Special Education Department

Individualized Education Program (IEP)

Student Name: Student Data/Cover Sheet (Form A-1) IEP Meeting Date:
Mary Smith 03/09/2020

Demographic Information

Student Number: Student (Pseudo) Birthdate: Gender: Grade:

Name:
N/A Mary Smith 10/14/2011 Female 2nd
Student Address: Home Phone:
3500 West Camelback Road Do not complete
City, State, Zip:
Phoenix, Arizona 85017
Parent 1 (Pseudo) Name: Teresa Smith Parent 1 Relationship: Mother

Parent 1 Address: Home Phone:

Do not complete. Do not complete.
City, State, Zip: Work Phone:
Do not complete. Do not complete.
Parent 1 Email:
Do not complete.
Parent 2 (Pseudo) Name: Gregory Smith Parent 2 Relationship: Father

Parent 2 Address: Home Phone:

Do not complete. Do not complete.
City, State, Zip: Work Phone:
Do not complete. Do not complete.
Parent 2 Email:
Do not complete.
Primary Language of Home: Primary Language Survey Date: 02/20/2020 Language of Instruction:
English Primary Language Survey Results: English English
Home District: Prosser Service Coordinator: Taylor Munoz
Attendance District: Prosser
Home School: Keene-Riverview Elementary Attending School: Keene-Riverview Elementary
Vision Screened On: Results: Hearing Screened On: Results:
02/20/2020 No vision impairment 02/20/2020 No hearing
impairment
Meeting Date: 03/09/2020 Anticipated Duration of IEP: Re-evaluation Due: 03/09/2023
From: 2:50pm To: 3:20pm Current Evaluation:
03/09/2020
Special Education Primary Category 1: Specific Learning Disability

Special Education Eligibility Category 2: N/A

Special Education Eligibility Category 3: N/A

For Students with SLD only, the following area(s) of eligibility was/were previously determined: Math and
reading
Level of Services: (A)
Type of Meeting:
Initial
Date Meeting Notice Sent to the Date Procedural Safeguards given to the
Parent(s): 02/21/2020 Parent(s): 02/21/2020
 This page will not need to be completed because it is a signature page.
Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: Student Data/Cover Sheet (Form A-2) IEP Meeting Date:

Student ID: DOB:

The following persons participated in the conference and/or the development of the IEP. Additionally, parents have
been given a copy of their rights regarding the student’s placement in special education and understand that they
have the right to request a review of their child’s IEP at any time.

Position/Relation to Student Participant Date (MM/DD/YY)

If during the IEP year the student turns 16, if the student is not present at the IEP meeting, the service coordinator
must review the IEP with the student and obtain the student’s signature and the date of this review.
 Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: Student Data/Cover Sheet (Form B) IEP Meeting Date:
Mary Smith 03/09/2020

Student ID: N/A DOB: 10/14/2011

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

(PLAAFP)

Section 1: Current IEP Information

Summarize special education services the student is receiving: This is an initial IEP meeting.
The student is not receiving any services at this time.

Section 2: Evaluation Information

Areas of Eligibility:

Special Education Primary Category: Specific Learning Disability

Special Education Eligibility Category 2: N/A
Special Education Eligibility Category 3: N/A
For students with SLD only, the following area(s) of eligibility was previously determined: Math and
reading.

State and District Assessment Scores:

State Assessment Scores: There is no state testing at the K-2 grade levels.
District Assessment Scores: Mary scored a 0 out of 5 on a place value assessment, a 0 out of 5 on a two
step addition and/or subtraction word problem assessment, read 75 out of 100 words correctly in a given
text and answered 2 out of 5 comprehension questions correctly for that text.
All other assessments given in preparation for this IEP resulted in grade level appropriate answers.

Section 3: Present Level of Academic Achievement and Functional Performance

A. Cognitive (academic performance in content areas, e.g., ELA/Reading/Writing, Math, Science, Social
Studies, Technology and Fine Arts, as applicable):

Math: Mary struggles to correctly complete grade level math work. She is attentive during lessons;
however, she rarely turns in homework and often does not complete work in class.
Reading: Mary currently reads at a first-grade level. She struggles with fluency and with
comprehension after reading. Mary’s reading logs show that she does not read at home.

