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Federal Placement Code: Select Placement Code Emotional Disturbance Initial IEP
Federal Student Ethnicity Code: Select Ethnicity Code Health Impairment Annual IEP
Address: 123 Main St. Hearing Impairment/Deaf IEP Following 3-Yr Reevaluation
Student Phone: 123-456-7890 Intellectual Disability Revision To IEP Dated
Interpreter or Other Accommodations NeededSelect Y or N Traumatic Brain Injury IEP SERVICES WILL BEGIN 2/10/19
Emergency Contact/Phone Number 123-456-7890 Visual Impairment/Blind ANTICIPATED
DURATION OF SERVICES 1 year
Current School Nice School Zoned School Nice School ELIGIBILITY DATE 1/10/18
IEP REVIEW DATE 1/10/20
ANTICIPATED 3-YR COMMENTS
REEVALUATION1/10/21
IEP PARTICIPATION
Parent/Guardian/Surrogate* Mrs. G Speech/Language Therapist/Pathologist/Specialist Polly Hespe
Student** Rita G School Nurse Nancy Lightfoot
LEA Representative* Sara Mac Interpreter N/A
Special Education Teacher* Shelby Olson Other (name and role)
Regular Education Teacher*** Mr. MIld Other (name and role)
School Psychologist Jordan McAfee Other (name and role)
*Required participant.
** Student must be invited when transition is discussed (beginning at age 14 or younger if appropriate).
***The IEP team must include at least one regular education teacher of the student (if the student is, or may be, participating in the regular education environment).
PROCEDURAL SAFEGUARDS
I have received a statement of procedural safeguards under the Individuals with Disabilities Education Act (IDEA) and these rights have been explained to me in my primary language.
Parent Signature
AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, STUDENTS MUST BE INFORMED OF THEIR RIGHTS UNDER IDEA AND ADVISED THAT THESE RIGHTS WILL TRANSFER TO THEM AT AGE 18.
Not applicable. Student will not be 18 within one year, and the student's next annual IEP meeting will occur no later than the student's 17th birthday.
The student has been informed of his/her rights under IDEA and advised of the transfer of these rights at age 18.
ASSESSMENTS CONDUCTED ASSESSMENT RESULTS EFFECT ON STUDENT'S INVOLVEMENT AND PROGRESS IN GENERAL EDUCATION
CURRICULUM OR, FOR EARLY CHILDHOOD STUDENTS, INVOLVEMENT IN
DEVELOPMENTAL ACTIVITIES
1. Wechsler Intelligence WISC-111 Full Scale IQ: 109 Rita seemed to give up as soon as items became difficult and did not seem to have any
Scale for Children-Third Verbal IQ: 128 system for attacking challenging problems. When items became hard for her, Rita seemed
Edition (WISC-111) Performance IQ: 87 helpless and simply said, "I can't do that. It's too hard for me."
2. Peabody Individual
Achievement Test-
Revised (PIAT-R), Key Scores ranged between 1.8 and 2.5. She does not volunteer to answer questions in class, and often gives up after struggling
Math-Revised, and with one question.
Brigance
Comprehensive
Inventory of Basic
Skills-Revised
3. Brigance
Comprehensive Scored satisfactorily in tests of word recognition, word When she was observed during the reading, she seemed to lose her place and had
Inventory of Basic identification, phonics skills and reading vocabulary. difficulty concentrating on the material.
Skills-Revised, the Her reading comprehension is at the independent
PIAT-R, the Woodcock reading level of second grade. Her word recognition
Reading Mastery Tests- skills are at the fourth-grade level.
Revised and the Gray
Oral Reading Tests,
Third Edition
4. Brigance
Comprehensive Written expression could not be tested because of her She is left-handed and has had much difficulty performing this visual-motor task. Her
Inventory of Basic extremely poor handwriting skills. written papers are a difficult for her and require much effort and time. And the final product
Skills-Revised is usually illegible and is quite sloppy. She begins many letters from the bottom, moving to
5. Brigance the top of a line. Tall letters are the same size as small ones and her pencil grasp is odd.
Comprehensive
scored at the second grade level.
Inventory of Basic she usually spelled words according to phonics rules, for
Skills-Revised, example, frend for friend, laf for laugh, and tok for talk. She showed poor visual memory for
the Woodcock- irregularly spelled words.
Johnson
Psychoeducational
Battery-111 (WJ-111),
and the Wide Range
Achievement Test-111
(WRAT-111)
Lowest scores were in the areas of daily living skills Rita relies on other people to tell her what to do and that she has made no friends and
6. Vineland Adaptive
and socialization. plays mostly with her younger sister. Rita lacks the motivation to organize herself to
Behavior Scales
complete school work and will often "just sit there".
7. Developmental Test of
Score was equivalent to that of a 6 year old, or three
Visual-Motor
full years below her chronological age. Although she could copy simple designs, such as the circle and plus sign, she had
Integration
difficulty with the triangle, diamond and other more complicated shapes.
8. Goldman-Fristoe-
scores were adequate
Woodcock Test of
Suggests a strength in auditory discrimination.
Auditory
Discrimination
STATEMENT OF STUDENT'S PREFERENCES AND INTERESTS (required if transition services will be discussed, beginning at age 14 or younger if appropriate)
If student was not in attendance, describe the steps taken to ensure that the student's preferences and interests were considered:
For Rita, we will ensure that she is kept on task by encorporating an artisic quality into lessons with music and rythems. Also, postive reinforcements could be implemented
through treats.
