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Individualized Education Program (IEP) Instructions for Fillable Version
This Microsoft Word document is the model form for the Individualized Education Program (IEP). The document can be edited using Microsoft Word. The user must “stop protection” on editing restrictions before making edits. The user must then “start enforcing protection” to make the fillable areas useable for completing electronically. Microsoft Word version 2007 1) Select the “Review” tab at the top. 2) Select the “Protect Document” dropdown menu on the top right. 3) Select “Restrict Formatting and Editing” from the menu. 4) In the column that appears on the right, click on the “Stop Protection” button at the bottom. 5) Make desired modifications to meet the needs of the district. 6) In the column on the right, make sure that under “Editing Restrictions” the option “Filling in forms” is selected and that the check box is checked. Then click the “Yes, Start Enforcing Protection” button. Microsoft Word version 2003 1) Select the “Tools” dropdown menu at the top. 2) Select the “Unprotect Document.” 3) Make desired modifications to meet the needs of the district. 4) Select the “Tools” dropdown menu at the top. 5) Select the “Protect Document.” The model form can be found on the following pages of this document. This instruction sheet is not part of the model form.

Michigan Department of Education, Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010

Page 2 of 21 IEP DATES IEP Team Meeting       Initial IEP Offer of a FAPE:       Implementation:       Annual/Review IEP Offer of a FAPE:       Implementation:       Reevaluation IEP Offer of a FAPE:       Implementation:      

Individualized Education Program (IEP)
Section 1 Demographic Information
Student Last:             First:       M: Birth Date:       City:       Gender:    Grade:       State:       UIC:       Zip:      

Address:       Phone:       Resident District:       County:       Parent Last:             First:       M:

Operating District:       Attending Building:       Relationship to Student:      

Native Language or Other Communication Mode:       Address (if different):       Home Phone:       Email:       Parent Last:       First:       M:       Relationship to Student:       Work Phone:       City:       State:       Pager/Cell:       Zip:      

Native Language or Other Communication Mode:       Address (if different):       Home Phone:       Email:       PURPOSE OF MEETING Check one of the following: Initial IEP Annual/Review IEP Reevaluation IEP Check all others that apply: Change of Placement Suspension/Expulsion Secondary Transition Change of Eligibility Other:       Graduation Other:       Work Phone:       City:       State:       Pager/Cell:       Zip:      

OFFICE USE PARENT CONTACT The parent/adult student was contacted to explain the purpose of the meeting and the roles and responsibilities of each participant via (check all that apply): IEP Invitation Results:       Michigan Department of Education, Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 Letter Phone Other:      

The student has turned age 18 and a legally designated representative has been appointed. IEP MEETING PARTICIPANTS IN ATTENDANCE Check the box indicating the IEP participant(s) who can explain the instructional implications of evaluation results. their curricular area/related services are not being modified or discussed in the meeting:       Parent and District Agreement on Excusal Prior to Meeting These members are absent and have submitted written input to the IEP team. The student has turned age 18 and the student and parent were informed of parental rights that were transferred to the student at age 18. prior to the meeting:       ELIGIBILITY FOR SPECIAL EDUCATION Eligible Ineligible Area of disability:       If the student is determined ineligible as a student with a specific learning disability (SLD). provide a statement of the basis for the determination of ineligibility:       If the student is determined eligible as a student with an SLD..g. trustee).       _________________________________________ District Representative/Designee       _________________________________________ General Education Teacher       _________________________________________ Special Education Teacher       _________________________________________ Other       _________________________________________ Other       _________________________________________ Student (must invite at age 16 and older)       _________________________________________ Parent       _________________________________________ Parent       _________________________________________ Agency Providing Secondary Transition Services (consent on file)       _________________________________________ Other Parent and District Agreement on Attendance Not Necessary These members are absent.306(c)(1).Page 3 of 21 PARENTAL RIGHTS AND AGE OF MAJORITY Check all that apply: The student will be age 17 during this IEP and the student was informed of parental rights that he or she will receive at age 18. The guardian is:      . check all that apply: Oral expression Reading fluency skills Listening comprehension Reading comprehension Written expression Mathematics calculation Basic reading skill Mathematics problem solving Determination of eligibility was made in accordance with IDEA regulations at § 300. or friend. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 . including the right to invite a support person such as a parent. The student has turned age 18 and there is a guardian established by court order. The representative is:       as       (e. power of attorney. advocate. Michigan Department of Education. including the parent.

