INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student’s Name: James Smith

INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

Student’s Name: James Smith

IEP Team Meeting Date (mm/dd/yy): 12/3/2019
IEP Implementation Date (Projected Date when Services and Programs Will Begin): 12/4/2019
Anticipated Duration of Services and Programs: 12/3/2020
Date of Birth: 5/10/2015
Age: 4
Grade: Pre-K
Anticipated Year of Graduation: 2032
Local Education Agency (LEA): Hancock County School District
County of Residence: Hancock County
Name and Address of Parent/Guardian/Surrogate: Phone (Home): (111) 111-1111
Sarah Smith Phone (Work): (222) 222-2222
123 Streetname Dr.
Weirton, WV 26062

Other Information: James’s parents are not married, the mother is the main guardian

The LEA and parent have agreed to make the following changes to the IEP without conven ing an IEP meeting, as documented by:
N/A

Date of Revision(s) Participants/Roles IEP Section(s) Amended

Page 1 of 25 April 2014

 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 Sarah Smith
Parent/Guardian/Surrogate N/A
Student* N/A
Regular Education Teacher** Jennifer Adams
Special Education Teacher Katie Burke
Local Ed Agency Rep Sam Pullman
Career/Tech Ed Rep*** N/A
Community Agency Rep N/A
Teacher of the Gifted**** N/A
Speech and Language Pathologist Hannah Newman

* 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:

N/A

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

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

X 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)
 Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
 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)
 Parental concerns for enhancing the education of the student
 How the student’s disability affects involvement and progress in the general education curriculum
 Strengths
 Academic, developmental, and functional needs related to student’s disability

Summary
James is a four-year-old male attending the Northern Panhandle Head Start in Hancock County. He was evaluated on November 15, 2019, and
found to have a developmental delay as well as a slight need for speech and language support. In this report, James’ assessment results, areas of
needs, and strengths are listed and discussed to develop a plan for academic support.

Present levels of academic achievement:

Literacy: When James was assessed using the Brigance Inventory of Early Development III (from here on, will be referred to as the Brigance),
James performed at an age equivalent level of 2 years and 11 months. He had a raw score of 24/170 and a composite score of 80. It is clear from
the assessment results that James shows little to no understanding of books and text, letter recognition, and visual discrimination. He does show
interest in books, listens to stories when they are read to him, and can turn the book right-side up. However, James was not able to identify the
front and back covers of a book, be engaged in the story by asking questions or making comments or understand how text progresses. In addition,
he was not able to recite any letters from the alphabet nor could he identify all 26 letters of the alphabet. James was able to successfully name
letters C and Z; however, was not able to identify them. He could not identify words that rhymed, nor could he segment words into two
individual words; however, he was able to blend two words into one. James was able to discriminate beginning and ending consonant sounds with
60% accuracy; however; he did struggle with identifying the beginning and ending consonant sounds that were the same.

Mathematics: When James was assessed in mathematics using the Brigance, he performed at an age equivalent of 2 years and 11 months. He had
a raw score of 14/101 and a composite score of 81. James can rote count to 5 and compare amounts with 83.3% accuracy. However, James has no
understanding of number concepts, sorting, matching quantities, identifying numerals, or word problems. James only understands number
concepts with 28% accuracy and cannot sort objects by color, size, or shape. James cannot match quantities of numbers, nor can he read
numerals. James was not able to solve word problems and can only identify missing numerals with 16.7% accuracy.

Present levels of functional performance:

Behavior: James is typically pleasant and is usually easy to redirect when needed. James is usually kind and sweet; however, he often makes
impulsive decisions and takes toys from his peers during free play. He has trouble listening during instructional periods and circle time and
struggles to focus on one task at a time. He is easily distracted which results in him having difficulty remaining on task. He often needs prompts
and reminders to help him stay on task and complete classroom routines. However, when James is redirected or given a prompt, he often
complies and completes the task without dispute. James is able to engage in play with peers the majority of the time and is typically respectful
to his peers and teachers.

Communication: When assessed for receptive language using the Brigance, James performed at an age equivalent of 4 years and 3 months,
receiving a raw score of 94/102 and a composite score of 94. James demonstrates early receptive language skills involving short commands such
as responding to the word give and putting a block into a box when asked to do so. James shows an understanding of animal words by making
connections to the sounds that those animals make. He can identify pictures by naming them or by pointing to them on command. James can
identify verbal concepts such as big/little, close/open, in/out, behind/in front of, bottom/top, etc.; however, he has difficulty identifying other
verbal concepts such as above/below and center/corner. He can follow one and two-step directions but has some difficulty when it comes to
three or more step directions in the classroom setting. He can identify his colors with 68% accuracy. When assessed for expressive language using
the Brigance, James performed at an age equivalent of 3 years and 9 months, receiving a raw score of 106 and a composite score of 89. James
demonstrates early expressive language skills through his ability to name objects and their use correctly with 100% accuracy. He can identify
parts of the body with 100% accuracy; however, can only identify colors with 36% accuracy. He can speak in sentences with at least 6 words.
James uses grammar and language in context with 70% accuracy and can use /s/ to use irregular plural nouns, use prepositions, and tell a small
story with 2-3 elements. That being said, his articulation of speech is 50% intelligible due to his inability to pace his speech.