B. Physical (gross motor, fine motor, vision, and hearing): Mary exhibits no problems with physical
abilities at her grade level. There is no concern about this area.
C. Oral Language and Communication: Mary exhibits good oral language and communication habits for
her grade level. There is no concern about this area.

D. Social and Emotional Behavior: Mary exhibits good social and emotional behavior habits for her
grade level. There is no concern about this area.

E. Adaptive: Mary exhibits good adaptive behaviors for her grade level. There is no concern about this
area.

Current Classroom-Based Data: Mary does not perform at grade level with the rest of her peers in
assignment and assessments in math and reading. She is struggling with these subjects as shown in the
assessments she took in preparation for this IEP.

Family’s Input on Student’s Current Performance: Family agrees that Mary struggles in math and reading.
They notice that she becomes stubborn when being asked to complete homework and she will not
complete it. They do not ask her to complete her homework when she gets like this.

Summary of Work Habits: Mary struggles in class. While she is attentive during lessons, she rarely
completes homework. When doing work in class, Mary shuts down and refuses to work when she comes
to problems she does not know.

Section 4: Summary of Educational Needs and General Accommodations

Special Education Department

Individualized Education Program (IEP)
Student (Pseudo) Name: Considerations Form (Form C) IEP Meeting Date:
Mary Smith 03/09/2020

Student ID: N/A DOB : 10/14/2011

ADDITIONAL DOCUMENTATION/CONSIDERATION OF SPECIAL FACTORS

Considered
Not Needed Included

Individual Transition Plan ☒ ☐

Statement of Transfer of Parental Rights at Age of Majority ☒ ☐
Statement of Positive Behavior Interventions, Strategies, and Supports ☒ ☐
Considered for a Student Whose Behavior Impedes his or her Learning,
or That of Others

Statement of Language Needs in the Case of a Child with Limited ☒ ☐

English Proficiency
Statement of Provisions of Instruction in Braille and User of Braille for ☒ ☐
a Visually Impaired Child

Statement of the Language of Needs, Opportunities for Direct ☒ ☐

Communication with Peers in the Child’s Language, and
Communication Mode

Statement of Required Assistive Technology Devices and Services ☒ ☐

Statement of Communication Needs for a Child with a Disability ☒ ☐
 Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: Accommodations (Form F) IEP Meeting Date:
Mary Smith 03/09/2020

Student ID: N/A DOB: 10/14/2011

ASSESSMENTS
(Rationales for the accommodations that are being chosen specific to assessments.)

Rationale:
The assessments given were ones that showed Mary’s ability level in math and reading at current 2 nd
grade levels. These were prime indicators to Mary’s difficulties within these subjects. The interventions
that are given are based on the assessments results as well as teacher and family observations about
Mary’s difficulties.

State Assessments

Standard Accommodation(s): Math and Reading: When Mary takes state tests next year (3rd grade;
2020-21), she will not be timed on the tests. She will be able to have questions and possible answers read
to her unlimited times.

District Assessments

Standard Accommodation(s): Math: When Mary takes district tests, she will not be timed on the tests.
She will be able to have questions and possible answers read to her unlimited times. Reading: When
Mary takes district tests, she will be able to look back in the book to help her answer comprehension
questions. She will not be timed.

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

**There is no state testing at this grade level**

Testing Area Test Results Grade Semester Year

Reading
Writing
Math
Science

LEAST RESTRICTIVE ENVIRONMENT (LRE)

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

Mary will be receiving special education services for 2 forty-minute blocks in an 8 block school
day including lunch. This means that for 25% of her instruction will be in a resource room with
other students who are learning at a more individualized pace and will spend the other 75% of
her time in her general education classroom.

Consider any potential harmful effects of this placement for the child or on the quality of
services that he or she needs §300.552 (a-b):

There are no anticipated harmful effects that this placement could have on Mary. The majority of
her time will be spent with her peers and she will receive services with other students for the
other 25% of her time.

Reason for different services at school:

Mary will be receiving services at school for math and reading support. This in done in a
resource room where students are given more individualized attention and are working at a pace
that is beneficial to them.

