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Seton Hill University

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
School Age
 
Student's Name: Cindy W Hines  
IEP Team Meeting Date (mm/dd/yyyy):
IEP Implementation Date (Projected Date when Services and Programs Will Begin):
Anticipated Duration of Services and Programs:

Date of Birth: 11/15/2007  
Age: 10
Grade: K (Full)
Anticipated Year of Graduation: 2025

Local Education Agency (LEA): Seton Hill University  
County of Residence: Luzerne County

Name and Address of Parent/Guardian/Surrogate:
  Mrs. Diana E Hines   Phone (Home): 7125560352   Email (Home): dhines0352@home.iep
1553 Lake Court   Phone (Work): 7125559352   Email (Work):

Leaderton, PA 18123   Phone (Cell):  
 
 
Name and Address of Parent/Guardian/Surrogate:
  Mr. Enrique G Hines   Phone (Home): 7125560352   Email (Home): ehines0352@home.iep
1553 Lake Court   Phone (Work): 7124559352   Email (Work):

Leaderton, PA 18123   Phone (Cell):  
 
 

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    Cindy W Hines , SHU56352

Other Information: Jon Snow
DOB: 09/23/1999
Age: 13
Date Evaluation Completed: 4/8/2013
Date of Evaluation Planning Meeting: 1/24/2013
Grade: 7th
School: ABC Academy
Date of Eligibility Determination: 4/19/2013

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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    Cindy W Hines , SHU56352

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.
Printed Name Role Signature
Enrique Hines Father
Diana Hines Mother
Jimmie J Farmer Regular Education Teacher
Madison Mackewicz School Psychologist
     
     
     

* 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.

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    Cindy W Hines , SHU56352

PROCEDURAL SAFEGUARDS NOTICE

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:    

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    Cindy W Hines , SHU56352

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?
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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
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 Yes
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.
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 No
 
Is the student deaf or hard of hearing?
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The IEP must include a communication plan to address the following: language and communication needs; opportunities for direct communications with peers and
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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
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Does the student have communication needs?
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Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)
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 No
 
Does the student need assistive technology devices and/or services?
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Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)
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Does the student have limited English proficiency?
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The IEP team must address the student’s language needs and how those needs relate to the IEP.
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Does the student exhibit behaviors that impede his/her learning or that of others?
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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
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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
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 No
 
Other Assistive Technology:
(specify): Jon was given Ipad to type the same 4-word sentence as above. He was very familiar with the keyboard and

was able to touch type quickly and with confidence. He then continued and typed 5 sentences in less than 5
minutes using the Word prediction and Ipad application. Mother reports he has been doing long assignments
on his laptop at home and now is training dragon diction.

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    Cindy W Hines , SHU56352

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)
Jon’s most recent grades indicate significant scatter. He is currently passing Spanish, math, science, and introduction to family and consumer
science, but is failing English/language arts and social studies. His grades from first to second gave varied as well – improving in some
classes and falling in others. Information in Jon’s previous IEP from 3rdgrade indicated that he was able to read and perform math activities
on grade level at that time. His IEP provided supporting instruction to improve his skills in reading, writing, and math. The team requested
additional information in this area to assist with educational planning.
Jon was administered the Woodcock-Johnson Tests of Achievement III in the areas of reading fluency, reading
comprehension, math calculation, math reasoning, and written expression by M. Retan, Special Education Teacher across
2 different days. Jon tried his best on all subtests, but did state that math was his least favorite and that he did not like
math. Standard scores ranged from 62-94 (the average range is 90-109). Jon’s reading fluency was his highest score. He
was able to read smoothly and quickly. Reading fluency was in the average range for his age. Passage comprehension
standard score was an 88, which is in the low average range.
Writing fluency subtest standard score was an 84, which fell in the limited range. Observations of Jon’s writing sample
during this subtest were varied. Jon was able to compose simple sentences given three words and a picture fairly easily.
He did not use capitalization or punctuation in most of his sentences. However, he was able to construct simple sentences
at an average rate with minimal effort. Spelling subtest standard score was 79, which fell within the limited range. Jon
tends to spell words just how they sound to him, and did so on the subtest.
Jon reported prior to the testing that math was his least favorite subject and that he did not like to do math, especially
without a calculator. Jon achieved a standard score of 62 on the subtest for math calculation, and a 75 subtest score for
applied problems. He was unable to subtract with re-grouping or multiply other than a basic multiplication fact. He did
not attempt to divide and stated that he did not know how to divide. He was unable to complete any fraction problems
either. His standard score for math calculation fell in the very limited range based on age level norms. During the applied
reasoning subtest, Jon did not use paper or pencil or any apparent strategy to solve the problems. He reported that he did
them in his head, and once he was unable to do that, he simply said he did not know. His score for math reasoning again
fell in the very limited range based on age level norms.
• Present levels of functional performance  (e.g., results from a functional behavioral assessment, results of ecological assessments, progress toward current goals)

