Education

10

Special Education Department

Individualized Education Program (IEP)

Student Name: Student Data/Cover Sheet (Form A-1) IEP Meeting Date:

Student ID: DOB:

Demographic Information

Student Number:

Student Name:

Birthdate:

Gender:

Grade:

Student Address:

Home Phone:

City, State, Zip:

Parent 1 Name:

Parent 1 Relationship:

Parent 1 Address:

Home Phone:

City, State, Zip:

Work Phone:

Parent 1 Email:

Parent 2 Name:

Parent 2 Relationship:

Parent 2 Address:

Home Phone:

City, State, Zip:

Work Phone:

Parent 2 Email:

Primary Language of Home:

Primary Language Survey Date:

Primary Language Survey Results:

Language of Instruction:

Home District:

Attendance District:

Service Coordinator:

Home School:

Attending School:

Vision Screened On:

Results:

Hearing Screened On:

Results:

Meeting Date:

Anticipated Duration of IEP:

To

Re-evaluation Due:

Current Evaluation:

Special Education Primary Category #1:

Special Education Eligibility Category #2:

Special Education Eligibility Category #3:

For Students with SLD only, the following area(s) of eligibility was/were previously determined:

Level of Services: (A)

Type: of Meeting:

Date Meeting Notice Sent to the Parent(s):

Date Procedural Safeguards given to the Parent(s):

Special Education Department

Individualized Education Program (IEP)

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.

Special Education Department

Individualized Education Program (IEP)

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Section 1: Current IEP Information

Goal Number Written:

Summarize special education services the student is receiving:

Section 2: Evaluation Information

Areas of Eligibility

Special Education Primary Category:

Special Education Eligibility Category #2:

Special Education Eligibility Category #3:

For students with SLD only, the following area(s) of eligibility was previously determined:

Section 3: Present Level of Academic Achievement

READING

WRITING

MATH

Parent’s Input on Student’s Current Academic Achievement:

Current Classroom-Based Data:

State and District Assessments:

Section 4: Functional Performance

Social Emotional and Behavior:

Parent’s Input and Student’s Current Functional Achievement:

Summary of Work Habits:

Section 5: Summary of Educational Needs

Special Education Department

Individualized Education Program (IEP)

ADDITIONAL DOCUMENTATION/CONSIDERATION OF SPECIAL FACTORS

Considered Not Included

Needed

Individual Transition Plan

Statement of Transfer of Parental Rights at Age of Majority

For a student whose behavior impedes his/her learning, or that of

others, positive behavior interventions, strategies, and supports have

been considered.

Statement of Language Needs in the Case of a Child with Limited English

Proficiency

Statement of Provisions of Instruction in Braille & 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

Statement of Health Concerns

Special Education Department

Individualized Education Program (IEP)

Skill Area:

Standard:

Annual Goal:

Baseline Level of Mastery:

Service Provider(s) for this goal:

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:

Skill Area:

Standard:

Annual Goal:

Baseline Level of Mastery:

Service Provider(s) for this goal:

Special Education Department

Individualized Education Program (IEP)

ACCOMODATIONS

Date given to Genera Ed. Teacher: Service Coordinator:

Accommodations do not change now much of the curriculum the student is expected to learn. It only changes how students access and express knowledge on a daily basis. Accommodations are changes in how a student accesses information and demonstrates learning. Accommodations do not substantially change the instructional level, content, or performance criteria. The changes are made in order to provide a student with equal access to learning and equal opportunity to show what he or she knows and can do. Students with disabilities who qualify in one academic area are eligible for accommodations in other areas to the extent that their disability would affect performance in those areas.

Accommodations

Type

Location

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 Ed.

K = Lunch L = Transition / Vocation M = Library N = Title 1 Special / Exploratory

Parental Communication

How will the parent be informed of their child’s academic progress and the extent to which that profess is sufficient to enable the child to achieve annual goals by the end of the year?

IEP Team Consideration for Extended School Year

Consideration for eligibility: IEP team considered ESY eligibility in the areas of regression and recoupment factors and essential skills at a critical stage of development.

Eligible for ESY:

Written explanation as to why ESY is or is not needed:

Special Education Department

Individualized Education Program (IEP)

ASSESSMENT

Rationale: Students with disabilities will participate in usual district assessments unless indicated by this form. Only those accommodations that are provided for instruction and are required by the IEP should be provided for assessment. All students will be assessed at grade level, other than the few who must be provided alternative assessments.

State Assessments

Standard Accommodation(s):

District Assessments

Standard Accommodation(s):

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

Testing Area

Test Results

Grade

Semester

Year

Reading

Writing

Math

Science

Special Education Department

Individualized Education Program (IEP)

SPECIAL EDUCATION SERVICES TO BE PROVIDED

Special Education Program(s) 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 Education Services

Instructional Setting / Location

Start Date

Frequency

Provider

Duration / End Date

RELATED SERVICES

Educationally Relevant Related Services Are Listed Below

Special Education Services

Instructional Setting / Location

Start Date

Frequency

Provider

Duration / End Date

Clarification:

SUPPLEMENTARY AIDS / ASSISTIVE TECHNOLOGY AND SERVICE FOR STUDENTS

Educationally Relevant Supplementary Aides / Assistive Technology and Services Are Listed Below.

SUPPORTS FOR SCHOOL PERSONNEL

Supports For School Personnel Are Listed Below

Clarification:

LEAST RESTRICTIVE ENVIRONMENT

Provide an explanation of the extent, if any, to which the student will NOT participate with non-disabled students in the general curricular, extracurricular and nonacademic activities, and program options. §300.347(a)(4):

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):

Reason for Different Services School:

Rationale

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