OR, if the above LRE information does not apply to this student, explain why:
 Standard 3: Individualized Education Plan - Part 2

Special Education Department

Individualized Education Program (IEP)
Student (Pseudo) Name: Student Goals and Performance Objectives IEP Meeting Date:
Mary Smith 03/09/2020

Student ID: N/A Progress Report DOB: 10/14/2011

Skill Area: Math

Standard: Understand that the three digits of a three-digit number represent amounts of hundreds, tens,
and ones; e.g., 706 equals 7 hundreds, 0 tens, and 6 ones.

Annual Goal: Mary currently is able to correctly identify the place values (ones, tens, hundreds)
by sorting one, two, and three digit numbers 0 out of 5 times. By this time next year, Mary will
be able to correctly identify and sort one, two, and three digit numbers 3 out of 5 times.

Baseline Level of Mastery: 0 out of 5 times correct

Service Provider(s) for this goal: Resource Room Special Education Teacher: Taylor Munoz

Skill Area: Math

Standard: Fluently add and subtract within 100 using strategies based on place value, properties of
operations, and/or the relationship between addition and subtraction.

Annual Goal: Mary currently is able to correctly solve two-step addition and/or subtraction
problems 0 out of 5 times. By this time next year, Mary will be able to solve 3 out of 5 two-step
addition and/or subtraction problems correctly.

Baseline Level of Mastery: 0 out of 5

Service Provider(s) for this goal: Resource Room Special Education Teacher: Taylor Munoz

Skill Area: Reading

Standard: Read grade-level text orally with accuracy, appropriate rate, and expression on successive
readings.

Annual Goal: Mary currently reads with a fluency of 75/100 words correctly which is a 75%.
By this time next year, Mary will be able to read 90/100 words correctly which is a 90%.
 Baseline Level of Mastery: 75 out of 100 words correctly
Service Provider(s) for this goal: Resource Room Special Education Teacher: Taylor Munoz

Skill Area: Reading

Standard: Read with sufficient accuracy and fluency to support comprehension.

Annual Goal: Mary currently is able to answer 2 out of 5 comprehension questions correctly after
reading a literature or informational text. By this time next year, Mary will be able to answer 4 out of 5
questions correctly after reading a literature or informational text.

Baseline Level of Mastery: 2 out of 5 comprehension questions correct

Service Provider(s) for this goal: Resource Room Special Education Teacher: Taylor Munoz
 Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: Accommodations (Form E) IEP Meeting Date:
Mary Smith 03/09/2020

Student ID: N/A DOB: 10/14/2011

ACCOMODATIONS

Date Given to General Education Teacher: 03/09/2020 Service Coordinator: Taylor Munoz

Accommodations Type Location

State testing will be given with no time limits and unlimited opportunities 2 C&E
to have questions and possible answers read to the student.
Student will be able to use text as a reference during reading assessments. 2 C
Homework will be accepted as complete with at least one problem 1 A
attempted.

LEGEND FOR TYPE AND LOCATION FIELDS

Type:
1 = Class work/assignments 2 = Assessments/tests 3 = Both class work/assignments/assessments
Location:
A = All Subjects B = Language Arts/English C = Reading D = Spelling E = Math
F = Science G = Social Studies H = Health I = Electives J = Physical Education
K = Lunch L = Transition / Vocation M = Library N = Title 1 O = Special/Exploratory

Family Communication
How will the family be informed of their child’s academic progress and the extent to which that progress
is sufficient to enable the child to achieve annual goals by the end of the year?
The family will be updated with the students progress three times throughout the school year towards the
end of each trimester. The special education teacher will meet with the family during both of the parent
teacher conferences throughout the school year and during the yearly review of the IEP. The special
education teacher will be available for additional meetings if the family would like to talk about the
student’s progress outside of the specified times.

IEP Team Consideration for Extended School Year

Consideration for eligibility:

Mary would be able to attend summer school (extended school year) with her general education peers.
There is no need for an ESY to be mandatory.

