PURPOSE: The IEP is designed to clearly communicate to the parents, the student, and providers the type and

amount of special education and any necessary related services or

supports that will be made available to the student. The most recent evaluation report is used to develop the IEP. The IEP is individualized to reflect the unique needs of the student and
how these needs will be addressed to permit the student to be included and progress in the general education curriculum.

INDIVIDUALIZED EDUCATION PROGRAM (WITH SECONDARY TRANSITION)

Student name: Paul Dominguez Student ID No.: 123456789 Date of IEP meeting: September 20th 2019
Birthdate: May 20th 2003 Age: 16.5 Grade: 11 IEP annual review date: September 10th 2019
Adult student: Yes No Eligibility category: Intellectual Disability Date of most recent eval: September 16th 2017
Race/Ethnicity: Primary language: English Reevaluation due date: September 16th 2020
District: Brier School District Resident School: Pinewood High School Serving School (if different):
Parent(s) name(s): Mr. Dominguez and Mr. Dominguez Primary language at home:
Parent interpreter needed? Yes No Surrogate parent: Yes No If yes, name:
Primary staff contact name: Kelsey Barrett Title: Special Education Teacher

PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE POINTS THAT MUST BE
CONSIDERED IN
Present levels of academic achievement: DEVELOPING THE IEP (refer
Reading to WAC 392-172A-03110):
 Paul can read his first and last name 10 out of 10 times with 100% accuracy.  Results of the most current
evaluation, and the academic,
 Paul can read bathroom signs labeled Men’s, Woman’s, Boys and Girls wo out of 10 times with 100% accuracy. developmental, and functional
 Paul can read bathroom signs with alternative names such as Gentleman’s, Ladies, etc., with 0% accuracy. needs of the student.
 Paul is working on reading basic sight words that will facilitate his community access in English class with 40%  Positive behavioral supports
accuracy 10 out of 10 opportunities. and interventions, if the
student’s behavior impedes the
student’s learning or that of
Writing others.
 Paul can print his first and last name with 100% accuracy 10 out of 10 opportunities.  Language needs of students
 Paul can print his phone number with 100% accuracy 10 out of 10 opportunities. with limited English
proficiency as they relate to the
 Paul can print his name in cursive with 0% accuracy 3 out of 3 opportunities. child’s IEP.
 Paul can print his relevant personal information commonly asked on job applications with 10% accuracy on 3  Supports for blind/visually
occasions. impaired students, include
Math Braille instruction.
 Communication needs of the
 Paul can add and subtract single-digit numbers with 100% accuracy 10 out of 10 opportunities. student, including the needs for
 Paul can complete basic mathematic algorithms (addition, subtraction, division and multiplication) with the deaf and hard of hearing
assistance of a calculator with 80% accuracy 10 out of 10 opportunities. students.
 Paul can tell time on an analogue clock at the hour, half hour and 15 minute mark with 100% accuracy 5 out of 5  Assistive technology devices
and services.
times.  Supplementary aids/services,
 Paul can comprehend the concepts of less and more than with 100% accuracy 25 out of 25 times. program modifications, and
 Paul can discriminate between $1, $5 and $10 bills with 50% accuracy 10 out of 10 opportunities. support for school personnel.

Student Name: ____________________________ Date: _____________ Page ____ of _____

Communication
 Paul can communicate utilizing a vocabulary of mainly 100 words that are nouns and verbs 100% of the time
when communicating independently without any technological device or communication system.
 Paul can produce sentences with 4-5 words with 100% accuracy when focused.
 Paul can follow 2 step directions and wait for instruction 5 out of 5 times with 100% accuracy.
 Paul is able to communicate his needs and wants to his family, peers and teachers with his Board Maker device
with 100% accuracy.
Present levels of functional performance (i.e. – communication, motor, social, behavior, life/adaptive skills, etc.):

 Paul has exceptionally close bonds with everyone around him .

 Paul is always ready to go to work on time.
 Paul gets involved with tasks without hesitation.
 Paul likes to help around the house and has chores which include cleaning his room, unloading the dishwasher
and gardening.
 Paul is reported to often needing redirection and reminders when performing tasks around his house.
 Paul can only cook following a pictorial cook book with instruction and redirection, Paul is not proficient
enough to cook independently.
 Paul is has not yet learned how to do his laundry independently.
 Paul does not yet know how to ride the bus systems and read bus maps and routes.
 Paul’s receptive communication is stronger than his expressive communication, and his expressive
communication is much stronger when he is utilizing an AAC device or technology.
 Paul is beginning to initiate social interactions with peers, such as greetings.