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    Cindy W Hines , SHU56352

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE (Continued)

• Present levels of functional performance  (e.g., results from a functional behavioral assessment, results of ecological assessments, progress toward current goals)
Jon’s functional behavior was assessed using a variety of methods including direct observations across times and
settings; information from parents, teachers and Jon himself via rating scales and interviews; review of behavioral data
including referral reasons, times, and details and anecdotal data.
The following information was obtained from observations that were conducted across small and large group and one-on
-one sessions and instructional, transition, and evaluative sessions:
Jon was observed with other seventh grade students during transition in the hallway. Jon came out of his classroom very
hurriedly, bumping into a student and continued to the locker area. He did not go to his locker, but stood in the hallway,
as if waiting for something. He did not talk with other students, including his brother. He ignored his brother when he
was spoken to during this time.
Jon did not respond to the teachers in the hallway when asked to move on into class, rather he appeared not to hear them
and then walked slowly into the classroom after other students had cleared the hall. Upon entering the room, Jon sat at
the side of the door, near the back, away from many students. There was no interaction between Jon and the other
students. He was interested in his notebook and did not seem to notice that class was beginning. He got up and came to
the doorway for a brief moment, as if he were looking for someone and then returned to his seat. There was a substitute
in the classroom and he did answer when the roll was called. He did not engage in any other conversation that he
observer noticed. Additionally, he did not begin the work, rather after he was given the assignment; he got up and left the
room.
The observer followed him and observed him going to the STOP room. He went inside and said he needed to work in
that room. He said there was a substitute and he couldn’t stay there, referring to the other classroom. After realizing the
observer was “watching” him, he mumbled to himself. The observer concluded the observation.
Jon was observed during a PE class as well. He entered the gym with other 7thgrade students. He walked around while others were entering.
As the class began, Jon took part in the warm up activity. He did not talk to other students and tended to separate himself from the group. Jon
participated and responded appropriately when called on by the coach to do his part of the strength training. He completed the activities and
then walked along the stage for the remaining 10 minutes.

During an observation in the large group language arts setting, Ms. Calvo, the teacher, was using literacy circles (peer groups) to promote
student discussion. Students were called on to report their interpretations of what had been read. Jon was observed to be without a pencil and
had to get a pencil from Ms. Calvo. Within 5 minutes, he asked for another pencil. Jon dropped that pencil on the floor and did not attempt to
pick it up. When novels for reading were passed out, Jon placed his novel under his desk and put his head down. Ms. Calvo
walked over to try and engage Jon in the lesson. She spoke quietly to him, but Jon did not respond to the directions. He
then attempted to engage another student in conversation, but was ignored by the student. The teacher attempted to
redirect Jon again to begin reading, but Jon put his head down once more. He kept his head down for another 25 minutes.
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    Cindy W Hines , SHU56352

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE (Continued)

