team must answer “YES” to ALL
six criteria in order for the student to participate in the PASA. If the answer is “NO” to any of the questions, the student must participate in the
PSSA/ Keystones with or without accommodations, as determined appropriate by the IEP team.

1. Will the student be in grade 3,4,5,6,7,8, or 11 by September 1st of the school year during which the IEP will be operative?
2. Does the student have significant cognitive disabilities? Pennsylvania defines significant cognitive disabilities as pervasive and global
in nature, affecting student learning in all academic content areas, as well as adaptive behaviors and functional skills across life
domains.
3. Does the student require intensive, direct, and repeated instruction in order to learn and generalize academic, functional, and
adaptive behavior skills across multiple settings?
4. Does the student require extensive adaptations and support in order to perform and/or participate meaningfully and productively in
the everyday life activities of integrated school, home, community, and work environments?
5. Does the student require substantial modifications to the general education curriculum?
6. Does the student’s participation in the general education curriculum differ substantially in form and/or substance from that of most
other students? Students found eligible to take the PASA must have measurable annual goals AND short-term objectives reflected in
the IEP.
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Student will participate in the PASA.

Explain why the student cannot participate in the PSSA or the Keystone Exams, even with accommodations:

Explain why the PASA is appropriate considering the six eligibility criteria:

Explain any specific accommodations the student may require on the PASA (i.e., Assistive Technology, Signing):

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ACCESS for ELs (Administered in grades K-12)

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to
Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking

Alternate ACCESS for ELs (Administered in grades 1-12)

Student will participate in the Alternate ACCESS for ELs.

Explain why the student cannot participate in the ACCESS for ELs:

Explain why the Alternate ACCESS for ELs is appropriate:

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to

Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking

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Local Assessments

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

Student will participate in local assessments without accommodations; OR

x Student will participate in local assessments with the following accommodations; OR

- Small group testing
- Short, frequent breaks to promote attention
- Allow Scripting
- Extended Time
- Test and directions read aloud when permissible

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:

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V. GOALS AND OBJECTIVES – Include, as appropriate, 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 periodic
Include: Condition, Name, Behavior, and Criteria student’s progress toward
reports on progress will be Report of Progress
(Refer to Annotated IEP for description of these meeting this goal will be
provided to parents
components) measured

Given direct instruction in social and coping skills, Daily data collection Monthly
Luke will be able to listen and follow the sheets
teacher’s directions with no more than two
prompts 85% of the time for 4 consecutive weeks.

Baseline: Luke listens and follows the teacher’s

directions 68% of the time given two prompts or
less.
Given direct instruction in social and coping skills, Daily data collection Monthly
Luke will be able to display physical self-control, charts
which is observed as having a safe and calm body,
not breaking items, keeping hands and feet to
self, and not yelling, with no more than two
prompts 90% of the time for four consecutive
weeks.

Baseline: Luke displays physical self-control 75% of

the time when provided 2 prompts or less.
Given a primer level list of sight words, Luke will Biweekly reading probes Quarterly
read the words with at least 85% accuracy on 3
out of 4 biweekly assessments.

Baseline: 20% (8/41) on pre-primer level sight

words.
Given a one minute probe, Luke will be able to Biweekly reading probes Quarterly
state the beginning sound when orally provided
a word for a total of 30 words on 3 out of 4
biweekly probes.

Baseline: Luke is able to state the beginning

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sound for 13 words within one minute

Given CVC nonsense words within one minute, Biweekly reading probes Quarterly
Luke will be able to read 54 correct letter
sounds and 13 correct whole words on 3 out of
4 biweekly probes.

Baseline: Luke is able to read 13 correct letter

sounds and 1 correct whole word in one
minute
Given instruction with first level computation Biweekly math probes Quarterly
problems, Luke will score 17 points (85%
accuracy) on 3 consecutive biweekly data
collections.

Baseline: 3 points on first level computation

problems
When given a one minute probe, Luke will be Biweekly math probes Quarterly
able to extend a counting sequence which
counts by 1s, 5s, or 10s, and orally state which
number is missing from a set of 4 numbers for
a total of 10 numbers 3 out of 4 probes.