Effect of the disability on the student’s involvement and progress in the general education curriculum:

Student Name: ____________________________ Date: _____________ Page ____ of _____

Paul’s diagnosed Intellectual Disability impacts his progress in the general education curriculum at Pinewood High School. His most recent
reevaluation recommends that Paul receives designed instruction in the areas of reading, writing, math and communication.

CONSIDERATION OF SPECIAL FACTORS:

If yes, describe (if not already addressed on the service matrix):
1. Does this student require special
Yes No
transportation?

Yes No
3. Does this student require Extended School Will be determined by If ESY is determined by the IEP team to be necessary, complete and
Year (ESY) services? the IEP team by: attach the ESY addendum.
Date: September 20th 2019
If yes, consider the student’s need for positive behavioral supports/
interventions, a Functional Behavioral Assessment (FBA), and/or a
4. Does the student’s behavior negatively impact Behavioral Intervention Plan (BIP).
Yes No
his/her learning or the learning of others?
A Behavioral Intervention Plan has been developed for this
student (refer to the BIP addendum).
If yes, describe:

5. Are there any other factors not already

addressed (such as medical concerns or other Yes No Paul has a seizure disorder.
issues) or other adaptations needed? Paul has an AAC device.

The parent and the school district have agreed that this student requires advanced educational planning that may involve the use of isolation,
restraint, or a restraint device. Refer to the Emergency Response Protocol addendum to this IEP.

Student Name: ____________________________ Date: _____________ Page ____ of _____

PURPOSE: The purpose of transition planning is to develop a coordinated set of activities designed within a results-oriented process that is focused on improving the academic
achievement and functional performance of the student in order to facilitate the student’s movement from school to post-school activities, including postsecondary education/training,
employment, and if appropriate, independent living skills.

SECONDARY TRANSITION
Student participated in IEP meeting? If no, what steps were taken to ensure that the student’s preferences/interests were considered? POINTS TO CONSIDER:
Yes No  Secondary transition
AGE APPROPRIATE TRANSITION ASSESSMENTS (include results of informal and/or formal assessments including must be addressed in the
student’s needs, strengths, preferences, and interests): first IEP to be in effect
when the student turns
surveys/questionnaires profiles/portfolios vocational assessment(s) other: 16, or younger if
determined appropriate
Paul’s Needs: by the IEP team, and
updated annually.
 Paul’s needs include learning money management skills.
 Measurable
 Paul’s needs include learning how to read bus schedules and routes. postsecondary goals,
 Paul’s needs include learning how to ride the public transportation in his city. based upon age-
 Paul’s needs include learning how to live on his own, therefore cooking, laundry, and independent living skills. appropriate transition
assessment results, must
 Paul’s needs include frequent reminders and redirection. be included in the areas
of education/training,
(Student interview, job supervisor interview, job site evaluation, MAPS) employment, and (if
appropriate) independent
living skills.
Paul’s Strengths:
 Transition services
 Paul is proficient at cleaning his own room. should be based on the
 Paul is proficient at unloading his families dishwasher. individual student’s
 Paul is proficient at weeding and basic gardening tasks in his family and school garden. needs, taking into
account the student’s
 Paul is always ready to go to work. strengths, preferences,
 Paul gets involved in tasks without hesitation. and interests, and may
 Paul has strong receptive communication. include instruction,
related services,
 Paul is proficient at adding and subtracting single digit numbers. community experiences,
 Paul is proficient at printing his first and last name, as well as his phone number. the development of
employment and other
(Student interview, job supervisor interview, job site evaluation, MAPS) postschool adult living
objectives, and if
appropriate, the
Paul’s Preferences: acquisition of daily living
 Paul prefers to work with others. skills and provision of a
 Paul enjoys working in a stock room in a retail job. functional vocational
evaluation.
 Paul preferred to work at the paint store rather than his other work experiences with custodial staff and car washing.
 Paul enjoys gardening tasks both at school and at home.

(Student interview, job supervisor interview, job site evaluation, MAPS)

Student Name: ____________________________ Date: _____________ Page ____ of _____

Paul’s Interests:
 Paul wants to work in a retail after graduation
 Paul expressed interest in getting a bus pass and learning how to use public transportation to go to various locations.
 Paul expressed interest in learning how to cook for himself.
 Paul would like to learn how to do laundry.
 Paul is interested in soccer.
 Paul is interested in attending Zumba classes.