Eligible for ESY:

Eligible: Yes
Mandatory: No

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

Mary does well in her general education class and only requires services for two out of eight blocks in the
school day. An ESY would be beneficial to her as it would most students, but she should be able to have a
full summer vacation and come back to school in the fall without major deficits to her learning and
progress during the previous school year.
 Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: Services and Environment (Form I) IEP Meeting Date:
Mary Smith 03/09/2020
Student ID: N/A DOB: 10/14/2020

SPECIAL EDUCATION SERVICES TO BE PROVIDED

Special education services necessary to meet special education goals and objectives during the school
calendar year.
The child is in need of specially designed instruction in the following areas:
Special Instructional
Education Setting/ Start Date Frequency Provider Duration/ End
Services Location Date
Math Resource 03/11/2020 200 min/week Taylor Munoz TBD
Intervention Room
Reading Resource 03/11/2020 200 min/week Taylor Munoz TBD
Intervention Room

Clarification: Mary will be receiving intervention support in both reading and math each for 40 minutes
out of each school day.

EDUCATIONALLY RELEVANT RELATED SERVICES

Special Instructional
Education Setting/ Start Date Frequency Provider Duration/ End
Services Location Date

Clarification: There are no relevant related services that Mary is in need of.

EDUCATIONALLY RELEVANT SUPPLEMENTARY AIDS/ASSISTIVE TECHNOLOGY and

SERVICES for STUDENTS
.
Special Instructional
Education Setting/ Start Date Frequency Provider Duration/ End
Services Location Date

Clarification: There are no supplementary aids/assistive technology and services that Mary is in need
of.

SUPPORTS FOR SCHOOL PERSONNEL

Special Instructional
 Education Setting/ Start Date Frequency Provider Duration/ End
Services Location Date

Clarification: There are no school personnel supports that are needed for Mary’s services.
 IEP Meeting Planning
Required Participants/Roles: List the participants of an IEP meeting and their roles, including
whether or not the student is expected to participate.
Mary Smith (student): Not expected to participate
Teresa and Gregory Smith (parents): One or both parents are expected to come to the initial
IEP meeting. They will listen to Mary’s goals and voice any concerns or questions they may
have.
Taylor Munoz (special education teacher): Will discuss Mary’s IEP including assessment
results, goals and other important details.
Kris Moore (principal): Will observe and take notes of important information discussed during
the IEP.
Danielle Toop (general education teacher): Will listen to Mary’s IEP and offer and support she
finds necessary to discuss.
Lara Schab (student teacher): Observe the meeting and offer support if needed.

Required Agenda Outline: In 500-750 words, create an agenda for the IEP meeting. Discuss the
required topics you must address (i.e., introduction of team members, whether or not this is an initial or
review or an annual IEP, discussion of test results, present levels, goals, services, Least Restrictive
Environment (LRE) statement, Extended School Year (ESY) services, procedural safeguards, and prior
written notice.

Time Discussion Points

3 minutes Introduction of everyone present

2 minutes Type of meeting

 Initial IEP meeting

 Mary does qualify for services

7 minutes Discussion of Test Results and Present Levels of

Academic Achievement and Functional Performance
(PLAAFP)

 Mary is currently struggling in her general

education classroom in math and reading.
 Mary’s test results showed that she is below
grade level in both math and reading and
needs to receive services for those areas.

7 minutes Goals and Services

 Mary has two math goals. One is related to

identifying and sorting numbers into the
 correct place value and one is related to two
step word problems.
 Mary has two math goals. One is related to
fluency and the other is related to reading
comprehension.
 Explanation of services that will be received.

5 minutes Least Restrictive Environment (LRE) statement and

Extended School Year (ESY)

 Percent of time in special education and

percent of time in general education.
 Discussion of ESY and if it is recommended.

5 minutes Procedural Safeguards and Prior Written Notice

 Short explanation of parent and student

rights.

1 minute (goodbyes) Conclude

Any needed additional time  Questions

 Goodbyes

Plan for Conflicts: Provide a description of ways you can involve parents in the development of
the IEP. Discuss whether you anticipate issues or conflicts that may arise during the meeting and your
plan on addressing those concerns.
I will be sure to involve parents in every part of the discussion. When we begin talking about
Mary’s current scores and progress, I will be sure to ask them what they think. This will give
them an opportunity to discuss if they have seen similar traits at home or if this is new to them.
I will also be sure to check with them after each goal is described to be sure that any questions
and comments are addressed. I will also mention how we all have Mary’s best interest in mind
and these services are being put in place to help her move forward and succeed in the future. If
I find that a conflict may arise, I will be sure to slow down and talk through the conflict to be
sure there is no miscommunication present. If conflicts are not resolved through discussion,
other members may need to be involved to help find a resolution.