DATE 07-23-2021 PAGE 1 OF 10

STATE OF NEVADA

INDIVIDUALIZED EDUCATIONAL PROGRAM (IEP)

INFORMATION
STUDENT/PARENT INFORMATION ELIGIBILITY CATEGORY MEETING INFORMATION
Student Chloenette Baker Sex Female ✔ Autism Spectrum Disorder DATE OF MEETING 4/14/2017
DATE OF LAST IEP MEETING 4/14/2016
Birthdate 08/15/2008 Grade 3rd Student ID # 123456 Deaf/Blind
Student Primary Language English PURPOSE OF MEETING
Developmental Delay
Student English Proficiency Code (optional) Interim IEP
Emotional Disturbance
Address 111 Ocean Park Orange Ca 92677 Initial IEP
Health Impairment
Student Phone 818-898-9090 Annual IEP
Hearing Impairment/Deaf
✔ IEP Following 3-Yr Reevaluation
Intellectual Disability
Parent/Guardian/Surrogate Alice and Andy Baker Revision To IEP Dated
Multiple Impairment
Parent Phone (Home) 818-898-9090 (Work) 818-500-4000 Exit/Graduation
Orthopedic Impairment
Optional: Cell 818-432-1094 Email 1234ndsa@gmail.com
IEP Revision Without A Meeting:
Specific Learning Disability
Primary Language Spoken at Home English and Indonesian At the request of : ✔ Parent or School District
✔ Speech/Language Impairment
LEP Status Other
Federal Placement Code Traumatic Brain Injury
IEP SERVICES WILL BEGIN 4/15/2017
Federal Student Ethnicity Code 7 Visual Impairment/Blind
ANTICIPATED
Interpreter or Other Accommodations Needed N/A ELIGIBILITY DATE 4/14/2017 DURATION OF SERVICES 08/15/2029
Emergency Contact/Phone Number Aunt Baker 818-444-5555 ANTICIPATED IEP REVIEW DATE 04/14/2018
3-YR REEVALUATION 4/14/2020
Current School Sunnydale Elementary Zoned School Sunnydale Elementary COMMENTS

IEP PARTICIPATION
Parent/Guardian/Surrogate* Alice and Andy Baker Speech/Language Therapist/Pathologist/Specialist Kacy T M.A., CCC-SLP
Student** Chloenette Baker School Nurse
LEA Representative* N/A Interpreter
Special Education Teacher* Mrs. Wooley Other (name and role) Sarah W., M.A.E.D.
Regular Education Teacher*** Mr. Cooke Other (name and role) Dianna E., OTR/L
School Psychologist Megan R., M.S. Other (name and role) Alice Baker, Mother and Andy Baker, Father
*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 Alice and Andy Baker

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.

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PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Consider results of the initial evaluation or most recent reevaluation, and the academic, developmental, and functional needs of the student, which may include the following areas:

academic achievement, language/communication skills, social/emotional/behavior skills, cognitive abilities, health, motor skills, adaptive skills, pre-vocational skills, vocational skills, and other skills as

appropriate. For students who are 16 or older, or will turn 16 when this IEP is in effect, also consider the results of age appropriate transition assessments related to training/education, employment,

and independent living skills (as appropriate).