• Present levels of functional performance  (e.g., results from a functional behavioral assessment, results of ecological assessments, progress toward current goals)
Jon was observed again during language arts and science and his off-task behaviors were tallied and compared to a
“typical” student in each class. Over 2 thirty-minute observations, Jon was observed to be on-task significantly more than
the comparison student (Jon was off-task only2-3 times in 30 minutes whereas the comparison student was off-task 12-
16 times during the same time period).
Jon was seen on March 22 and 25, 2013 for a language evaluation. He was inquisitive as to the nature of the testing and
rapport was not easily established. He complained about the length of the testing and continually asked when he could
leave. He also expressed at times that the tasks were too hard or that he was tired. The second day of testing was difficult
as he refused to cooperate several times finally resulting in his mother removing him from to the room to address the
issue. He returned and resumed testing, but did not put forth much effort.
Jon was very calm during the OT evaluation and participated fully. Initially, he had his head on the table but quickly became engaged in
conversation and the assessment. Jon’s visual motor skills are higher than his chronological age. He also scored well overall on the Print Tool
assessment but has some weak areas when writing. Writing is laborious for him due to his hyper flexibility in his finger joints and his need
for proprioceptive input. Jon was very fidgety during the writing portion of the assessment. He changed postures and positions in his chair
frequently. He did extremely well on the assistive technology portion and was continuing with the device until he had to leave

• 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)
Speech and Language:
Each subtest standard score has a mean of 100 and a standard deviation of 15. Jon’s overall language score is 1.5
standard deviations below the mean. His receptive and expressive language scores fell in the same range, while his
language memory score was 2.5 standard deviations below the mean.

• Parental concerns for enhancing the education of the student
Jon was referredfor evaluation by his mother and teachersdue to concerns about how his emotions and behaviorsare impacting his ability to
access and progress in the general curriculum. Jon has difficulty controlling his anger; he often reacts impulsively when he is frustratedor
when he perceives he is being challenged. He will react both verbally and physically. Ms. Stark, Jon’s adoptive mother, provided information
concerning Jon’s background to the school when he enrolled in August. This is an expedited evaluation due to a disciplinary incident that led
to a recommendation for expulsion.

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    Cindy W Hines , SHU56352

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE (Continued)

• Parental concerns for enhancing the education of the student
A review of available information showed that Jon attended the preschool HeadStart program in Winterfell and then attended public school
in Winterfell. He had an IEP as early as 1stgradeand received services under the category of Other Health Impairmentdue to the adverse
effect of his Attention Deficit Hyperactivity Disorder (ADHD) on his ability to access and progress in the general curriculum. At the time of
the initial evaluation, he also had been diagnosed as having Depressive Disorder, a mixed receptive-expressive language disorder,a
developmental coordination disorder,and other developmental delays. Jon was reevaluated in 2ndgrade so that the team could gather
additional data in the area of need for assistive technology.
In 3rdgrade, Jon’s IEP addressed weaknesses in reading, writing, math, articulation, and functional behavior. Supplemental services included
OT consult and a behavior intervention plan. Ms. Snow homeschooledJon toward the end of this time. In January 2010, Jon was placed at
King’s Place, a residential treatment facilitythat provides intensive intermediate and long-term careto children and adolescents who have
psychiatric and behavioral health disorders. Diagnoses at the time of placement included ADHD, Mood Disorder, Oppositional Defiant
Disorder, Posttraumatic Stress Disorder, and Reactive Attachment Disorder. Jon was placed in order to have services that would address his
emotional/behavioral issues that were impacting him in his home and community settings. Jon was dismissed from King’s Place sometime
during the 2010-11 school year. He was then homeschooled for the 2011-12 school year and enrolled at ABCA in August of 2012 as a
7thgrader.

• How the student's disability affects involvement and progress in the general education curriculum
(an analysis of the educational relevance of the evaluation results, strengths and weaknesses, and a description of the adverse educational
impact, including how the disability affects involvement and progress in the general education curriculum (or for preschool children, in
appropriate activities)): Jon appears to have most of the basic academic skills needed to be successful in the general education setting. He is
able to complete many tasks that he is interested in and willing to attempt. Jon’s oppositional behaviors (related to his diagnoses of Episodic
Mood Disorder, Impulse Control Disorder, Antisocial Personality Disorder, and ADHD)often impact his daily performance, yielding very
inconsistent and misleading grades and outcomes. These oppositional behaviors, coupled with Jon’s difficulties with other functional
behavior such as organizational skills, auditory short-term memory, sequencing, and planning, significantly impact his ability to access and
progress in the general curriculum consistently because his disruptive, defiant, noncompliant, and sometimes aggressive behaviors often lead
to stopping of instruction and/or Jon’s removal from the classroom setting (by his own accord or at the direction of the teacher or
administrator). These behaviors also interfere with his ability to establish and maintain appropriate relationships with peers and adults. At
times his behaviors interfere with the ability of others to access instruction. Jon also displays some weak areas when writing. Writing is
laborious for him due to his hyper flexibility in his finger joints and his need for proprioceptive input. Jon responded extremely well on the
assistive technology portion of the assessment.