Michigan Department of Education. Braille instruction because the student is blind or visually impaired. The IEP team must consider the following for the student. The language needs of the student because the student has limited English proficiency. The mode of language and communication because the student is deaf or hard of hearing. to address behavior because the student has behavior that impedes his or her learning or the learning of others. and other strategies. as appropriate (check all that apply): The use of positive behavioral interventions and supports. The need for assistive technology devices and services for the student. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 .Page 4 of 21 Section 2-A Present Level of Academic Achievement and Functional Performance FACTORS TO CONSIDER General The IEP team must consider each of the following: The strengths of the student:       The concerns of the parent for enhancing the education of the student:       The results of the most recent evaluation(s) of the student:       Special Factors The IEP team must consider the following for the student (check boxes to indicate consideration): The communication needs of the student.

MEDICAL Health. student work. describe how the student accesses or makes progress in the general education curriculum based on grade level content standards for the grade in which the student is enrolled or would be enrolled based on age. Michigan Department of Education. Report and describe baseline data such as curriculum-based assessments. and functional needs affect involvement and progress in the general education curriculum or participation in appropriate activities for preschool students. or participation in age-appropriate activities for preschool students. developmental. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 . vision. education. and limb/body mobility.Page 5 of 21 Section 2-B: Option I Present Level of Academic Achievement and Functional Performance After reviewing the student’s progress in the general education curriculum and any prior special education goals and objectives. and other relevant data for each area of need. parent input.                                           SOCIO-EMOTIONAL/ BEHAVIORAL             PERCEPTION/MOTOR/ MOBILITY Gross and fine motor coordination. ACADEMIC/PRE-ACADEMIC ACHIEVEMENT Individual and/or district-wide assessments. employment. INDEPENDENT LIVING SKILLS Skills for academic success and independent living. COMMUNICATION/ SPEECH & LANGUAGE       Describe how the student’s academic. and independent living skills. SECONDARY TRANSITION ASSESSMENTS Age-appropriate assessment related to training. GENERAL EDUCATION CURRICULUM Involvement and progress in the general education curriculum. hearing.                                     Section 2-B: Option II Present Level of Academic Achievement and Functional Performance After reviewing the student’s progress in the general education curriculum and any prior special education goals and objectives. teacher observations. balance. or other physical/medical issues.