Social skills: When assessed for social and emotional development in the interpersonal domain using the Brigance, James performed at an age
equivalent of 6 years and 9 months, receiving a raw score of 18 and a composite score of 109. James demonstrates a strong relationship with
adults. He gives affection, demonstrates warmth and pride, is respectful, responds appropriately to directions, shares feelings, asks for guidance,
enjoys sharing information and ideas and responds appropriately to classroom instruction. With his peers, he has several friends but has one
special friend that he often plays with. He can play cooperatively in large-group games and engages in pretend play. However, James does not
have a best friend and does not prefer the companionship of children to that of adults. He does not incorporate verbal directions into play and
often has trouble being included in play. He struggles to make friends due to his trouble with communication and he often takes toys from his
peers which results in them not wanting him to play with them. When assessed for social and emotional development in the self-regulatory
domain using the Brigance, James performed at an age equivalent of 3 years and 9 months, receiving a raw score of 16 and a composite score of
96. James is developing in motivation and self-confidence. He is beginning to be aware of good and bad behavior in himself and others. He can
remain interested when engaged in a small-group activity, is eager to comply, insists on doing things independently, demonstrates satisfaction in
himself, and listens to feedback. He demonstrates self-confidence and independence and approaches new tasks with confidence. On the other
hand, James has difficulty finishing what he started and remaining engaged when minor distractions are present. James struggles with prosocial
skills and behaviors. He demonstrates prosocial skills and behaviors with 31% accuracy. He does not show concern when a playmate is hurt, is not
truthful, does not take turns, does not give as well as he takes, and does not participate well in group activities. He struggles to understand the
need to share and take turns and asking for permission. James does not act appropriately to conflict, does not offer apologies for mistakes, and
does not follow verbal conversational rules. James helps put things away, responds appropriately to criticism, and reacts to disappointment
appropriately.

Gross and Fine Motor Skills: When assessed for physical development in the gross motor domain using the Brigance, James performed at an age
equivalent of 3 years and 10 months, receiving a raw score of 49/63 and a composite score of 92. James can successfully complete all of the tasks
for early gross motor skills. For example, he can run well and can jump. James can stand on one foot momentarily for one second as well as stand
on one foot for one second with his eyes closed. He does have difficulty standing on one foot for 5 and 10 seconds with both the left and the right
foot. He can walk, skip, and gallop with 58% accuracy. He can walk on his tiptoes, skip on one foot, gallop (inefficiently), and skip with
alternating feet. However, James struggles with walking forwards heel-to-toe, walk backward toe-to-heel, and gallop without difficulty. He can
jump and hop with 50% accuracy. He can jump off the floor with both feet and can jump five or more times. On the other hand, he has difficulty
hopping on his preferred foot and his other foot. James can climb up and down the stairs with 100% accuracy. He also can throw and catch a
playground ball; however, he has difficulty catching a tennis ball with both hands. When assessed for physical development in the fine motor
domain using the Brigance, James performed at an age equivalent of 3 years and 2 months, receiving a raw score of 40/107 and a composite score
of 88. James can successfully hold a crayon and draw a vertical and horizontal line. He struggles with drawing a circle, a plus sign, an “X”, a
square, rectangle, and triangle. He also shows difficulty with drawing a person and when asked to do so, he was only able to draw a head. James
was unable to print any personal information, numerals, and letters of the alphabet.

Adaptive Skills: When assessed for adaptive skills using the Brigance, James performed at an age equivalent of 3 years and 3 months, receiving a
raw score of 34/48 and a composite score of 87. He can ask for food when hungry, hold a cup with one hand, use the side of the fork for cutting,
and eat independently. However, he has difficulty with inserting a spoon in his mouth without turning it upside down as well as holding his fork
with his fingers and not his fist. James can dress himself with 75% accuracy. He can put on a shirt, coat, shorts, pants, and shoes; however, he
struggles with dressing himself unsupervised, putting all clothes on correctly, tying his shoes, and fastening all fasteners. James can go to the
bathroom independently, but he does have difficulty with bathing himself. He can recite his first name and his age but cannot give any other
personal information.