ASSESSMENTS CONDUCTED
Review of School Records
Interviews
Observations
Review of Health and
Developmental History
Leiter International Performance
Scale, 3rd Edition
Wechsler Intelligence Scale for
Children, 5th Edition
The Berry-Buktenica
Developmental Test of Visual
Motor Integration, 6th Edition
Gilliam Autism Rating Scale, 3rd
Edition
Vineland Adaptive Behavior
Scales, 2nd Edition
Wechler Individual Test of
Achievement, 3rd Edition
Brigance Comprehensive
Inventory of Basic Skills, 2nd
Edition
Preschool Language Scales, 5th
Edition
Peabody Picture Vocabulary Test,
4th Edition
Expressive One-Word Picture
Vocabulary Test, 4th Edition
Informal Language Sample
Pragmatic Language Profile
Goldman-Fristoe Test of
Articulation, 3rd Edition
Bruininks-Oseretsky Test of Motor
Proficiency, 2nd Edition
Developmental Test of Visual
Perception, 3rd Edition
Sensory Processing Measure
(SPM)- Home Form, Completed by
her Mother, Amy Baker
Sensory Processing Measure
(SPM)- School Form, completed
by her teacher, Mrs. Wooley
ASSESSMENT RESULTS EFFECT ON STUDENT'S INVOLVEMENT AND PROGRESS IN GENERAL EDUCATION
CURRICULUM OR, FOR EARLY CHILDHOOD STUDENTS, INVOLVEMENT IN
DEVELOPMENTAL ACTIVITIES
Leiter International Performance Scale,Chloenette struggles with exapnsive verbal communication as
3rd Edition- well as with reading and writing related skills with her scores
ranging from very low to below average. Her verbal
Figure Ground - Scaled/Standard: 8 communication, comprehension, reasoning and vocabulary
(Average) can hinder her ability to interact with other classmates and
teacher within the classroom during assignments, individual or
Form Completion - Scaled/Standard: 14 partner, and group projects. It can cause her difficulties
(Above Average) responding to prompts/assignments that might require verbal
communication to show understanding. She also struggles
Classification/Analogies - with basic social skills like understanding jokes or expressions
Scaled/Standard: 12 (Average) and when she is being ridiculed, so that can cause another
stressor within the general education classroom which could
Sequential Order - Scaled/Standard: 11 add to her emotional repsonses (frustrated quickly, temper
(Average) tantrums) while she is working on her assignments. She
scores low with talking, listening, reading, and writing, so she
Nonverbal IQ - Scales/Standard: 105; would most likely have dificulties keeping up with the general
Percentile Rank 63 (Average) education curriruclum on her own without the needed support.
Berry-Buktenica Developmental Test of
Visual Motor Integration, 6th Edition-
VMI - Standard Score: 78; Percentile
Rank: 7 (Low)
Visual Perception - Standard Score: 89;
Percentile Rank: 23 (Below Average)
Motor Coordination - Standard Score:
71; Percentile Rank: 3 (Low)

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STRENGTHS, CONCERNS, INTERESTS AND PREFERENCES

STATEMENT OF STUDENT STRENGTHS

Highly organized, follows written schedule independently, highly motivated to learn, excellent fine motor skills, works well
individually, great balance, excellent memory, always remembers where she puts her things, self-learner, able to navigate
technology independently, very neat, fun loving, full of energy, excellent gross motor skills

STATEMENT OF PARENT EDUCATIONAL CONCERNS

Difficulty with unexpected schedule changes or transitions, easily frustrated when making a mistake, needs additional time to
respond to direction, visual motor control and precision, poor coordination, eloping, dropping to the floor, climbing, tantruming,
work on expression of feelings, writing, sitting still, ability to follow classroom's flow and her short attention span

STATEMENT OF STUDENT'S PREFERENCES AND INTERESTS (required if transition services will be discussed, beginning at age 14 or younger if appropriate)
Dora the Explorer, Spanish, Repeats words, Intense obsessive interest with specific intellectual subjects, enjoys crafting, loves
being around other people, books, math

If student was not in attendance, describe the steps taken to ensure that the student's preferences and interests were considered:

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CONSIDERATION OF SPECIAL FACTORS

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.

3. Does the student have limited English proficiency? ✔ No. Yes.

If YES, IEP committee must consider the following (check box if IEP committee considered the item):

Language needs of the student as those needs relate to the student's IEP.

4. Is the student blind or visually impaired? ✔ No. Yes.

If YES, IEP committee must evaluate reading and writing skills, needs, and appropriate reading and writing media (including an evaluation of the child’s future needs for
instruction in Braille or use of Braille) and must provide for instruction in Braille and use of Braille unless determined not appropriate for the student.
Braille instruction and use of Braille is not appropriate for student. Braille instruction and use of Braille is addressed in IEP.