•Strengths
Fine Motor Skills
Visual Motor
Handwriting

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    Cindy W Hines , SHU56352

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE (Continued)

•Strengths
Jon in interested in various rock formations and money from other countries. He currently has a collection of each of these items. He has
expressed interest in animals. Jon helps at home with laying hens, honey bees, and he also has a puppy that he helps with. He enjoys animals
and a career working with them is of interest to him. Jon is not sure what he will do after high school at this time.

• Academic, developmental, and functional needs related to student's disability
Academic:
Currently Jon is passing science with a 78 average and PE with a 97 average. He is failing social studies, math, and English/language arts.
His behavior is significant impacting his classroom performance and achievement. Ms. Calvo reported that when Jon took the recent
Measures of Academic Progress (MAP) test, she had given directions to the class to carefully read questions before clicking answers on the
computer. Jon immediately began to click answers indiscriminately. His score, of course, was lower than his fall score on the same measure.
This is typical of how Jon’s behavior often impacts his classroom performance.

Developmental:
Ms. Stark provided information about Jon’s birth, early development, medical, and family history. Jon and his twin were born prematurely,
with low birth weight, and positive for crack/cocaine. There was also prenatal exposure to alcohol and drugs. Jon also has a history of
physical abuse and neglect by his birth mother and sexual abuse while in foster care.
Jon and his brother were adopted by the Starks when they were 5 years old. Ms. Stark has little information about Jon’s infancy other than
knowing that he was severely delayed in all areas when he was adopted at age 5. He had an appendectomy at age 8; he developed an
infection and had to be readmitted to the hospital for treatment. Jon has environmental allergies that are treated with Zyrtec. He has also been
diagnosed with Episodic Mood Disorder, Impulse Control Disorder, Antisocial Personality Disorder, and ADHD. He takes Vyvanse, Zoloft,
Risperdal, and Depakote to help control the symptoms of these disorders.
Jon lives with his parents, twin brother, and older sister. Jon enjoys sports such as basketball, soccer, and swimming. He also enjoys playing
video games, reading, and watching movies. Ms. Stark described Jon as being kind, solicitous, charming, and determined when there is
something he wants. He works well towards goals he wants to achieve or on projects in which he is interested. Jon can become very
belligerent and disrespectful at times. He may threaten or hit others. Ms. Stark report that Jon typically requires disciplining 3 to 5 times daily
for anything from disrespect to lying to destroying someone else’s property. Discipline techniques used at home include loss of privileges,
assignment of additional chores, and removing Jon from the situation.

Functional:
Jon’s functional behavior was assessed using a variety of methods including direct observations across times and
settings; information from parents, teachers and Jon himself via rating scales and interviews; review of behavioral data
including referral reasons, times, and details and anecdotal data.

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    Cindy W Hines , SHU56352

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:  

Postsecondary Education and Training Goal: After graduating from high school, Jon will attend Measurable Annual Goal
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Kutztown University in Berks County, Pennsylvania to pursue a career in Management.  Yes /   No


(Document in Section V)
Courses of Study: Jon will take a sport management course in order to prepare himself for his long term goal after college of becoming the GA
for Kutztown or a basketball coach at another college.
Service/Activity Location Frequency Projected Anticipated Person(s)/Agency
Beginning Date Duration Responsible
           
           

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    Cindy W Hines , SHU56352