Baseline: 6 numbers correct

Luke will improve his visual motor skills in Data collection Quarterly
order to copy 1-2 sentences from near point
reference without verbal or visual cues with
90% legibility, 85% correct letter sizing, correct
orientation to line and 90% correct spacing
between words for 3 consecutive data
collection points.

Baseline: Luke is able to copy a 9 word

sentence with 94% legibility, 80% correct letter
size, 82% correct line orientation and 100%
correct spacing between words (cues to use
finger to space between words). When writing
on his own and not copying, Luke
demonstrates difficulty with letter size, letter to
line orientation, and use of capitalization.
Luke will improve upon his fine motor and self- Data collection Quarterly
care skills in order to demonstrate 3 out of 5
steps to shoe tying with verbal and visual
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prompts in 3 consecutive data collection

points.
1 - make the knot
2 – make first loop
3 – wrap the lace around the loop
4 – push the lace through the opening
5 – take both laces and pull tight

Baseline: Luke is able to complete the first

step of shoe tying which is forming the knot. He
is not sure the next steps, however seems
familiar with the process.

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

Short-term objectives / Benchmarks

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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)

 SDI may be listed with each goal or as part of the table below.
 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 general
education curriculum, as appropriate for a student with a disability.

Modifications and SDI Location Frequency Projected Beginning Date Anticipated Duration
Focus and Attention:
- Provide Luke with clear
and consistent expectations
for activities before he
begins work.
All Classrooms During instructional tasks 2/13/2024 2/11/2024
- Provide preferential
seating (close to the point
of instruction and away
from distractors) to
increase focus.
Focus and Attention:
Provide modeling and
prompting to Luke in order
All Classrooms During instructional tasks 2/13/2024 2/11/2024
to help support him
participate in adult
directed activities.
Assessment
Accommodations:
- Small group testing
- Short, frequent breaks
- Allow Scripting
Special Education
- Extended Time As assessments are given 2/13/2024 2/11/2024
Classroom
- Test and directions read
aloud when permissible.
- Math assessments may be
modified to support student
needs.
Behavior: School environment 5 days per week 2/13/2024 2/11/2024
Utilize a daily behavior
sheet that allows Luke to
earn
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points in exchange for

breaks and rewards. This
sheet
should be sent home each
day and signed.
Social and Coping Skills:
Direct instruction using a
research-based social and Special Education
2 x Week 2/13/2024 2/11/2024
coping skills program two Classroom
times per week for 20
minutes per session.
Behavior:
Allow Luke to take short
walks or breaks in the
special education classroom Regular Education
for no longer than 5 Classroom
Throughout the day 2/13/2024 2/11/2024
minutes. Build breaks into Special Education
Luke's schedule and Classroom
encourage Luke to
request breaks when he is
feeling frustrated.
Positive Behavior Support School Environment All new changes/events 2/13/2024 2/11/2024
Plan: Functional Behavior
Assessment (FBA) and
Positive Behavior Support
Plan
(PBSP) will be monitored on
an on-going basis
throughout
the school year by the
Learning Support,
Emotional Support,
and/or school staff. Based
on data collection and
observations, school
personnel, consultation and
further
observations will occur with
school staff, and if
necessary,
revisions will be made if
new behavior emerges,
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Student’s Name:

current
behaviors increase, new
antecedents or maintaining
consequences are observed,
behavior functions change
or
strategies require revision.
Reading:
Provide direct and explicit
instruction in reading using
a Special Education
5 days per week 2/13/2024 2/11/2024
research-based reading Classroom
program (5 days per week,
30
minute sessions).
Reading: Regular Education
Use of technology based Classroom
60 minutes per week 2/13/2024 2/11/2024
phonics program to address Special Education
Luke's basic reading needs. Classroom
Written Expression:
In order to support Luke's
needs in the area of written
expression, provide small
group support throughout
the
writing process. Utilize
sentence starters, fill in the Regular Education
During writing instruction 2/13/2024 2/11/2024
blanks, as well as scripting Classroom
by an adult during writing
instruction. Modify or
adjust the quantity of
sentences
Luke must write in order to
support academic and
behavioral needs.
Utilize modified classwork
in the regular education
setting to
Regular Education During instructional work
support Luke's reading, 2/13/2024 2/11/2024
Classroom tasks
math, writing, and
behavioral
needs.
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Student’s Name:

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

Service Location Frequency Projected Beginning Date Anticipated Duration

Occupational Therapy 30 sessions per IEP year/30
Eleanor Roosevelt El Sch 2/13/2024 2/11/2024
(group) min

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

School Personnel to Projected Beginning

Support Location Frequency Anticipated Duration
Receive Support Date
Special education
General Education Eleanor Roosevelt El All new
Teacher 2/13/2024 2/11/2024
Teacher Sch changes/events
Consultation
General Education Occupational
Teacher Therapist Eleanor Roosevelt El
1 x Month/15 Min 2/13/2024 2/11/2024
Special Education Consultation Sch
Teacher

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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:

Student IS eligible for ESY based on the following information or data reviewed by the IEP team:

OR

x 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 Provided Location Frequency Projected Beginning Date Anticipated Duration

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Student’s Name:

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.

It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public
or private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal
of students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education
in general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily.

 What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary
aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general
education class.

 What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?

 What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the
class, even with supplementary aids and services?

 To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:
Luke will not participate with students without disabilities in the regular education class when he
receives Small Group Reading, Small Group Math, Modified Spelling and Social Skills instruction in the
special education setting as well as Occupational Therapy as a related service.

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Luke will not participate with students without disabilities in the regular education curriculum when he
receives Small Group Reading, Small Group Math, Modified Spelling and Social Skills instruction as well
as Occupational Therapy. These services are not within the general education curriculum.

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B. Type of Support

1. Amount of special education supports

x Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day

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

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

Autistic Support

Blind-Visually Impaired Support

Deaf and Hard of Hearing Support

Emotional Support

x Learning Support

Life Skills Support

Multiple Disabilities Support

Physical Support

Speech and Language Support

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Student’s Name:

C. Location of student’s program

Name of School District where the IEP will be implemented:

Name of School Building where the IEP will be implemented:

Is this school the student’s neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
x Yes

No. If the answer is “no,” select the reason why not.

Special education supports and services required in the student’s IEP cannot be provided in the neighborhood school

Other. Please explain:

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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.
Calculation for this Student:

Column 1 Column 2 Calculation Indicate Percentage Percentage Category

Total hours the student Total hours in a typical (Hours inside regular Section A: The percentage of
school day classroom ÷ hours in
spends in the regular time student spends inside the
school day) x 100 = %
classroom per day regular classroom: Using the calculation result – select the appropriate percentage
(including lunch, recess category
& study periods) (Column 1 ÷ Column 2)
x 100 = %
5.3 6.5 (5.3 ÷ 6.5) x 100 = ___82__% of the day INSIDE the Regular Classroom 80% or More of the Day

81.5385%

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

EXAMPLES for Section A: How to Calculate PennData–Educational Environment Percentages

Column 1 Column 2 Calculation Indicate Percentage

Total hours the student spends in the Total hours in a typical school (Hours inside regular classroom ÷ hours in school day) Section A: The percentage of time student
day (including lunch, recess & x 100 = % spends inside the regular classroom:
regular classroom per day
study periods)
(Column 1 ÷ Column 2) x 100 = %
Example 1 5.5 6.5 (5.5  6.5) x 100 = 85% 85% of the day
(Inside 80% or More of Day)
Example 2 3 5 (3 5) x 100 = 60% 60% of the day
(Inside 79-40% of Day)
Example 3 1 5 (1 5) x 100 = 20% 20% of the day
(Inside less than 40% of Day)
For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on the website. If you do not have access
to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.

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