5. Does the student have communication needs that require IEP services? No. ✔ Yes.

If YES, IEP committee must determine nature and extent of services.

✔ Addressed in IEP.

6. Is the student deaf or hard of hearing? ✔ No. Yes.

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, including, 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 communication access.

7. 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.

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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 participate in a College and Career Readiness Assessment.

Alternative High School Diploma. Must complete all applicable credit requirements and participate in the Nevada Alternate Assessment.

STUDENT'S VISION FOR THE FUTURE

A short statement that directly quotes what the student wants for the future.

STATEMENT OF TRANSITION SERVICES: COURSE OF STUDY

Beginning at age 14 or younger if determined appropriate by the IEP team, describe the focus of the student's course of study.

STATEMENT OF MEASURABLE POSTSECONDARY GOALS

Beginning not later than the first IEP to be in effect when the student is 16, describe measurable postsecondary goals in the following areas:

Training/Education

Employment

Independent Living Skills (As Appropriate)

Other

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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

Any Other Agency Involvement (Optional):

Related Services

Any Other Agency Involvement (Optional):

Community Experiences

Any Other Agency Involvement (Optional):

Employment and Other Post-School Adult Living Objectives

Any Other Agency Involvement (Optional):

Acquisition of Daily Living Skills and Functional Vocational Evaluation (if appropriate)

Any Other Agency Involvement (Optional):

Other

Any Other Agency Involvement (Optional):

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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)
 Check here if this goal will be addressed during Extended School Year Services (ESY) Date Date Date Date

BENCHMARK OR SHORT-TERM OBJECTIVE

#
By 4/14/2018, Chloenette will be able to initiate a back and forth conversation with a peer during recess (for example, greeting and asking about interests) independently with 4/5 trials.
#1
By 4/14/2018, Chloenette will be able to initiate a back and forth conversation with a peer during recess (for example, greeting and asking about interests) independently with 1/5 trials.
#2
By 4/14/2018, Chloenette will be able to initiate a back and forth conversation with a peer during recess (for example, greeting and asking about interests) independently with 3/5 trials.
#3
By 4/14/2018, Chloenette will be able to initiate a back and forth conversation with a peer during recess (for example, greeting and asking about interests) independently with 4/5 trials.

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)
 Check here if this goal will be addressed during Extended School Year Services (ESY) Date Date Date Date

BENCHMARK OR SHORT-TERM OBJECTIVE

#
By 4/14/2018, Chloenette will be able to show effective coping strategies, like taking deep breaths for 7 seconds cycling 4 times, to handle stressful siturations when exhibiting tantrums and frustration on 4/5 occassions.

#1
By 4/14/2018, Chloenette will be able to show effective coping strategies, like taking deep breaths for 7 seconds cycling 4 times, to handle stressful siturations when exhibiting tantrums and frustration on 1/5 occassions.

#2
By 4/14/2018, Chloenette will be able to show effective coping strategies, like taking deep breaths for 7 seconds cycling 4 times, to handle stressful siturations when exhibiting tantrums and frustration on 3/5 occassions.

#3
By 4/14/2018, Chloenette will be able to show effective coping strategies, like taking deep breaths for 7 seconds cycling 4 times, to handle stressful siturations when exhibiting tantrums and frustration on 4/5 occassions.

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METHOD FOR REPORTING PROGRESS
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

SPECIAL EDUCATION SERVICES

SPECIALLY DESIGNED INSTRUCTION BEGINNING AND FREQUENCY OF LOCATION OF
ENDING DATES SERVICES SERVICES
Discrete Trial Training 4/15/2017 20-30 hours per week Resource Room
Predictable and Structured Routines 4/15/2017 Daily Resource and Gen Ed Room
Picture Communication Aides 4/15/2017 As Needed Resource Room
Visual Schedule 4/15/2017 Daily Resource and Gen Ed Room

SUPPLEMENTARY AIDS AND SERVICES

Includes aids, services, and other supports provided in regular education classes, other education-related settings (including special education settings), and in

extracurricular and nonacademic settings to enable students with disabilities to be educated with nondisabled students to the maximum extent appropriate.