III. TRANSITION SERVICES (Continued)

Employment Goal: While attending Kutztown University, Jon will qualify for a work study position. Measurable Annual Goal
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He will work 15 plus hours a week. He will work all of the sporting events, especially Women's  Yes /   No


(Document in Section V)
basketball.
Courses of Study:
Jon will work all of the Women's basketball games that fit into his schedule. He will have to write a blog for his sports
management class comparing and contrasting men’s basketball versus women's basketball.
Service/Activity Location Frequency Projected Anticipated Person(s)/Agency
Beginning Date Duration Responsible
           
           
Employment Goal: After graduating high school, Jon will work at youth basketball camps all Measurable Annual Goal
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summer. Coaching, training, and helping. He will be prompting himself for when he is a coach  Yes /   No


(Document in Section V)
and also for himself and his basketball skills.
Courses of Study: Jon will practice coaching this summer and helping the youth to prompt himself for his future goal.
Service/Activity Location Frequency Projected Anticipated Person(s)/Agency
Beginning Date Duration Responsible
           
           

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    Cindy W Hines , SHU56352

III. TRANSITION SERVICES (Continued)

Independent Living Goal, if appropriate: While attending college, Jon plans to live in the dorms for the Measurable Annual Goal
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first year with one of his teammates then move off campus into the basketball house.  Yes /   No


(Document in Section V)
Courses of Study: Jon will make friends on the basketball team who can help mentor him through his first year of college. (Big brother
system)
Service/Activity Location Frequency Projected Anticipated Person(s)/Agency
Beginning Date Duration Responsible
           
           
Independent Living Goal, if appropriate: Community: Measurable Annual Goal
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 Yes /   No
(Document in Section V)
Jon will complete 15 hours of community services hours the summer before he goes to
Kutztown University to demonstrate the humbleness of helping others. The basketball team
at Kutztown does local community services all year round.
Courses of Study: Jon will go to the local soup kitchen and he will go to the local library to read to the youth because of how much he enjoys
reading. He wants to spread his knowledge to the younger children because he never had these experiences when he was younger.
Service/Activity Location Frequency Projected Anticipated Person(s)/Agency
Beginning Date Duration Responsible
           
           

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    Cindy W Hines , SHU56352

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
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No statewide assessment is administered at this student’s grade level
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No English proficiency assessment administered because the student is not an English Language Learner.
End of
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.

PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5 and 8; and ELA*)
Tested Subject Without With Accommodations to be Provided
Accommodations Accommodations
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description
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End of

Reading End of image

Extended time
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.
.

Keyboard, word processor, or computer
One-on-one setting
Read Aloud Directions  
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Math End of image

Calculator
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Electronic screen reader
Extended time
Interpret/translate
Keyboard, word processor, or computer
One-on-one setting  
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description
. not
checked . checked
End of

Science End of image

Extended time
image description
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One-on-one setting
Interpret/translate  
Image
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description
. not
checked . checked
End of

Writing End of image

Enlarged Print
image
description description
.
.

Extended time
Interpret/translate
One-on-one setting
Read Aloud Directions  
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ELA* End of End of

 
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*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

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IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS (Continued)

Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11th grade)
Tested Subject Without With Accommodations to be Provided
Accommodations Accommodations
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description Image
description
. not
checked . checked
End of

Algebra I End of image

Calculator
image
description description
.
.

Electronic screen reader
Extended time
Interpret/translate
One-on-one setting
Read Aloud Directions  
Image
description Image
description
. not
checked . checked
End of

Literature
End of image

Extended time
image
description description
.
.

Interpret/translate
One-on-one setting
Read Aloud Directions  
Image
description Image
description
. not
checked . checked
End of

Biology End of image

Interpret/translate
image
description description
.
.

One-on-one setting
Read Aloud Directions
Extended time  

Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam module.)
Tested Subject Without With Accommodations to be Provided
Accommodations Accommodations
Image Image
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not
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Endchecked
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Algebra I End of image

Calculator
image description
.description .

Extended time
Interpret/translate
One-on-one setting  
Image
description Image
description
. not
checked . checked
End of

Literature End of image

Extended time
image
description description
.
.