(Student interview, job supervisor interview, job site evaluation, MAPS)

EDUCATION/TRAINING (Required to be addressed for all students)

Measurable Postsecondary Goal(s)
(What the student will do after graduation from high Paul will receive job training for the retail industry after graduation.
school in the area of education/training)

Transition Services (list Transition Services related to Education/Training, including IEP goal number(s) if applicable)
Transition Service Staff/Agency Responsible IEP Goal #
Instruction in functional academics to maximize access to training Pinewood High School,
materials. Pinewood Highschool Staff
Pinewood High School,
Instruction in communication with coworkers and supervisors.
Pinewood Highschool Staff
Pinewood High School,
Instruction in learning and knowing a variety of retail jobs and tasks.
Pinewood Highschool Staff

EMPLOYMENT (Required to be addressed for all students) POINTS TO CONSIDER

(continued):
Measurable Postsecondary Goal(s)
(What the student will do after graduation from Paul will get a hob in the retail industry following graduation.  Transition services may be
high school in the area of employment) special education, if provided
as specially designed
Transition Services (list Transition Services related to Employment, including IEP goal number(s) if applicable) instruction or related
Transition Service Staff/Agency Responsible IEP Goal # services, if required to assist
Pinewood High School, the student in benefitting
Instruction in functional academics to maximize access to a job site. from special education.
Pinewood Highschool Staff
Pinewood High School,  Representatives of any
Instruction in communication with coworkers and supervisors. agencies that are likely to be
Pinewood Highschool Staff responsible for providing or
Pinewood High School, paying for transition services
Instruction in a verity of retail jobs. to the student should be
Pinewood Highschool Staff

Student Name: ____________________________ Date: _____________ Page ____ of _____

 invited to the IEP meeting,
with parent consent.

INDEPENDENT LIVING SKILLS (Must be addressed if determined appropriate by the IEP Team) POINTS TO CONSIDER
(continued):
Measurable Postsecondary Goal(s) Paul will be able to successfully complete all necessary tasks to be able to  Independent living skills
(What the student will do after graduation from are “those skills or tasks
high school in the area of living skills)
independently live with friends or alone.
that contribute to the
Transition Services (list Transition Services related to Independent Living Skills, including IEP goal number(s) if applicable) successful independent
functioning of an
Transition Service Staff/Agency Responsible IEP Goal #
individual in adulthood”
Pinewood High School, (Cronin, 1996) in the
Instruction in cooking independently
Pinewood Highschool Staff following domains:
Pinewood High School, leisure/recreation, home
Instruction in public transportation in his city. maintenance and personal
Pinewood Highschool Staff
care, and community
Pinewood High School, participation.
Instruction in communicating self-advocacy.
Pinewood Highschool Staff
Pinewood High School,
Instruction in how to do his own laundry.
Pinewood Highschool Staff

COURSE(S) OF STUDY (list the course(s) of study needed to assist the student in reaching his/her postsecondary goals, unless already POINTS TO
described above, or attach a list of courses) CONSIDER
 The IEP must include a
description or list of the
course(s) of study
needed to assist the
During High School, Paul will participate in the following courses to support his transition goals: student in reaching
 Daily Living Skills. his/her specific
 Applied Academics. postsecondary goals.
 Vocational Tech.

Student Name: ____________________________ Date: _____________ Page ____ of _____

PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the student’s educational needs that result
from the student’s disability to enable the student to be involved and make progress in the general education curriculum. For students using an alternate assessment aligned to alternate
achievement standards, benchmarks or short-term objectives in the areas being assessed must also be included. In order to be measurable, the goal should include a baseline, a target,
and a unit of measure.

MATH MEASURABLE ANNUAL GOAL(S) WITH SHORT-TERM OBJECTIVES/BENCHMARKS

Method/Criteria for POINTS TO
Goal Measurable Annual Goals Progress Notes (if not maintained separately) CONSIDER:
Evaluating Progress
# MATH (if not addressed in a Date Date Date Date  Measurable annual
separate document) goals stem from the

All of the goals are on the following

page, I am not sure why I cannot get
the formatting for all of them to fit on
one page.