1. Does the student's behavior impede the student's learning or the learning of others? No. Yes.
If YES, IEP committee must provide positive behavioral strategies, supports and interventions, or other strategies, supports and interventions to address that
behavior.
Addressed in IEP.
2. Does the student require assistive technology devices and services? No. Yes.
If YES, IEP committee must determine nature and extent of devices and services.
Addressed in IEP.
If YES, IEP committee must consider the student’s language and communication needs and consider the following (check box if IEP committee considered the
item):
The related services and program options that provide the student with an appropriate and equal opportunity for communication access.
The student’s primary communication mode.
The availability to the student of a sufficient number of age, cognitive, academic and language peers of similar abilities.
The availability to the student of adult models who are deaf or hearing impaired and who use the student’s primary communication mode.
The availability of special education teachers, interpreters and other special education personnel who are proficient in the student’s primary communication
mode.
The provision of academic instruction, school services and direct access to all components of the educational process, includ ing, without limitation, advanced
placement courses, career and technical education courses, recess, lunch, extracurricular activities and athletic activities.
The preferences of the parent or guardian of the student concerning the best feasible services, placement and content of the student’s IEP.
The appropriate assistive technology necessary to provide the student with an appropriate and equal opportunity for communica tion access.
6. Does the student have a Specific Learning Disability and Dyslexia? No. Yes.
If YES, the IEP committee must consider the following instructional approaches (check box if IEP committee considered the item):
Explicit, direct instruction that is systematic, sequential and cumulative and follows a logical plan of presenting the alphabetic principle that targets the specific needs
of the student.
Individualized instruction to meet the specific needs of the student in an appropriate setting that uses intensive, highly-concentrated instruction methods and
materials that maximize student engagement.
Meaning-based instruction directed at purposeful reading and writing, with an emphasis on comprehension and composition.
Multisensory instruction that incorporates the simultaneous use of two or more sensory pathways during teacher presentations and student practice.
TRANSITION
DIPLOMA OPTION SELECTED FOR GRADUATION (Diploma option must be declared at age 14 and reviewed annually.)
Standard or Advanced High School Diploma. Must complete all applicable credit Adjusted High School Diploma. Must complete IEP requirements.
requirements and pass the High School Proficiency Examination (with permissible accommodations as needed).
Training/Education
Employment
Other
TRANSITION (continued)
STATEMENT OF TRANSITION SERVICES: COORDINATED ACTIVITIES
Beginning not later than the first IEP to be in effect when the student is 16, develop a statement of needed transition services, including strategies or activities, for the student.
Instruction
Related Services
Community Experiences
Acquisition of Daily Living Skills and Functional Vocational Evaluation (if appropriate)
Other
IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS, AND BENCHMARKS OR SHORT-TERM OBJECTIVES
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress Being Made (continue)
Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)
Training/Education Employment Independent Living Skills Other 3. Goal Met (note date)
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
2. Satisfactory Progress Being Made (continue)
Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)
Training/Education Employment Independent Living Skills Other 3. Goal Met (note date)
IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS, AND BENCHMARKS OR SHORT-TERM OBJECTIVES
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
3. Satisfactory Progress Being Made (continue)
Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)
Training/Education Employment Independent Living Skills Other 3. Goal Met (note date)
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
4. Satisfactory Progress Being Made (continue)
Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)
Training/Education Employment Independent Living Skills Other 3. Goal Met (note date)
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METHOD FOR REPORTING THE STUDENT'S PROGRESS TOWARD MEETING ANNUAL GOALS (check all PROJECTED FREQUENCY OF REPORTS
methods that will be used)
IEP Goals Pages District Report Card Quarterly Semester
Specialized Progress Report Parent Conferences Trimester Other
Other
N/A -
-
-
-
-
-
RELATED SERVICES
RELATED SERVICE SERVICE TYPE AND/OR BEGINNING FREQUENCY LOCATION
DESCRIPTION AND ENDING OF SERVICES OF
A - Assessment DATES SERVICES
C - Consultative
D - Direct
PLACEMENT
PLACEMENT CONSIDERATIONS PERCENTAGE OF TIME
IN REGULAR EDUCATION ENVIRONMENT
Selected Rejected Regular class with supplementary aids and services (no removal)
Selected Rejected Regular class and special education class (e.g., resource) The student will spend 90 % of his or her school day in the
combination Selected Rejected Self-contained program regular education environment.
Selected Rejected Special School
Selected Rejected Residential
Selected Rejected
Hospital
Selected Rejected
Home
Selected Rejected Other
*Regular education environments include academic classes (which might include field trips linked to the curriculum), nonacademic settings (such as recess), and extracurricular activities
(for example, sports, after-school clubs, band, etc.).
IEP IMPLEMENTATION
As the parent, I agree with the components of this IEP. I understand that its provisions will be implemented as soon as possible after the IEP goes into effect.
As the parent, I disagree with all or part of this IEP. I understand that the school district must provide me with written notice of any intent to implement this IEP. If I wish to prevent the implementation of this IEP, I must
submit a written request for a due process hearing to the local school district superintendent.
Parent Signature
A copy of this IEP was provided to the student’s parent on : ________2/19/19___________by_Shelby ______________________________Olson_________________
(2/19/19) (Shelby Olson)(Special Education Teacher)