Student’s Name:

Teacher’s Name: Click here to enter text.

Date: Click here to enter text.
Teacher Input for IEP Goals
What can the student do well?
(This can be academic, behavioral, social, etc.)
Click here to enter text.

What can the student do with partial success?

(Content related please)
Task Required How often are
they successful?
LA Ex: Write paragraphs that include
LA Ex: 0/5 attempts
appropriate topic sentences.
Ma Ex: 40% of attempts.
Ma Ex: Graph linear equations
1.) Click here to enter text. Click here to enter text.
Comments (optional)
LA Ex: The student requires multiple
reminders to begin writing tasks.
Ma Ex: Student does not
understand where to place y-
intercept.
Click here to enter text.

2.) Click here to enter text. Click here to enter text. Click here to enter text.

3.) Optional Click here to enter text. Click here to enter text. Click here to enter text.

Current Grade in Class: Click here to enter text.

Primary Reason Grade is below a C (if applicable): Choose an item.

 Accommodations and Modifications
(District examples below)
What seems to be working? What does NOT seem to be working?
Click here to enter text. Click here to enter text.

Other Comments: Click here to enter text.

Please return the completed form to the student’s case manager, Janett Du Bois, at your earliest convenience
(preferably attached to an email.) If you have questions about this form or wish to discuss the student’s progress in your
class, please contact me @ jmdubois1@seattleschools.org/ Room 241 X22332.

Example Content Area Accommodations

 accept close approximations  present information auditorally

 allow extra time to respond  present information visually
 allow student to give oral responses  provide a copy of the notes/study guides
 break material into manageable parts  provide immediate feedback
 check work frequently to ensure  provide individual assistance
understanding  read material/tests to student
 cover sheet for math problems  reading marker
 difficult assignments to be completed in  reduce length of assignments
resource room  reduce number of problems
 dual grades on written work for content and  repeat directions as needed
writing mechanics  study carrel/eliminate distractions
 extra set of books  taped text/audio materials
 extra time if student effort is shown  use a number line in math
 give short, concise directions  use concrete manipulatives
 give student a copy of his/her schedule  use drill and repetition
 homework assignment sheet/agenda  use graph paper for math
 large print  use graphic organizers
 non-grading of class/course tests/exams  use of graph paper for math
 peer tutor/helper  write assignments on board
 preferential seating