INDIVIDUALIZED EDUCATION PLAN (IEP)

INFORMATION
STUDENT/PARENT INFORMATION ELIGIBILITY CATEGORY MEETING INFORMATION
___ Autism DATE OF MEETING _______________
Student _______________________________ Sex __________ ___ Deaf/Blind DATE OF LAST IEP ________________
Birthdate ______________Grade ______ Student ID#__________ ___ Developmentally Delayed PURPOSE OF MEETING :
Student Primary Language __________________________________ ___ Emotional Disturbance ___ Interim IEP
Student English Proficiency Code (optonal) _____________________ ___ Initial IEP
___ Health Impairment
Address _________________________________________________ ___ Annual IEP
___ Hearing Impairment/Deaf ___ IEP Following 3-Yr Reevaluation
Student Phone ____________________________________________
Parent/Guardian/Surrogate___________________________________
___ Mental Retardation ___ Revision to IEP Date___________
Parent Phone (Home) _________________ Work_________________ ___ Orthopedic Impairment ___ Exit/Graduation_______________
Mobile Phone/CellphoneNo. _______________ Email______________ ___ Specific Learning Disability ___ IEP Revision Without a Meeting:
Primary Language Spoken at Home ____________________________ ___ Speech/Language Impairment At the request of ___Parent
Interpreter or Other Accommodations Needed_____________________ ___ Traumatic Brain Injury ___School/District
Emergency Contact/Phone Number_____________________________ ___ Visual Impairment/Blind OTHER ADDENDUM MEETING
Current School ______________________________District_________ ___ Multiple Impairment IEP Services will begin __________
Eligibility Date Anticipated
____________________ Duration of Services ___________
IEP Review Date _________________
ANTICIPATED:
COMMENTS:
3-YR REEVALUATION_____________
__________________________________
__________________________________
IEP PARTICIPATION
*Parent/Guardian/Surrogate____________________________________________________ Speech/Language Therapist/Pathologist/Specialist___________________________
Student ___________________________________________________________________ School Nurse ________________________________________________________
Interpreter __________________________________________________________
*Special Education Teacher ___________________________________________________ Other (name and role) _________________________________________________
*Regular Education Teacher __________________________________________________ Other (name and role) _________________________________________________
School Psychologist __________________________________________________________ Other (name and role) _________________________________________________
*Required participation
**Student must be invited when transition is discussed (beginning at age 14 or younger if appropriate)
*** The IEP team must include at least one regular education teacher of the student (if the student is or may be participating in the regular education environment)
PROCEDURAL SAFEGUARDS
___I have received a statement of procedural safeguards under the individuals with Disabilities Education Act (IDEA) and these rights have been explained to me
in my primary language Parent Signature :_______________________________________________________
AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, STUDENTS MUST BE INFORMED OF THEIR RIGHTS UNDER IDEA AND ADVISED THAT THESE RIGHTS WILL
TRANSFER TO THEM AT AGE 18.
___ Not Applicable (Student will not be 18 within one year ____The student has been informed of his/her rights under IDEA and advised of the transfer of rights at age 18
Distribution: __Confidential Folder __Parent/Guardian/Surrogate __Special Education teacher __Case Manager __Diagnostic Center
Student:______________________
Date_________________________ PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Consider results of the initial evaluation or most recent reevaluation, and the academic, developmental and functional needs of the student, which may include the
following areas: academic achievement, language/communication skills, social/emotional/behavior skills, cognitive abilities, health, motor skills, adaptive skills,
pre-vocational skills, vocational skills and other skills as appropriate. For students who are 16 or older, or will turn 16 when this IEP is in effect, also consider the
results of age appropriate transition assessments related to training/education, employment and independent living skills (as appropriate).
ASSESSMENT CONDUCTED ASSESSMENT RESULTS EFFECT ON STUDENT’S INVOLVEMENT AND PROGRESS
IN GENERAL EDUCATION CURRICULUM OR, FOR EARLY
CHILDHOOD STUDENTS,, INVOLVEMENT IN
DEVELOPMENTAL ACTIVITIES
Student:_____________________________________
Date: _______________________________________ STRENGTHS, CONERNS, INTERESTS AND PREFERENCES Page____ of ____
STATEMENT OF THE STUDENT’ STRENGTH

STATEMENT OF PARENTS’ EDUCATIONAL CONCERNS

STATEMENT OF STUDENT’S PREFERENCES AND INTERESTS (required if transition services will be discussed, beginning at age 14 ir younger if
appropriate)

CONSIDERATION OF SPECIAL FACTORS

1. Does the student’s behavior impede the student’s learning or the learning of others? ____No action needed ___Yes, addressed in IEP
If yes, team must consider the use of positive behavioral interventions, support and other strategies, to address behavior.

2. Does the student have limited English proficiency? ____No action needed ___Yes, addressed in IEP
If yes, team must consider language needs of the student as those needs relate to the student’s IEP.

3. Is the student blind or visually impaired? ____No action needed ___Yes, addressed in IEP
If yes, team must evaluate reading and writing needs and provide for instruction in Braille unless determined not appropriate for the student.
4. Is the student deaf or hard of hearing? ____No action needed ___Yes, addressed in IEP
If yes, team must consider communication needs.