Student Name: ____________________________ Date: _____________ Page ____ of _____

 MATH recommendations
for specially
designed instruction
When given 10 addition problems in the evaluation
with double-digit numbers under 30, report.
Paul will be able to accurately add the  Measurable annual
sums together without the use of a goals must relate to
the general
calculator using the correct
education
1 mathematical addition methods from curriculum or, for
0 out of 10 opportunities to 10 out of preschool students,
10 consecutive opportunities in participation in
months. appropriate
activities.
 Measurable annual
When given 10 10 subtraction goals must also
problems with double-digit numbers address other
under 30, Paul will be able to educational needs
accurately add the sums together that result from the
2 without the use of a calculator using All annual student’s disability.
 The IEP must
the correct mathematical subtraction
methods from 0 to 10 opportunities, goals will be include a description
of how the district
to 10 out of 10 consecutive
opportunities.
evaluated and will measure the
student’s progress
measured by and when progress
will be reported to

When given $1, $5, $10 and $20, Paul educator data parents.

will be able to accurately pay for collection

items under $35 dollars from 0 out of
5 opportunities to 5 out of 5
3 consecutive opportunities.

When shown a digital clock, Paul will

be able to identify and state the time
including hour and minutes from 0
4 out of 10 opportunities to 9 out of 10
opportunities.

Student Name: ____________________________ Date: _____________ Page ____ of _____

 
Benchmarks or Short-Term Objectives - MATH
1) When given 10 addition problems with double-digit numbers under 20, Paul will be able to accurately add the sums together 
without the use of a calculator using the correct mathematical addition methods from 0 out of 10 opportunities to 8 out of 10
consecutive opportunities.

2) When given 10 10 subtraction problems with double-digit numbers under 20, Paul will be able to accurately add the sums 
together without the use of a calculator using the correct mathematical subtraction methods from 0 to 10 opportunities, to 8 out
of 10 consecutive opportunities.


3) When given $1, $5, $10 and $20, Paul will be able to accurately pay for items under $20 dollars from 0 out of 5 opportunities
to 4 out of 5 consecutive opportunities.

4) When shown a digital clock, Paul will be able to identify and state the time including hour and minutes from 0 out of 10 
opportunities to 6 out of 10 opportunities.

Copy additional pages as necessary

Student Name: ____________________________ Date: _____________ Page ____ of _____

 READING MEASURABLE ANNUAL GOAL(S) WITH SHORT-TERM OBJECTIVES/BENCHMARKS
Method/Criteria for POINTS TO
Goal Measurable Annual Goal Progress Notes (if not maintained separately) CONSIDER:
Evaluating Progress
# READING (if not addressed in a Date Date Date Date  Measurable annual
separate document) goals stem from the
recommendations
When given the menu at Paul’s five for specially
favorite restaurants, Paul will be able designed instruction
1
to accurately read the menu items in the evaluation
from 1 out of 10 opportunities to 10 report.
out of 10 opportunities.  Measurable annual
goals must relate to
the general
When given the bus schedule, Paul education
2
will be able to read the schedule and curriculum or, for
choose the correct route and time to All annual preschool students,
participation in
go to his desired location from 0 out
of 10 opportunities to 10 out of 10 goals will be appropriate
activities.
opportunities. evaluated and  Measurable annual
goals must also
When given the schedule of Paul’s measured by address other
educational needs
Zumba Classes, Paul will be able to
3
chose a class to attend that aligns with educator data that result from the
student’s disability.
his schedule from 0 out of 10 collection  The IEP must
opportunities to 10 out of 10 include a description
opportunities. of how the district
will measure the
student’s progress
When given a mock job application, and when progress
Paul will be able to read the desired will be reported to
personal information from 0 out of 5 parents.
4
opportunities to 5 out of 5
opportunities.

Reading Benchmarks or Short-Term Objectives

1) When given the menu at Paul’s five favorite restaurants, Paul will be able to accurately read the menu items from 1 out of 10
opportunities to 5 out of 5 opportunities

2) When given the bus schedule, Paul will be able to read the schedule and choose the correct route and time to go to his desired
location from 0 out of 10 opportunities to 3 out of 3 opportunities.

Student Name: ____________________________ Date: _____________ Page ____ of _____

 
3) When given the schedule of Paul’s Zumba Classes, Paul will be able to chose a class to attend that aligns with his schedule
from 0 out of 10 opportunities to 3 out of 5opportunities.