However. The Draw-a Person assessment indicated that his drawing was significantly immature for a 1st grader. and functional needs affect involvement and progress in the general education curriculum or participation in appropriate activities for preschool students. Written Low. In addition to trouble with literacy. Woodcock-Johnson Tests of Achievement--Third Edition (WJ-III). Jay's relative strength on this assessment was the "Applied Problems" subtest with a standard score of 78 (85 to 115 are condsidered average). For instance. His weakness was the "Calculation" subtest with a standard score of 56. Relevant data includes the fact that Jay already has an IEP for language deficits. The Adaptive Behavior Composite Standard Score was a 68. behavioral observations. Vineland Adaptive Behavior Scales (parent interview). Behavior: The Vineland Adaptive Behavior Scales--Second Edition was the assessment used to measure Jay's behavior with the informant being his mother. He currently takes several medications throughout the day and both parent and teacher report that he acts like a completely different child when he does not take his medication. at the winter benchmarking of early literacy skills. and other relevant data for each area of need. Jay needs more intensive school-based services to remediate his academic and behavior difficulties. parent input. Jay has a relative strength of being able to identify the majority of capital and lower case letters. He was diagnosed with Attention Deficit Hyperactivty Disorder around 5 or 6 years old and shortly after he was diagnosed with Bipolar Disorder. and Draw-a-person. Standard scores between 85 to 115 are considered average. Jay is not reaching the 1st grade benchmarks. Jay appears to have a relative strength in interpersonal relationships. Applied Problems SS 78. His teacher also explained that Jay needs directions not only repeated by further explained step-by-step. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 . Letter/Word Identification SS 73. according to the teacher interview. Sources of data used with Jay include teacher/student/parent intereviews. As mentioned earlier his interpersonal relationships appear to be a relative strength. Jay can not read any sounds or words in three-letter short vowel nonsense words (>50 is expected for 1st graders in the winter). The Draw-a Person assessment indicated that his drawing was significantly immature for a 1st grader. Calculation SS 56. Jay performed significantly better on the reasoning subtests. however his coping skills are a relative weakness. According to classroom observations and testing. The WJ-III further indicated that Jay falls in the below average range. teacher observations. Overall Daily Living Skills being a Standard Score of 69 with Personal Low. For example. Stanford-Binet Intelligence Scale--Fifth Edition (SB-V). on a timed test with addtion sums to ten. Jay's score fell at the Low Range. Spelling SS 71. Writing Samples SS61. His weakness was the "Calculation" subtest with a standard score of 56. He seemed to change his mind while he was drawing. Academics: The Woodcock-Johnson Tests of Achievement--Third Edition (WJ-III) indicated that Jay falls in the below average range. According to the assessment results. Jay's scores includes overall Communication being a Standard Score of 70 with Expressive and Receptive Below Average. His strength on this assessment was the "Applied Problems" subtest with a standard score of 78 (85 to 115 are condsidered average). He seemed to change his mind while he was drawing. Jay got 1 of 36 correct. Describe how the student’s academic. Domestic and Community Below Average. Jay falls in the low range. but consistently needs one-on-one assistance for academic tasks. developmental. Jay's student interview indicated that Jay's favorite part of school is computer time while his least favorite parts of school are science and math. though he still fell below average for his age. Jay performed significantly better on the reasoning subtests. When it comes to behavior. According to this assessment.Page 6 of 21 describe the student’s present level of academic achievement and functional performance. Report and describe baseline data such as curriculum-based assessments. When it comes to academics. Jay seems to be struggling to understand the concepts behind basic addition and subtraction. A parent interview was conducted using the Vineland Adaptive Behavior Scales to measure Jay's adaptive behavior. though he still fell below average for his age. Passage Comprehension SS 72. and Brief Writing SS 60. Overall Socialization being a Standard Score of 69 with Interpersonal Relationships being Below Average and Play & Leisure Time and Coping Skills Low.   Michigan Department of Education. student work.

Michigan Department of Education. domestic. his goals and objectives will be aligned with Kindergarten GLCEs. coping skills). community). He also is below average in the area of mathematics indicated by answering only 1 of 36 problems correctly on a timed test of additions sums to ten. Because Jay ranks academically at a beginning to mid-kindergarten level. Behavior: According to classroom observations and testing. One area of concern indicated by the parent interview is that Jay reacts strongly when there is a change in plans or when he does not get his own way at home. he is still below average in the area of literacy. his goals and objectives will be aligned with Kindergarten GLCEs. receptive. he has weaknesses in the areas of communication (expressive. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 . and written). Another area addressed in the interview was that Jay does not like to play alone and when playing games he has trouble waiting his turn and likes to change the rules. Goals and objectives will be centered around these areas of concern to decrease some of those behaviors as well as have him reach behaviors of what is expected of him for a 1st grader. daily living skills (personal. intensive school-based services when it comes to all areas of academics. Even though Jay has a relative strength in interpersonal relationships.Page 7 of 21 Describe how the student accesses or makes progress in the general education curriculum based on grade level content standards for the grade in which the student is enrolled or would be enrolled based on age. Even though Jay can identify the majority of capital and lower case letters. Because Jay ranks academically at a beginning to mid-kindergarten level. Academics: As observations and testing have occurred. and socialization (play and leisure time. Jay needs support not only in academics. it has proved that Jay needs the appropriate. but with behavior as well.