Electronic screen reader
Interpret/translate
One-on-one setting
Read Aloud Directions  
Image
description Image
description
. not
checked . checked
End of

Biology End of image

Frequent time
image
description description
.
.

One-on-one setting
Read Aloud Directions  

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    Cindy W Hines , SHU56352

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS (Continued)

Validated Local Assessment (Available when selected as option by LEA)
Tested Subject Without With Accommodations to be Provided
Accommodations Accommodations
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Algebra I End of End of

 
image
description image
description
. .

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description Image
description
. not
checked . not
checked

Literature
End of End of

 
image
description image
description
. .

Image Image
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Biology
End of End of

 
image image
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PASA (Administered in grades 3-8, 11 for Reading and Math; Grades 4, 8, 11 for Science)
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Student will participate in the PASA.
End of
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Explain why the student cannot participate in the PSSA or the Keystone Exam for Reading/Literature, Math/Algebra 1, Science/Biology, and Composition  (The Composition exam will be
available for the 2016-17 school year):

Explain why the PASA is appropriate:

Choose how the student's performance on the PASA will be documented.
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 Videotape (preferred method)
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 Written narrative notes (requires prior approval in accordance with PDE guidance)

ACCESS for ELLs (Administered in grades K-12)
Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to Participate in Selected Domains
Accommodations Accommodations Participate
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not
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Listening image End of End of

 
description
. image image
.description .description

Image
description Image
description Image
description
. not
checked . checked
End of . not
checked

Reading End of image End of

One-on-one setting
image
description description
. image
description
. .

Extended time  
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description Image
description
. not
checked . checked
End of . not
checked

Writing
End of image End of

Extended time
image
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. image
description
. .

One-on-one setting  
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. checked
End of . not
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checked

Speaking image End of End of

 
description
. image
description image
description
. .

May 2014   Page 16 of 30
    Cindy W Hines , SHU56352

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS (Continued)

Alternate ACCESS for ELLs (Administered in grades 1-12)
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Student will participate in the Alternate ACCESS for ELLs.
End of
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Explain why the student cannot participate in the ACCESS for ELLs:

Explain why the Alternate ACCESS for ELLs is appropriate:

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


Accommodations Accommodations Participate
Image
description Image
description Image
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. not
checked . not
checked . not
checked

Listening End of End of End of

 
image
description image
description image
description
. . .

Image
description Image
description Image
description
. not
checked . not
checked . not
checked

Reading
End of End of End of

 
image
description image
description image
description
. . .

Image
description Image
description Image
description
. not
checked . not
checked . not
checked

Writing
End of End of End of

 
image image image
.description .description .description

Image
description Image
description Image
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. not
checked . not
checked . not
checked

Speaking End of End of End of

 
image
description image
description image
description
. . .

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IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS (Continued)

Local Assessments
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Local assessment is not administered at this student's grade level; OR
End of
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.

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Student will participate in local assessments without accommodations; OR
End of
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End of

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

  Jon has difficulty controlling his anger; he often reacts impulsively when he is frustrated or when he perceives he is being challenged. He will
react both verbally and physically.

Diagnoses at the time of placement included ADHD, Mood Disorder, Oppositional Defiant Disorder, Posttraumatic Stress Disorder, and
Reactive Attachment Disorder.
ADHD, Depression Disorder, a mixed receptive-expressive language disorder, a developmental coordination disorder, and other developmental
delays.

Weakness in reading, writing, math, articulation, and functional behavior.
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The student will take an alternate local assessment.
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  Explain why the student cannot participate in the regular assessment:

Explain why the alternate assessment is appropriate:

May 2014   Page 18 of 30
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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 reports on progress will be
(Refer to Annotated IEP for description of these components) toward provided to parents
meeting this goal
will be measured
While completing a three paragraph essays using a topic sentence, a list of collective of At the end of a four week period date on earned
three examples from the story, and a summary that predicts a conclusions three essays accomplishments of Jon's essays along with
Jon Snow will write in essay format three times during the week with five each week. samples essays that will be provided in a data
or less grammatical errors.  scatter plot.

