Name of Student (Last, First): INDIVIDUAL STUDENT GENERAL SUPERVISION FILE REVIEW CHECKLIST Revised 2017 Reviewed by District Al School Date of Birth Grade Category of Eligibility Aectual Disabivts Lep Current Eligibility Report Date |) 29/2017 Current Annual IEP Date Secondary Transition Student “Yes No Preschool Student. Please refer to the directions for additional guidance on each item. Written Notice or Parental Consent for initial Assessment was obtained prior to administrating assessments or evaluation on initial Vv _ | evaluation. wen 3009 aa st. 20 ao 00503 Documentation of consent for Reevaluation OR reasonable attempts is present for a 3-year re-evaluation. OR Documentation of ~ | written notice for a reevaluation consisting only of 2 review of Vv Reviewerconments Te a ‘comprehensive evaluation was conducted and al areas of | concern identified on the Consent for Assessment are reflected in |, he Eligibility Report. (scosoxbsn Eligibility Category [Autism Spectrum Disorder | Ci Hearing impairment Ti Specific Learning Disabil >| Di Deaf-Blindness intellectual Disability Speech/Language Impairment: Language ‘[Didesiness Tl Multiple bisabiities TD Speech/Language Impairment: Speech DDevelopmental Delay | ClOrthopedi Impairment | Traumatic Brain injury Ti Emotional Disturbance | [Other Health Impairment | E1 Visual impairment including blindness Evaluations and Assessment show that the student meets the State || eligibility criteria for disability category identified tneasoo.s0ena, wo =| smsoct-09. _| i Check box for SUb a ‘and complete Sib checklist Reviewer Cofnments 5/5 ue esate ae ‘GSFR Checklist / Special Education / SDE/'2Eligiblity Report appropriately addresses need for specially designed instruction. CoMMentS T= ms is SBE Limited English Proficiency: A language proficiency score was “| obtained and appropriate assessments were selected based on the Vv student's level of proficiency. commie 8 Be Sa “Individualized Education Program | IEP Team Members in attendance: CHstudene and | Elvorentor | Elsetool outer | Elcenera! | lsoecat win appopats) | Gunan | Administer or | Edxaton | Eaveaton Toeramaanioy | toe Dengae Teacher | Teacher seaponszioin) | Sndextaey | oextonszsiara| tora | toes in Sonsesiyay | Srosexy TEP includes appropriate Present Levels of Academic Achievement and Functional Performance (PLAAFP) and Appropriate || corresponding Goal(s). Please see criteria checklist below: resent level(s)iof Academic Achievement aad Functional Perfornnanice (PUAAFP) and Goal Aligned toithat PLAFP: Each skill area will have a corresponding goal(s). Checked boxes indicate criteria was met: [ED Disabitty affects involvement in ganeral ed. QOEA ‘Skill Area | [E] strength and needs of the child 1D€A 2000.324(aM. o0azoraN ai TA sasetine [ED condition [EI Targeted [EI criteriaor [EQ Procedure [1 schedule daily] (1 References an Jannat Gon {® f.vinen |Sidlor |ievelof |sonaz0nio |weety, mony |eccepae eho Stand sooseeaie [given or [behavior |ertrmance Soran During Skil Area {1 strength and needs ofthe child (IDEA 3000324) ea ae Karlsen In aera BORA: leaseline |O conditior Ci targeted [Di criteriaor |D) Procedure | D1 Schedule~daily| 1 References an panacea (MA lee vinen |Siforbevador|ieelof |2ona2a100 |weety, monthly |acepabe sho stando =! TSoosaasna |gen or erormance Seosonanain During : ons diay acs involvement in general ed J0EA ‘Skil Acoa | stangth and neds ofthe eile (Dc 3000 240. a Cisasetine [Oi conditiod Oi targeted [Di criteriaor |C Procedure | Schedule ~daily] D] References an pnnuat on |W. Jee When|siitorberedor|ivetot |soaszaK) |weety, manly” |acceptabedaho stand Scomaeanw |gtenor Performance oozabarain pune jRivisiver Comnmantei0l Common SEH : 7] l€P includes a statement about Written Progress Reports (inca soso « Aeviebier Comments 1 ESE ‘GSFR Checklist / Spedal Education / SDE / 2fant The IP incudes a description ofthe specal education and related services being provided to the student including: Please see criteria checklist below: ‘Checked boxes indicate criteria was met: [Especial esvestion and/or | Te of [Eh Frequencyof Ed tocaton | start dat] Pl end date service 1 | lated Service DEA Profesional staf’ |serice 200.320(9)7)|32032teK | 00.220 |soas20017) 3000 2088) Responsible nea 300 204) [El special education and/or | Cl Tike of BiFrequency of |[tocation — [I start dat service [Rested Sence pen Professional Staff [service an.za(jin|200sz0texm | 20032048 300001) Responsible EA son 2038) Tr Speciat ucation andor | The of Th requeneyof [Location — [Start dau ena dane service. |Relsted Sevice nex Professional stat [service s.snay7y}300220t87 }s00. zt | 200.2047 3000 ta) Responsible ink son 20) TD Special eaucation and/or | Te of [Ei requency of [TE vocation — [ED Stare da ena date Ssenice 4. [Related Service Des Profesional stat service scosaniarn|300s20aK7) | 2003208017) 200.2007) 3000 sta). Responsible ia 500 2019) IE Special Education and/or | tite of [Ei Frequencyot | Citocation | stare datf TT end date services. [elated serie inca Profesional tat service 2oo.azo(etn)30020=K7) [30032087] 300200017) soca sae) Responsible inex 500 3200) Reviener Commenada aE eT 1B i Te 13, °4| Services show a direct relationship in other components of the IEP. x Reviewereommentais SEL oe jaa. ‘The IEP team has explained the extent, if any, to which a student will not participate in general education and has provided a rationale for that placement decision toeasonszuais._ ReviewBt Commente™ 45. The Least Restrictive Environmental Code is reflective ofthe time documented on the IEP service grid. so0320(s4s) Reviewercomients is: on Pama oan eee ES ! a6, | When applicable, ESY addressed as a consideration and services “| are identified in the 1EP josasco.06, “ Reviewericomnmentse = = i = i ‘When behavior impedes student’s learning or the learning of others, itis addressed in the IEP. (Positive behavior supports incorporated within the IEP or Behavior Intervention Plan attached) scm 31022492 and 30050) \EP lists accommodations/adaptations the student requires to be involved and make progress in the general education curriculum to | the maximum extent possible. worasonszoman-iasenszoy6m 19. Participation is addressed for each individual statewide assessment. ioea so0szotane}a. Reviewercomments 198 mt