specific to       (content area). developmental. or participation in appropriate activities for preschool students?       Include a graph of individual student and peer group performance over time. and other relevant data. student work.       For an area of academic need. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 . Michigan Department of Education. parent input.Page 8 of 21 Section 2-B: Option III Present Level of Academic Achievement and Functional Performance After reviewing the student’s progress in the general education curriculum and any prior special education goals and objectives. and functional needs affect involvement and progress in the general education curriculum. What is the identified area of need?       Report and describe baseline data such as curriculum-based assessments. describe the student’s present level of academic achievement and functional performance. teacher observations. what are the district’s prioritized content expectations for the student’s grade level?       What predictive measure(s) does the district use to determine progress on these prioritized expectations?       What do we know about       (grade level) graders’ skills in       (content expectation)?       How does the student’s academic.

Instruction Service:       Activity:       Activity:       Activity:       Considered. and Present Level Identify the service needed in at least one of the six areas below.g. eating out. etc. arts. not needed (explain):       Development of Employment Service:       Activity:       Activity:       Activity:       Considered.)?       Postsecondary Education/Training—After high school. where do you want to live?       Career/Employment—As an adult.. Secondary transition considerations must be updated annually thereafter. not needed (explain):       Community Experiences Service:       IEP Team Must Consider Activity:       Activity:       Activity:       Considered. recreational activities. not needed (explain):       Other Post-School Adult Living Objectives Service:       Activity:       Activity:       Activity:       Considered. IEP teams are recommended to consider secondary transition services at a younger age if appropriate. STUDENT’S POSTSECONDARY GOALS (VISION) Data Sources Used Educational Development Plan (EDP) Transition Assessment(s) (specify):       If the student did not attend the IEP team meeting. what hobbies and activities do you want to do (e.Page 9 of 21 Section 3 Secondary Transition Considerations Secondary transition services are required to be in effect when the student turns 16. Postsecondary Goals. Include the coordinated activity/activities for the service. shopping. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 Responsible agency/other:       Responsible agency/other:       Responsible agency/other:       Expected completion date:       Responsible agency/other:       Responsible agency/other:       Responsible agency/other:       Expected completion date:       Responsible agency/other:       Responsible agency/other:       Responsible agency/other:       Expected completion date:       Responsible agency/other:       Responsible agency/other:       Responsible agency/other:       Expected completion date:       . what kind of work do you want to do?       Community Participation—As an adult. not needed (explain):       Planning/Community Secondary Transition Services continues on next page Michigan Department of Education. what additional education and training do you want?       PLANNING/COMMUNITY SECONDARY TRANSITION SERVICES Needed Service Related to the Student’s Strengths. describe steps taken to ensure consideration of the student’s preferences/vision:       Adult Living—As an adult. Identify the responsible agency/other for each activity for the needed service.

Course of study leading to:       Anticipated graduation or completion date:       Responsible agency/other:       Responsible agency/other:       Responsible agency/other:       Expected completion date:       Responsible agency/other:       Responsible agency/other:       Responsible agency/other:       Expected completion date:       Michigan Department of Education. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 .Page 10 of 21 PLANNING/COMMUNITY SECONDARY TRANSITION SERVICES continued Acquisition of Daily Living Skills Consider When Appropriate Service:       Activity:       Activity:       Activity:       Considered. not needed (explain):       THE COURSE OF STUDY TRANSITION SERVICE Indicate how the student’s course of study aligns with the postsecondary goals (check one): Michigan Merit Curriculum (MMC) leading to a high school diploma (effective for students who entered 8th grade in 2006-2007 school year or later). MMC modification using Personal Curriculum on file: Yes No Curriculum leading to a high school diploma (effective for students who entered 8th grade prior to the 2006-2007 school year). not needed (explain):       Functional Vocational Evaluation Service:       Activity:       Activity:       Activity:       Considered.

Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 .. strand/domain): Literacy and Math Michigan Content Expectations Upon Which Goal Will Be Based—List the appropriate GLCE.Page 11 of 21 Section 4: Option I Goals and Objectives/Benchmarks Instructional Area—List the appropriate content area (e. Short-Term Objective/Benchmark:       Performance Criteria:       Evaluation Procedure:       Evaluation Schedule:       Status Date:       Progress Toward Annual Goal:       Comments:       Status Date:       Progress Toward Annual Goal:       Comments:       Status Date:       Progress Toward Annual Goal:       Comments:       Status Date:       Progress Toward Annual Goal:       Comments:       Short-Term Objective/Benchmark:       Performance Criteria:       Evaluation Procedure:       Evaluation Schedule:       Status Date:       Progress Toward Annual Goal:       Comments:       Status Date:       Progress Toward Annual Goal:       Comments:       Status Date:       Progress Toward Annual Goal:       Comments:       Status Date:       Progress Toward Annual Goal:       Comments:       SCHEDULE FOR REPORTING PROGRESS When:       Position(s) responsible for implementing goal activities (check all that apply): Special Education Teacher School Social Worker Other:       Position(s) responsible for reporting progress on goal:       Teacher Consultant Occupational Therapist Speech and Language Provider Physical Therapist Michigan Department of Education. HSCE. EHSCE. the student will identify lower and captial letters of the alpahbet. EGLCE. and use one-to-one correspondence in math (demonstrate skill) when/at Literacy and Math (conditions criteria) on end of marking period (assessment/evaluation). write upper and lowercase letters. or Early Childhood Standards of Quality for Pre-kindergarten:       Baseline Data The student is currently standard scores between 56-78 (data) on the WJ-III (assessment).g. Annual Goal By January 2012 (date).

the standard score of 73 (Letter/Word Identification). strand/domain): ELA and Math      Michigan Content Expectations Upon Which Goal Will Be Based—List the appropriate GLCE.Page 12 of 21 Section 4: Option II Goals and Objectives/Benchmarks Instructional Area—List the appropriate content area (e. and the standard score of 60 (Writing) (data) on the WJ-III (assessment).03 Baseline Data The student is currently at the standard scores of 56 (Math). the student will identify lower and captial letters of the alpahbet. EGLCE.00.WS.ME. W.01. By the end of the       (#) marking period of       (school year) the student will       (criteria) on       (assessment/evaluation). c)use one-to-one correspondence (criteria) on end of the card marking assessment a)student will be asked to identify the letters verbally with flashcards (lowercase and capital). By the end of the 3 (#) marking period of 2011 (school year) the student will       a)identify all lowercase and captial letters b)write all lowercase and captial letters correctly c)use one-to-one correspondence in math (criteria) on end of card marking and through weekly informal assessments a)identify the letters verbally with flashcards (lowercase and capital) b)write all lowercase and capital letters on lined paper c)Compare and order sets of objects up to 30 (assessment/evaluation). b)writing at least a quarter of the lowercase letters and at least a quarter of the uppercase letters. EHSCE. c)put chips in squares and count the chips as they are put into squares (assessment/evaluation). SCHEDULE FOR REPORTING PROGRESS When:       Insert Progress Monitoring Data Michigan Department of Education. b)write down letters on lined sheet of paper. SHORT-TERM OBJECTIVES/BENCHMARKS By the end of the 1 (#) marking period of 2011 (school year) the student will a)identify at least a quarter of the lowercase letters and at a quarter half of capital letters. c)verbally describe different scenarios using manipulatives using phrases like "more than" or "less than") (assessment/evaluation). Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 .00.02.g. By the end of the 2 (#) marking period of 2011 (school year) the student will a)identify at least half of the lowercase letters and at least half of capital letters b)writing at least half of the lowercase letters and at least half of the captial letters. Annual Goal By January 2012 (date). write upper and lowercase letters.HW. c) use one-to-one correspondence in math (criteria) on end of marking period assessments and through informal assessments weekly a)student will be asked to identify the letters verbally with flashcards (lowercase and capital) b)write down letters on lined sheet of paper.. R. or Early Childhood Standards of Quality for Pre-kindergarten: Kindergarten ELA and Math GLCEs: N. HSCE. and use one-to-one correspondence in math (demonstrate skill) when/at Reading/Writing Workshop and Math (conditions criteria) on end of marking period (assessment/evaluation).00.

Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 .Page 13 of 21 Progress Reporting Report Date:       Report Date:       Report Date:       Report Date:       Progress:       Progress:       Progress:       Progress:       Comments:       Comments:       Comments:       Comments:       Position(s) responsible for implementing goal activities (check all that apply): Special Education Teacher School Social Worker Other:       Position(s) responsible for reporting progress on goal:       Teacher Consultant Occupational Therapist Speech and Language Provider Physical Therapist Section 5 Supplementary Aids and Services Supplementary aids and services are provided to enable the student: Michigan Department of Education.

etc. Michigan Department of Education. Presentation. Training Needs. Response.                   Other Supports. and Modifications                   Time/Frequency/Condition Location                                                 Time/Frequency/Condition Location                                                 Time/Frequency/Condition Location                   Time/Frequency/Condition                                     Location                   All aids and services identified will begin on the implementation date of the IEP and continue for the duration of the IEP. Assignments. Books. Ongoing Instruction and Assessment Scheduling. Health-Related Needs. etc. Supplementary aids and services are not needed at this time. Supplementary aids and services are needed at this time. Tests. Explain the extent.                         Supports and Modifications to the Environment Classroom Environment. To be educated and participate in activities with other students with disabilities and nondisabled students. Grading. Social Interaction Supports for the Student.                         Curriculum Supports and Adjustments Directions. if any.Page 14 of 21 • • • To advance appropriately toward attaining the annual goals. Behavioral. etc. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 . To be involved and progress in the general education curriculum and to participate in extra-curricular and other nonacademic activities. to which the student will not participate with nondisabled students:      . Accommodations. Handwriting. Physical Needs. Assistive Technology.

gov/meap-access to determine if MEAP-Access is appropriate.Page 15 of 21 Section 6: Grades K-9 Assessment—Participation and Provisions Based on Grade Level.michigan. If the IEP team determines that the student must take an alternate assessment (MEAP-Access. or a district-determined social studies assessment) instead of a particular MEAP assessment. If the IEP team determines the Michigan Educational Assessment Program (MEAP) is not appropriate. Identify any individual appropriate accommodations that are necessary on these state assessments. Assessment Area Reading Grades 3-8 Writing Grades 4 and 7 MEAP MEAP-Access MI-Access: Functional Participation MEAP Mathematics Grades 3-8 MEAP-Access MI-Access: Functional Participation MEAP Science Grades 5 and 8 MI-Access: Functional Participation MEAP District-Determined Assessment       Supported Supported Supported Assessment Rationale The MEAP is not appropriate because:       The alternate assessment is appropriate because:             Accommodations       The MEAP is not appropriate because:       The alternate assessment is appropriate because:       The MEAP is not appropriate because:       The alternate assessment is appropriate because:       The MEAP is not appropriate because:       The alternate assessment is appropriate because:             Social Studies* Grades 6 and 9       * If the MEAP Social Studies Assessment is not appropriate for the student. complete the Rationale column. the IEP team MUST identify a district-determined assessment until there is a state-developed MI-Access Social Studies Assessment.gov/meap.michigan. and English Language Proficiency State Assessments: Grades 3-9 Is a state assessment administered at the grade level(s) covered by this IEP? Yes No If a state assessment is being administered. “District-wide assessments: Grades K-9” on next page Michigan Department of Education. Independence Level. See the Revised Assessment Accommodation Summary Table at www. MI-Access. indicate in the Assessment column in which assessment the student will participate. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 . see the MEAPAccess eligibility criteria at www.

Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 . Identify any individual appropriate accommodations that are necessary on these assessments. indicate in the Assessment column in which assessment the student will participate. If the IEP team determines that district-wide assessment is not appropriate and that the student must take an alternate assessment.Page 16 of 21 District-wide Assessments: Grades K-9 Is a district-wide assessment administered at the grade level(s) covered by this IEP? Yes No If a district-wide assessment is being administered. identify the alternate assessment and complete the Rationale column. Assessment District-wide Assessment       Alternate Assessment       District-wide Assessment       Alternate Assessment       District-wide Assessment       Alternate Assessment       The district-wide assessment is not appropriate because:       The alternate assessment is appropriate because:             The district-wide assessment is not appropriate because:       The alternate assessment is appropriate because:             Rationale The district-wide assessment is not appropriate because:       The alternate assessment is appropriate because:             Accommodations Michigan Department of Education.

Page 17 of 21 Section 6: Grades 10-12 Assessment—Participation and Provisions Based on Grade Level. and English Language Proficiency State Assessment—Michigan Merit Exam: Grades 11-12 For students at grade level 11: In which assessment will the student participate? Michigan Merit Exam (MME) MI-Access For students at grade level 12: For MME retest eligibility. See the Revised Assessment Accommodation Summary Table at www. “District-wide assessments: Grades 10-12” on next page Michigan Department of Education. identify any individual appropriate accommodations that are necessary on these state assessments. Assessment Area English Language Arts Grade 11 MI-Access/ Alternate Assessment Functional Supported Participation Functional Supported Participation Functional Supported Participation Social Studies* Grade 11 District-Determined Assessment       Rationale The MME is not appropriate because:       The alternate assessment is appropriate because:       The MME is not appropriate because:       The alternate assessment is appropriate because:       The MME is not appropriate because:       The alternate assessment is appropriate because:       The MME is not appropriate because:       The alternate assessment is appropriate because:                               Accommodations Mathematics Grade 11 Science Grade 11 * If the MME Social Studies Assessment is inappropriate for the student. the IEP team MUST identify a district-determined assessment until there is a state-developed MI-Access Social Studies Assessment. Identify any individual appropriate accommodations that are necessary on these state assessments.gov/mi-access.gov/mme. See the MME Chart of Accommodations Dates – ACT-Approved and State-Allowed at www. Will the student participate in the MME? Yes No If the IEP team determines the student will participate in the MME.michigan. Assessment Area ACT Reading Comprehension ACT English ACT Mathematics ACT Science ACT Writing WorkKeys Reading for Information WorkKeys Applied Math WorkKeys Locating Information Michigan Mathematics Michigan Science Michigan Social Studies                                                                   Accommodations State Assessment—MI-Access: Grade 11 For Grade 11: If the IEP team determines the MME is not appropriate. identify the alternate assessment in which the student will participate and complete the Rationale column.michigan. Independence Level.michigan. see details in the MME Student Eligibility document at www. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 .gov/mme.

Assessment District-wide Assessment       Alternate Assessment       District-wide Assessment       Alternate Assessment       District-wide Assessment       Alternate Assessment       The district-wide assessment is not appropriate because:       The alternate assessment is appropriate because:             The district-wide assessment is not appropriate because:       The alternate assessment is appropriate because:             Rationale The district-wide assessment is not appropriate because:       The alternate assessment is appropriate because:             Accommodations Michigan Department of Education. If the IEP team determines that district-wide assessment is not appropriate and that the student must take an alternate assessment. Identify any individual appropriate accommodations that are necessary on these assessments. indicate in the Assessment column in which assessment the student will participate. identify the alternate assessment and complete the Rationale column.Page 18 of 21 District-wide Assessments: Grades 10-12 Is a district-wide assessment administered at the grade level(s) covered by this IEP? Yes No If a district-wide assessment is being administered. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 .