MODIFICATION, ACCOMMODATION, OR SUPPORT FOR STUDENT OR PERSONNEL BEGINNING AND FREQUENCY OF LOCATION OF
Provide specific description(s) below. ENDING DATES SERVICES SERVICES
1:1 with Teacher 4/15/2017 As Needed Resource and Gen Ed Room
Positive Reinforcement 4/15/2017 Daily Resource Room and Gen Ed
Use of visuals within instruction and around classroom 4/15/2017 Daily Resource and Gen Ed Room
Keep Language Concrete 4/15/2017 Daily Resource and Gen Ed Room
Possible Behavior Specialist 4/15/2017 30 min twice a week Resource Room
Longer-Time for Test 4/15/2017 During Testing Gen Ed Room
Aid Present in General Education Room 4/15/2017 Few Times Gen Ed Room
Tests will be broken up into several days 4/15/2017 During Testing Resource and Gen Ed Room

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RELATED SERVICES
RELATED SERVICE SERVICE TYPE AND/OR DESCRIPTION BEGINNING AND FREQUENCY OF LOCATION OF
A – Assessment C - Consultative D - Direct ENDING DATES SERVICES SERVICES

✔ Speech/Language D 4/15/2017 30 min 3 times a week Individual and Group

Physical Therapy
✔ Occupational Therapy D 4/15/2017 30 min 1 times a week Group Setting
Transportation
Counseling
Psychological Services
Orientation and Mobility
Audiology
School Health Services
and School Nurse Services
Medical Services for Diagnostic
or Evaluation Purposes
Recreation, including
Therapeutic Recreation
Parent Counseling and Training
Interpreting Services
Social Work Services
Assistive Technology
Other

PARTICIPATION IN STATEWIDE AND/OR DISTRICT-WIDE ASSESSMENTS

Indicate how the student will participate If the student will participate in an alternate assessment, explain why If the student will participate in a regular
in statewide or district-wide assessments. the student cannot participate in the regular assessment, and why assessment, does the student require
the particular alternate assessment selected is appropriate. accommodations?

State Criterion-Referenced Test (CRT) ✔ No Yes

Yes N/A Alternate If YES, list on "Accommodation(s) for the Nevada
Proficiency Examination Program" (attach form).
College and Career Readiness Assessment ✔ No Yes
Yes N/A Alternate If YES, list on "Accommodation(s) for the Nevada
Proficiency Examination Program" (attach form).
Other (List): ✔ No Yes List Accommodation(s):
Yes N/A Alternate

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EXTENDED SCHOOL YEAR SERVICES

Does the student require extended school year services?
No ✔ Yes If YES, IEP goals and benchmarks/short-term objectives and/or related services to be implemented in ESY must be identified.
If need for ESY is to be determined at a later date, indicate date by which IEP decision will be made:

PLACEMENT
PLACEMENT CONSIDERATIONS PERCENTAGE OF TIME
IN REGULAR EDUCATION ENVIRONMENT
✔ Selected Rejected Regular class with supplementary aids and services (no removal)
✔ Selected Rejected Regular class and special education class (e.g., resource) combination The student will spend 30 % of his or her school day in
Selected Rejected Self-contained program the regular education environment.
Selected Rejected Special school
Selected Rejected Residential
Selected Rejected Hospital
Selected Rejected Home
Selected Rejected Other

JUSTIFICATION FOR PLACEMENT INVOLVING REMOVAL FROM REGULAR EDUCATION ENVIRONMENTS*

Explain why the IEP goals and objectives cannot be implemented in regular education environments, including the reasons why the team rejected a less restrictive placement.
Include an explanation of any harmful effects on the learning of this or other students which affected the placement selection.

*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
Alice and Andy Baker

✔ 4/14/2017 Mrs. Wooley

A copy of this IEP was provided to the studentʼs parent on: _________________________ by _________________________________________________________
Sepcial Education (SAC) Teacher
(date) (name) (title)

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