5. Does the student require assistive technology devices and services? ____No action needed ___Yeas addressed in IEP
If yes, team must determine nature and extent of devices and services.
 IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS AND BENCHMARKS OR SHORT-TERM OBJECTIVES

MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress being
made (Continue)
2. Unsatisfactory Progress being
made (need to review/revise)
3. Goal met (note date)

Date Date Date Date

BENCHMARK OR SHORT-TERM OBJECTIVES

MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
4. Satisfactory Progress being
made (Continue)
5. Unsatisfactory Progress being
made (need to review/revise)
6. Goal met (note date)

Date Date Date Date

BENCHMARK OR SHORT-TERM OBJECTIVES

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MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
7. Satisfactory Progress being
made (Continue)
8. Unsatisfactory Progress being
made (need to review/revise)
9. Goal met (note date)

Date Date Date Date

BENCHMARK OR SHORT-TERM OBJECTIVES

MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
10. Satisfactory Progress being
made (Continue)
11. Unsatisfactory Progress being
made (need to review/revise)
12. Goal met (note date)

Date Date Date Date

BENCHMARK OR SHORT-TERM OBJECTIVES

3
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
13. Satisfactory Progress being
made (Continue)
14. Unsatisfactory Progress being
made (need to review/revise)
15. Goal met (note date)

Date Date Date Date

BENCHMARK OR SHORT-TERM OBJECTIVES

MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
16. Satisfactory Progress being
made (Continue)
17. Unsatisfactory Progress being
made (need to review/revise)
18. Goal met (note date)

Date Date Date Date

BENCHMARK OR SHORT-TERM OBJECTIVES

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Student:____________________________
Date_______________________________ METHOD FOR REPRTING PROGRESS Page____of ______

METHOD FOR REPORTING THE STUDENT’S PROGRESS TOWARD MEETING ANNUAL PROJECTED FREQUENCY OF REPORTS
GOALS (Check all methods that will be used)
___IEP Goals Pages ____Report Card ____Quarterly ____Semester
___Specialized Progress Report ____Parent Conferences
___Other:_______________________________________________________________ ____ Trimester ____Other

SPECIAL EDUCATION SERVICES

SPECIALLY DESIGNED INSTRUCTION BEGINNING AND FREQUENCY OF LOCATION OF

ENDING DATES SERVICES SERVICES

SUPPLEMENTARY AIDS AND SERVICES

Includes aids, services and other supports provided in regular education classes or other education-related settings to enable participation with nondisabled students
MODIFICATION, ACCOMODATION OR SUPPORT FOR STUDENT BEGINNING AND FREQUENCY OF LOCATION OF
OR PERSONNEL (Describe below or select from supplemental ENDING DATES SERVICES SERVICES
“Modifications, Accommodations and supports”

Student:____________________
Date:______________________ RELATED SERVICES Page ____ of ____
RELATED SERVICES SERVICES TYPE AND/OR BEGINNING AND ENDING FREQUENCY OF LOCATION PF SERVICES
DESCRIPTION DATES SERVICES
___Speech/Language
___Physical Therapy
___Occupational Therapy
___Transportation
___Counseling
___Psychological Services
___Orientation and Mobility
___Audiology
___School Health Services
___Medical Service for
Diagnostic or Evaluation
___Recreation Therapy
___Parent Counseling &
Training
___Interpreting Services
___Social Work Services
___School Nurse Services
Other
EXTENDED SCHOOL YEAR SERVICES
Does the student require extended School year services?
___No ___Yes If YES, IEP goals and benchmarks/short-term objectives and/or related services to be implemented in ESY must be identified
If need for ESY is to be determined at a later date, indicate date by which IEP decision will be made:

PLACEMENT
PLACEMENT CONSIDERATIONS PERCENTAGE OF TIME IN REGULAR EDUCATION
ENVIRONMENT
___Selected ____Rejected Regular class w/ supplementary aides and services
___Selected ____Rejected Regular class and SPED class (i.e. resource) combination
___Selected ____Rejected Self-contained program
___Selected ____Rejected Special School
___Selected ____Rejected Residential
___Selected ____Rejected Hospital
___Selected ____Rejected Home
___Selected ____Rejected Other
JUSTIFICATION FOR PLACEMENT INVOLVING REMOVAL FROM REGULAR EDUCATION ENVIRONMENTS
Explain why IEP goals and objectives cannot be implemented in regular education environments, including the reasons why the team rejected a less
restrictive placement. Include an explanation of any harmful effects on the learning of this or other students which affected the placement selection.

IEP IMPLEMENTATION

___As the parent, I agree with the components of this IEP, I understand that its provisions will be implemented as soon as possible after the IEP goes
into effect

___As the parent, I disagree will or part of this IEP. I understand that the School must provide me with written notice of of any intent to implement this
IEP. If I wish to prevent the implementation of this IEP, I must submit a written request for a due process hearing to the school principal

Parent’s Signature