Report of Progress

Goal Specific SDI

SHORT TERM OBJECTIVES - Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
Short term objectives / Benchmarks Level of Achievement Method of Evaluation Report of Progress
       
       

May 2014   Page 19 of 30
    Cindy W Hines , SHU56352

V. GOALS AND OBJECTIVES (Continued)

MEASURABLE ANNUAL GOAL Describe HOW the Describe WHEN periodic


Include: Condition, Name, Behavior, and Criteria student's progress toward reports on progress will be
(Refer to Annotated IEP for description of these components) meeting this goal will be measured provided to parents
When in the classroom and Jon feels frustrated or challenged he will Jon will have a sticker chart that At the end of each week Jon will
learn three different ways to communicate verbally when anger so he allows him to add stickers each time have to go back to his sticker
does not get verbally or physically aggressive towards anyways. Jon he is able to control his anger when chart to see if he earned 5/5 each
will need to earn 5 stickers a day for his sticker chart. He will need to feeling frustrated. Jon will need to day to be able to get the reward at
earn 25 stickers at the end of the week to be able to receive a reward.  earn 5/5 stickers each day.  the end of the week.

Rewards will vary based on his
likes, interests, and mood for that
week.

Report of Progress

Goal Specific SDI

SHORT TERM OBJECTIVES - Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
Short term objectives / Benchmarks Level of Achievement Method of Evaluation Report of Progress
       
       

May 2014   Page 20 of 30
    Cindy W Hines , SHU56352

V. GOALS AND OBJECTIVES (Continued)

MEASURABLE ANNUAL GOAL Describe HOW the Describe WHEN periodic


Include: Condition, Name, Behavior, and student's progress toward reports on progress will be
Criteria meeting this goal will be measured provided to parents
(Refer to Annotated IEP for description of these
components)
Jon will be able to keep his hands and feet Jon will maintain positive behavior At the end of each day Jon will be reviewed on a scale of 1-
to himself, raise his hand 5/5 times, and while waiting to be called on in the 5, 1 being horrible and a 5 being excellent. At the end of the
wait to be called on before speaking while classroom at 100% accuracy and will week we will report back to him to see what score he
the teacher is giving instructions / during a not get frustrated when doing so. If reached each day. If there was a particular day he received a
lesson with 100% accuracy.  frustrated he can get out his fidget 1 or 2 I will sit down and think what the topic was and see if
spinner or his stress ball.  there was another way I could help him. 

Report of Progress

Goal Specific SDI

SHORT TERM OBJECTIVES - Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
Short term objectives / Benchmarks Level of Achievement Method of Evaluation Report of Progress
       
       

May 2014   Page 21 of 30
    Cindy W Hines , SHU56352

V. GOALS AND OBJECTIVES (Continued)

MEASURABLE ANNUAL GOAL Describe HOW the Describe WHEN periodic


Include: Condition, Name, Behavior, and Criteria student's progress toward reports on progress will be
(Refer to Annotated IEP for description of these components) meeting this goal will be provided to parents
measured
While we are practicing our spelling and numbers Jon will have Having practice pages At the end of each week we will together go through
100% accuracy with capital letters, lower case letter, and once each day to see if Monday- Friday's practice pages to see improvement.
numbers. He will have a spacer so that he does not space the he has improved as the If he has improved we will reward him. If not we will
words or letter to close to each other. The size of his letters and week goes on.  fix something so that he will improve the following
numbers will be 90% all correct. week. 

Report of Progress

Goal Specific SDI

SHORT TERM OBJECTIVES - Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
Short term objectives / Benchmarks Level of Achievement Method of Evaluation Report of Progress
       
       

May 2014   Page 22 of 30
    Cindy W Hines , SHU56352

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

May 2014   Page 23 of 30
    Cindy W Hines , SHU56352

VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS (Continued)

Modifications and SDI Location Frequency Projected Beginning Date Anticipated Duration
(determined through the     9/8/2018 9/7/2019
evaluation process and
from parental input,
including any
r e c o m m e n d e d
supplementary aids and
services for the child
and program
modifications or
supports for school
personnel, if needed):
The team needs to plan
for use of assistive
technology to
compensate for his
weak fine motor skills.
Positive behavior
supports should be used
to teach and reinforce
appropriate functional
behaviors in the
classroom and school
settings and to decrease
Jon’s inappropriate,
disruptive behaviors.