4) When given a mock job application, Paul will be able to read the desired personal information from 0 out of 5 opportunities
to 3 out of 3 opportunities.
Copy additional pages as necessary

PURPOSE: The purpose of the report of student progress is to inform the parents and the student of the student’s progress toward meeting the measurable annual goal(s) and to
specify how and when parents will be informed.

Student Name: ____________________________ Date: _____________ Page ____ of _____

 WRITING MEASURABLE ANNUAL GOAL(S) WITH SHORT-TERM OBJECTIVES/BENCHMARKS
Method/Criteria for POINTS TO
Goal Writing Measurable Annual Progress Notes (if not maintained separately) CONSIDER:
Evaluating Progress
# Goal (if not addressed in a Date Date Date Date  Measurable annual
separate document) goals stem from the
recommendations
for specially
designed instruction
in the evaluation
report.
 Measurable annual
goals must relate to
When given a writing utensil and the general
1 asked to write his signature, Paul will education
be able to sign his name in cursive curriculum or, for
from 0 to 5 opportunities to 5 out of 5 preschool students,
participation in
opportunities. appropriate
activities.
 Measurable annual
2 When given a mock job application, goals must also
Paul will be able to print the desired All annual address other
educational needs
personal information asked on the
application (address, DOB, etc.) from
goals will be that result from the
student’s disability.
0 out of 6 to 6 out of 6 opportunities. evaluated and  The IEP must
measured by include a description
of how the district
3 When given a list of foods that Paul
prefers, Paul will be able to write a educator data will measure the
student’s progress
shopping list by copying food names collection and when progress
from his food list onto a grocery will be reported to
shopping list from 0 out of 3 parents.
opportunities to 3 out of 3
opportunities.

4 When given a calendar of the next

week, Paul will be able to write
important events on his schedule such
as school, work, games, social events,
classes and appointments from 0 out
of 5 opportunities to 5 out of 5
opportunities.

Student Name: ____________________________ Date: _____________ Page ____ of _____

 
Writing Benchmarks or Short-Term Objectives

When given a writing utensil and asked to write his signature, Paul will be able to sign his name in cursive from 0 to 5
opportunities to 2 out of 2 opportunities.


When given a mock job application, Paul will be able to print the desired personal information asked on the application (address,
DOB, etc.) from 0out of 3 to 3 out of 3opportunities


When given a list of foods that Paul prefers, Paul will be able to write a shopping list by copying food names from his food list
onto a grocery shopping list from 0 out of 3 opportunities to 2 out of 3 opportunities.


When given a calendar of the next week, Paul will be able to write important events on his schedule such as school, work,
games, social events, classes and appointments from 0 out of 5 opportunities to 2 out of 3 opportunities.

COMMUNICATION MEASURABLE ANNUAL GOAL(S) WITH SHORT-TERM OBJECTIVES/BENCHMARKS

POINTS TO
Communication Measurable Method/Criteria for Progress Notes (if not maintained separately) CONSIDER:
Annual Goal Evaluating Progress Date Date Date Date

Student Name: ____________________________ Date: _____________ Page ____ of _____

 
Benchmarks or Short-Term Objectives

When Paul is at one of his five favorite restaurants, Paul will be able to order his favorite drink and food item from the menu
with from 1 out of 5 occasions to 3 out of 3 occasions.


When speaking without the use of an AAC device or technology, Paul will be able to say a sentence with at least six words
instead of four to five words from 0 out of 20 opportunities to 3 out of 5 opportunities.


When using the app ProLoQuo2Go, Paul will be able to express basic wants and needs to strangers from 0 out of 10
opportunities to 7 out of 10 opportunities.

When asked to state his important personal information, such as his phone number, address, full name, blood type and 
close family members, Paul will be able to verbalize the correct answers from 0 out of 5 opportunities to 3 ut of 5
opportunities.
Copy additional pages as necessary