complete the following section. a Title VI reporting requirement. Please consider these two questions annually: Is the student’s native tongue a language other than English? Yes No Is a language other than English spoken in the student’s home or environment? When either answer is Yes. Independence Level. or to identify any individual appropriate accommodations that are necessary for each of the ELPA domains. is given to all students at the time of enrollment. and English Language Proficiency National Assessment: National Assessment of Educational Progress (NAEP) Is a NAEP assessment administered to the student’s district at the grade level(s) covered by this IEP? Yes No Yes No Has the student participated in the Michigan Educational Assessment Program (MEAP) in the subject being tested? Can the student participate in the NAEP with allowable accommodations? See the Revised Assessment Accommodation Summary Table at www. see the Revised Assessment Accommodation Summary Table at www.Page 19 of 21 Section 6: ELPA/NAEP (Grades K-12) Assessment—Participation and Provisions: ELPA Based on Grade Level. Independence Level.michigan. state the reason why a specific NAEP assessment is not appropriate. Yes No Can the student participate in the NAEP with allowable accommodations. or needs accommodations not allowed by the NAEP? Yes No If YES. for each content area. indicate any assessment accommodation(s) that the student may need. and English Language Proficiency State Assessment: English Language Proficiency Assessment (ELPA) The Home Language Survey (HLS). Assessment Level and Grade for Spring ELPA and ELPA Initial Screening Level I—Grade K Level II—Grades 1-2 Level III—Grades 3-5 Level IV—Grades 6-8 Level V—Grades 9-12 Initial Screening                               Spring ELPA                               Yes No For additional information regarding ELPA or the ELPA screener. If NO.gov/naep. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 .gov/elpa. Assessed Domains Listening Reading Writing Speaking                         Accommodations Assessment—Participation and Provisions: NAEP Based on Grade Level.                   Yes Yes Yes No No No                   Assessment Participation Michigan Department of Education. even if the student did not participate in the MEAP.michigan.

Participation in General Education (students age 6-26) 80% of the day or more 79% to 40% of the day less than 40% of the day separate facility =       (=) Total (minutes/hours per week) Location             Duration             SPECIAL TRANSPORTATION Yes (specify):       No Michigan Department of Education.Page 20 of 21 Section 7 Special Education Services and Programs Related Service                   Rule Number                   Specific Amount of Time and Frequency                   Location                   Yes No Duration*                   Duration*                   Does the student have needs that require placement with a teacher with a particular endorsement? Program                   Rule Number                   Departmentalized Yes Yes Yes No No No Specific Amount of Time and Frequency                   Location                   * All programs and services listed above will begin on the implementation date of the IEP and continue for the duration of the IEP. Participation in a Regular Early Childhood Program (students age 3-5) At least 10 hours per week and: receives the majority of special education and related services IN a regular early childhood program. receives the majority of special education and related services OUTSIDE of a regular early childhood program. the student will be educated with students who are nondisabled. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 . or other removal of the student from the general education environment occurs only when the student’s needs cannot be met satisfactorily in the general education setting with supplemental aids and services. It was determined that no ESY services are needed. Less than 10 hours per week and: receives the majority of special education and related services IN a regular early childhood program. receives the majority of special education and related services OUTSIDE of a regular early childhood program. Service             Specific Amount of Time and Frequency             INSTRUCTIONAL TIME General Education Instruction (minutes/hours per week)       (+) Special Education Instruction (minutes/hours per week) +       EDUCATIONAL ENVIRONMENT The district ensures that. separate schools. unless otherwise indicated above in the column “Duration.” EXTENDED SCHOOL YEAR (ESY) SERVICES Extended School Year (ESY) services were considered. and special classes. Current annual goals address one or more skills that require ESY services. to the maximum extent appropriate.

Page 21 of 21 Michigan Department of Education. Office of Special Education and Early Intervention Services OSE-EIS Model Form IEP 003  December 2010 .

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