Present levels related to current postsecondary transition goals:

Transition services are not appropriate at this time.

Parental concerns for enhancing the education of the student:

James’s mother would like James to learn to write his name so he can not only gain some independence when doing an assignment or art project
but also so he can begin developing his writing skills needed for kindergarten and beyond. James’s mother would also like to see him work on his
listening skills.

How the student’s disability affects involvement and progress in the general education curriculum:
James is academically and functionally performing at an age equivalent of 3 years and 3 months. There is not a significant difference between his
chronological age and his cognitive level; however, this gap affects his ability to be academically and functionally proficient according to the
standards set for his grade-level. While he is not too far behind, receiving services will be beneficial for his personal growth as a whole.

Strengths (per the information above):

-James shows interest in a book when it is read to him.
-James can distinguish the beginning and ending sounds that were not the same.
 -James is kind to his peers and adults
-James is respectful to adults and peers.
-James is compliant when given a direct command.
-James demonstrates early receptive skills such as responding to short commands and identifying animals and the sounds they make.
-James can identify parts of the body with 100% accuracy.
-James has strong interpersonal skills by playing cooperatively, responding appropriately to classroom instruction, and sharing his feelings.
-James can run and jump well.
-James can walk on his tiptoes for more than 5 steps.
-James can dress, feed and go to the bathroom independently.

Academic, developmental, and functional needs related to student’s disability:

Academic Skills/Cognitive Development:
The Literacy Assessment of the Brigance indicated that James has very weak letter recognition. He was unable to recite or identify any of the 26
letters of the alphabet. A weakness in this foundational element of academic development impacts his ability to advance in his literacy skills such
as identifying letter-sound correspondence, decoding words, writing his name, and eventually reading. James must learn his letters so that he can
be successful in his literacy development.

Academic Skills/Cognitive Development:

The Mathematics Assessment of the Brigance indicated that James has very weak number recognition. While he was able to rote count until 5, he
was unable to continue counting and was unable to identify numbers by name. A weakness in this foundational element of academic development
impacts his ability to understand number concepts, read numerals, solve simple mathematic equations, and eventually advance in mathematics.
James must learn his numbers so that he can be successful in his mathematic development.

Physical Development:
The Fine-Motor Skills Assessment of the Brigance indicated that James has weak writing skills. While he is able to hold a crayon and draw lines
and scribbles, he was unable to write his name or any letters in his name. A weakness in this foundation element of academic development
impacts his ability to write and eventually, will affect his ability to meet grade-level writing standards. His ability to write is name is a goal his
mother has for him and is something that he must learn to be successful in his writing development.

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:

 N/A

Postsecondary Education and Training Goal:

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

Courses of Study:
N/A

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible

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

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible
Independent Living Goal, if appropriate:
Measurable Annual Goal
N/A Yes/No
(Document in Section V)

Courses of Study:
N/A

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.state.pa.us.

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 Language Learner.

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*)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Math
Science
Reading
Writing
ELA*
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11 th 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 Reading and Math; Grades 4, 8, 11 for Science)
Student will participate in the PASA.

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.

Videotape (preferred method)

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
Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking

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

Student will participate in the Alternate ACCESS for ELLs.

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

Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking

Local Assessments

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

Student will participate in local assessments without accommodations; OR

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

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:

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

When presented with the 26 letters of the Once a week, the special Progress will be reported to
alphabet in written form, James will identify the education teacher will parent quarterly with report
letters with 80% accuracy for 3 consecutive present the alphabet, in cards.
progress monitoring sessions. written form, to James.
The special education
teacher will record each
letter James identifies
correctly as well as record
the number of letters he
identifies correctly. The
number of correct
responses will be
recorded out of 26 and
graphed.

When presented with a group of 20 objects, James Once a week, the special Progress will be reported to
will count the objects, in numeric order, with 80% education teacher will parents quarterly with
accuracy, for 3 consecutive progress monitoring present James with a report cards.
sessions. group of 20 objects. The
special education teacher
will ask James to count
the objects and will
record the number that
James was able to count
to correctly, in numerical
order. If James, counts
and recites numbers that
are not in numerical
order, it will be marked
incorrect. The number of
correct responses will be
 recorded out of 20.

When presented with primary lined writing paper, Once a week, the special Progress will be reported to
James will write his first name with 80% accuracy, educator will present parents quarterly with
for 3 consecutive progress monitoring sessions. James with a primary report cards.
lined writing paper and
prompt him to write his
name. The special
education teacher will
observe and record the
number of letters James
can write correctly, in the
correct order, out of 5.