Copy additional pages as necessary

PARTICIPATION IN STATE AND DISTRICTWIDE ASSESSMENTS OF STUDENT ACHIEVEMENT

State Assessments – The student will participate in the following state assessment(s) during this annual IEP: POINTS TO CONSIDER:
 The IEP team makes the
English/ determination of what type of
Lang Arts Math Science assessment the student will
Regular State Assessment take and what administrative
modifications and individual
Regular State Assessment with Accommodations accommodations are
Alternate Assessment – WA-AIM necessary.
Other:  Accommodations provided on
state and districtwide
Districtwide Assessments – The student will participate in the following districtwide assessment(s) during this
Student Name: ____________________________ Date: _____________ Page ____ of _____
annual IEP: assessments should be those
that are provided as part of the
regular instructional program.
 For further information
Accommodations – List any individual accommodations in the administration of the state or districtwide assessments regarding the state assessment
necessary for the student to participate: system, allowable
accommodations, and
The WA-AIM is an individualized assessment. graduation requirements,
please refer to OSPI’s website
(www.k12.wa.us/assessment).
If the student: (a) will not participate in the regular state assessment (with or without accommodations) or (b) is unable  Other assessment options are
to participate in a regular districtwide assessment, explain why the student cannot participate in the regular assessment available to students if
and why the selected assessment option is appropriate: required to meet graduation
requirements.
The WA-AIM is the best state assessment currently available to measure Paul’s skills.

Graduation – If the student requires other assessments in order to meet graduation requirements, describe  Parents and students should be informed that
any assessment other than the regular state
here (specify assessment and grade level as appropriate):
assessment (with or without accommodations)
leads to a Certificate of Individual
Achievement (CIA), rather than a Certificate
of Academic Achievement (CAA).

PURPOSE: The purpose of this page is to document the modifications and/or accommodations that the student requires, based on the student’s assessed needs, in order to advance
appropriately toward attaining the identified annual goals, to be involved and make progress in the general education curriculum, and to be educated with non-disabled peers to the
maximum extent appropriate.

ACCOMMODATIONS, MODIFICATIONS, AND ASSISTIVE TECHNOLOGY

Subject Subject Accommodations/Modifications Needed POINTS TO
(codes below)
Accommodations/Modifications Needed (codes below) CONSIDER:
 The IEP team

Student Name: ____________________________ Date: _____________ Page ____ of _____

 Presentation Setting
what
modifications and
individual
accommodations
are necessary for
the student.
 Copies of this
page should be
provided to the
general education
teacher(s) or other
staff who will be
responsible for
making these
accommodations.
 Accommodations
provided on state
and districtwide
assessments (as
noted on the
previous page)
should be those
that are provided
as part of the
regular
instructional
program.
Use large print/Braille/recorded books a Provide individualized/small group instruction
a Alter format of materials (highlight, type, spacing, color-code etc.) a Read class materials orally
Low-vision devices (magnifiers, Closed Circuit TV, etc.) a Provide study outlines/guides/graphic organizers
Sign Language – ASL or SEE a Modify/repeat/model directions
a Shortened assignments Take test in separate location
a Preview test procedures a Preferential seating
a Limited multiple choice Other:
Rephrase test questions and/or directions Response
b,c,e Provide test/quiz study guide Utilize oral responses to assignments/tests
a Provide extra credit options a Text-to-Speech (Kurzweil, WYNN, Text Help, etc.)
b,c,e Simplify test wording Allow dictation to a scribe
Read class materials orally a Allow use of a calculator
Assign peer tutor/note taker Allow use of tape recorder
Other: a Spelling and grammar devices
Timing/Scheduling a Speech-to-text software
Prior notice of tests/quizzes Hands-on assignments
a Extra time to complete assignments Other:

Student Name: ____________________________ Date: _____________ Page ____ of _____

 Modify student’s schedule (describe below): Other
Provide desktop list of tasks
b,c,e,f,g,h
Provide homework lists
Behavior plan/contract
Extra time on tests/quizzes a Provide daily assignment list
Allow breaks (during work, between tasks, during testing, etc.) a Modified grading
Other: Other:
Assistive Technology
a Describe: Paul will use ProLoQo2Go as an AAC device, he is receiving training with the device at Pinewood High School.
Describe:
Describe:
a. All subjects e. Math i. Health m. Vocational p. Extracurricular Activities
b. Reading f. Science j. Economics n. Lunch/Recess q. Other:
c. English g. Social Studies k. Physical Education o. Library r. Other:
d. Spelling h. History l. Music/Art

Student Name: ____________________________ Date: _____________ Page ____ of _____

PURPOSE: The information on this page is a summary of the student’s program/services, including when services will begin, where they will be provided, who will be responsible for
providing them, and when they will end.