May 2014   Page 24 of 30
    Cindy W Hines , SHU56352

VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS (Continued)

Modifications and SDI Location Frequency Projected Beginning Date Anticipated Duration
(recommendations to     9/8/2018 9/7/2019
the IEP team to assist in
the development of the
IEP’s present levels of
performance and
annual goals. Specify
the areas in which the
child requires specially
designed instruction
(i.e. math, gross motor,
social skills, etc.)):
Specially designed
instruction is required in
the areas of social skills,
work completion, and
organizational skills.

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


Assistive Technology   3 time(s) per Day for 12 9/8/2018 9/7/2019
Devices and Services minutes/session
Occupational Therapy     9/8/2018 9/7/2019
Physical Therapy     9/8/2018 9/7/2019
Counseling Services     9/8/2018 9/7/2019
Audiological Services     9/8/2018 9/7/2019
Interpreter     9/8/2018 9/7/2019

May 2014   Page 25 of 30
    Cindy W Hines , SHU56352

VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS (Continued)

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 Support Location Frequency Projected Beginning Date Anticipated Duration
Receive Support
           
           
           

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:
Image
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Student IS eligible for ESY based on the following information or data reviewed by the IEP team:
End of
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OR
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Endchecked
of

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:
image
description
.

The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the student's ESY Program are:

May 2014   Page 26 of 30
    Cindy W Hines , SHU56352

VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS (Continued)

If the IEP team has determined ESY is appropriate, complete the following:
ESY Service to be Provided Location Frequency Projected Beginning Date Anticipated Duration
         
         
         

May 2014   Page 27 of 30
    Cindy W Hines , SHU56352

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?
  The team needs to plan for use of assistive technology to compensate for his weak fine motor skills. Positive behavior supports should be
used to teach and reinforce appropriate functional behaviors in the classroom and school settings and to decrease Jon’s inappropriate,
disruptive behaviors.
• 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:
 
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
 

May 2014   Page 28 of 30
    Cindy W Hines , SHU56352

VII. EDUCATIONAL PLACEMENT (Continued)

B. Type of Support
1. Amount of special education supports
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Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day
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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
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Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day
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2. Type of special education supports
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 Autistic Support
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 Gifted Support
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 Multiple Disabilities Support
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 Blind or Visually Impaired Support
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 Learning Support
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 Physical Support
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 Deaf or Hearing Impaired Support  Life Skills Support  Speech and Language Support


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 Emotional Support

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)?
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 Yes
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 No
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Special education supports and services required in the student's IEP cannot be provided in the neighborhood school
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Other. Please explain:
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May 2014   Page 29 of 30
    Cindy W Hines , SHU56352

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 Nondisabled 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 classroom Section A: The percentage of Using the calculation result -
spends in the regular school day (including ÷ hours in school day) x 100 = % time student spends inside select the appropriate percentage category
classroom per day lunch, recess & study periods) (Column 1 ÷ Column 2) x 100 = % the regular classroom:
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  INSIDE the Regular Classroom 80% or More of the Day
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  INSIDE the Regular Classroom 79-40% of the Day
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  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)
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  Approved Private School (Non Residential)   Other Public Facility (Non Residential)
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  Approved Private School (Residential)
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  Hospital/Homebound
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  Other Private Facility (Non Residential)
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  Correctional Facility
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  Other Private Facility (Residential)
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  Out of State Facility
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  Instruction Conducted in the Home

EXAMPLES for Section A: How to Calculate PennData – Educational Environment Percentages
  Column 1 Column 2 Calculation Indicate Percentage
(Hours inside regular classroom ÷ hours in
Total hours the student spends in the Total hours in a typical school day Section A: The percentage of time student
  school day) x 100 = %
regular classroom – per day (including lunch, recess & study periods) spends inside the regular classroom:
(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.

May 2014   Page 30 of 30