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

Short term objectives / Benchmarks

N/A
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
SDI for Goal 1:
The general education
teacher or special
education teacher will
provide direct and explicit
instruction by working one-
on-one with Jim using
letter cards. The teacher General Education
4 times per week 12/4/19 12/4/19-12/3/20
will use guided practice by Classroom
identifying the letter,
saying the letter with Jim,
then instructing Jim to say
the letter individually.
Reinforcement will be
provided continuously.

SDI for Goal 1:

Following the direct and
explicit instruction, the
general education teacher
or the special education
teacher will use a dry erase
dice with the letters that
were taught through the
General Education
direct instruction on it. The 4 times per week 12/4/19 12/4/19-12/3/20
Classroom
student will roll the dice
and identify the letter that
the dice lands on. The
teacher will give
reinforcement and record
student responses.
Reinforcement will be
provided continuously.
SDI for Goal 2:
The general education
teacher or the special
education teacher will
provide direct and explicit
instruction by working one-
on-one with James using
number cards. The teacher
General Education
will use guided practice to 3 times per week 12/4/19 12/4/19-12/3/20
Classroom
teach each number by
identifying the number,
repeating the number with
James, and then instructing
James to say the number.
Reinforcement will be
provided continuously.

SDI for Goal 2:

Following the direct and
explicit instruction, the
general or special
education teacher will use
number matching cards to
practice identifying
numbers. The cards will
follow the same rules as
matching games. When General Education
3 times per week 12/4/19 12/4/19-12/3/20
James flips over a card, he Classroom
will have to identify the
number and try to find the
match for the number.
When he finds a match, he
will set it aside and
eventually attempt to put
the matches in numeric
order. Reinforcement will
be provided continuously.
SDI for Goal 3: General Education 2 times per week 12/4/19 12/4/19-12/3/20
The general education Classroom
teacher or the special
education teacher will
provide explicit and direct
instruction by working one-
on-one with James to teach
him to write his name. The
teacher will implement
guided practice by first
writing his name, use hand-
over-hand to help him write
his name, and then have
him attempt to write his
name independently.
Reinforcement will be
provided continuously.

SDI for Goal 3:

Following the direct and
explicit instruction, James
will participate in
independent practice. The
teacher will give James a
white board and a dry erase General Education
2 times per week 12/4/19 12/4/19-12/3/20
marker. James will practice Classroom
writing his name
independently and the
teacher will monitor James’
writing attempts.
Reinforcement will be
provided continuously.

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

30 minutes every two
Speech and Language Resource Room 12/4/19 12/4/19-12/3/20
weeks

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 Update from the Special Education Once a Month for 20 12/4/19 12/4/19-12/3/20
Teacher Speech Pathologist Classroom minutes
on Jim’s progress
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 N/A

Support Service N/A
Support Service N/A

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:
X

James will be evaluated for ESY services during the 2019-2020 school year winter holiday break. Data regarding any regression or
recoupment will be collected and recorded 10 days prior to break and again, 10 days after James returns to school. This data will be
analyzed for any regression that affects his academic, social, and/or functional performance per his IEP goals. After this data is
analyzed, a decision about an ESY placement will be discussed and made by March 2020.

The Annual Goals and, when appropriate, Short Term Objectives f rom 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
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:
James is academically and functionally performing at an age equivalent of 3 years and 3 months. While
there is an age gap between his chronological age and his developmental age, it is not a large enough
gap for him to need another placement or more time out of the regular education classroom. He will
continue to participate in the regular education classroom and will only be pulled-out for the services
provided.

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
James is academically and functionally performing at an age equivalent of 3 years and 3 months. While
he is participating in the regular education classroom, his specific needs show that he requires support
services to succeed in the general education curriculum.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

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

Page 23 of 25 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

C. Location of student’s program

Name of School District where the IEP will be implemented: Hancock County School District

Name of School Building where the IEP will be implemented: Northern Panhandle Head Start

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

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

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

Other. Please explain:

Page 24 of 25 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

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 Using the calculation result – select the appropriate percentage category
spends in the regular time student spends inside the
(including lunch, recess school day) x 100 = %
classroom per day & study periods) (Column 1 ÷ Column 2) x regular classroom:
100 = %

5.95 6 (5.95 ÷ 6) x 100 99% of the day X INSIDE the Regular Classroom 80% or More of the Day
INSIDE the Regular Classroom 79-40% of the Day
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)
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 day (Hours inside regular classroom ÷ hours in school day) Section A: The percentage of time student
(including lunch, recess & study x 100 = % spends inside the regular classroom:
regular classroom per day
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.

Page 25 of 25 April 2014