(Was told on 11/26/2019 this section does not need to be

completed)
SUMMARY OF SERVICES MATRIX

Location of Staff Responsible POINTS TO

Initiation Frequency CONSIDER:
Service Service Duration for Delivering  If the position
Date (i.e. – minutes per week)
(setting) Service responsible for
Special Education (specially designed instruction): delivering the
specially designed
instruction is anyone
other than a
certificated special
education teacher or
related service
provider, then the
certificated special
education
teacher/related
service provider must
design and supervise
the instruction, and
Related Services (i.e. – speech, motor, counseling, vision/hearing, transportation, interpreting services, orientation/mobility, parent training, etc.): monitor and evaluate
the student’s
progress.
 For definitions of
special education,
related services, and
supplementary aids
and services, refer to
WAC 392-172A-
Supplementary Aids and Services (allows student to be educated with non-disabled peers to the maximum extent in general education or other 01020 through
educational setting): -01200.

Program Modifications or Support for School Personnel (i.e. – staff development/training, technical assistance, etc.):

Student Name: ____________________________ Date: _____________ Page ____ of _____

PURPOSE: The purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum, participate in extracurricular and
nonacademic activities and be educated and participate with other special education students and non-disabled students. Other education-related factors that may impact the student
should also be considered.

(Was told on 11/26/2019 this section does not need to be

completed)
LEAST RESTRICTIVE ENVIRONMENT:
Students ages 6 and above Choose one: POINTS TO CONSIDER:
 Children should be educated
= Total minutes per week of building with non-disabled peers to the
maximum extent appropriate.
A. instructional time available for this student  The IEP Team, including the
(excluding lunch) In general education setting 80 to 100% of the parent(s), is responsible for
time determining the educational
In general education setting 40 to 79% of the time placement of the child.
= Total of those minutes in A. above in which
In general education setting 0 to 39% of the time  Job placements and
B. this student is in a special education setting community-based instruction
(excluding lunch) In separate day school (public or private) are considered to be general
Residential facility (public or private) education settings, unless only
Correctional facility disabled individuals are present
(such as in a sheltered
Homebound/hospital workshop).
= Percent of time spent in a general education
setting (A minus B divided by A) Home-school/parentally-placed private school  For additional information on
LRE for students ages 6 and
above, refer to the LRE
Calculator.

An explanation of the extent, if any, to

which the student will not participate
with nondisabled students in the general
education class, and in nonacademic and
extracurricular activities, including a
description of any adaptations needed for
participation in physical education:

Student Name: ____________________________ Date: _____________ Page ____ of _____

 PARTICIPANTS IN IEP MEETING (Signatures are used to document participation in the meeting and do not constitute
agreement or disagreement):
POINTS TO CONSIDER:
Mr. Dominguez  IEP team membership is described
Parent/Guardian Name/Title in WAC 392-172A-03095.
 School district must give prior
written notice when proposing or
Mrs. Dominguez refusing to initiate or change the
Parent/Guardian Name/Title identification, evaluation,
educational placement, or
provision of FAPE.
Paul Dominguez  A required team member may be
Student Name/Title excused from attending an IEP
meeting with the agreement/
consent of the parent(s) and the
Kelsey Barrett district, depending upon whether
Special Education Teacher Name/Title that member’s area is being
discussed or modified at the
meeting. See WAC 392-172A-
Kaylee Leatherwood 03095 (5) for additional related
General Education Teacher Name/Title requirements.
 The IEP must include the district’s
Vice Principal procedures for notifying parents
regarding the use of restraint or
District Representative Name/Title
isolation. Districts must also
provide parents with a copy of the
district’s policy on the use of
isolation and restraint.

Other individuals who should be informed of his/her responsibilities in implementing the IEP (bus driver, librarian, etc.):

Bus Driver, Nurse, Custodial Staff, Paraeducators.

TRANSFER OF RIGHTS: Beginning at least one year before reaching age 18, POINTS TO CONSIDER:
 When the student reaches age 18 (or majority), the
the student has been informed that all rights will transfer to the student at age 18,
Yes No district must notify the parents and the student that
unless there is a guardianship or other determination that the student cannot make rights have transferred to the student, and provide
educational decisions. any notices required to the student and parents.

The district has procedures for notifying parents regarding the use of restraint or isolation. A copy of those procedures is attached to this IEP.

*Note: Before providing initial special education services to a student, the district must obtain informed written parental consent.
(See model form 3)

Student Name: ____________________________ Date: _____________ Page ____ of _____