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STUDENT NAME: Martin Curtin SIMS: 4803-4494

PARENT/GUARDIAN NAME: Mr. and Mrs. Lap PHONE: 6053490283
ADDRESS: 583 Wisconsin drive SE WK PHONE: 6052839203
SCHOOL DISTRICT: Northern School District SCHOOL: Northern Elementary
DOB: February 1st, 2013 AGE: 8 GRADE: 2nd Grade
GENDER: __Male_________ RACE: HI: Hispanic

Meeting Date: 5/05/2021 Purpose of Meeting

☐ Initial Eligibility, IEP, Placement
Date Services Begin: 5/10/2021 ☐ Annual Review of IEP
Annual Review Date: 5/03/2022 ☒ Three Year Reevaluation
☐ Dismissal from Services - Date Effective:    
Date of Eligibility Determination: April 2018 ☐ Parent Request
Three Year Reevaluation Due By: 4/3/2021 ☐ Other:    

Discussed evaluation results/progress/assessment
method ☒ Yes
    (Parent/Guardian initial)
Copy of evaluation results received ☐ Yes
    (Parent/Guardian initial)
Transition Planning Needed ☒ No ☐ Yes
(*If yes, attach applicable transition pages.)
Student is eligible for special education or special education
and related services as determined by the IEP team
☒ Yes ☐ No
An annual copy of Parent/Guardian Rights was received and
reviewed
4/12/2021 (Date)     (Parent/Guardian Initial)
A copy of the IEP was provided to parent/guardian ☒ Yes
    (Parent/Guardian Initial)

Primary Disability: _________________

IEP Team Membership Signature Date

Parent/Guardian
Parent/Guardian
Student
School Representative
General Education Teacher
Special Education Teacher or Provider
Speech/Language Pathologist
Individual who can interpret evaluation results
Other:    
Other:    
Other:    

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Present Levels of Academic Achievement and Functional Performance

In developing each student’s IEP, the IEP Team must consider 1) the strengths of the student; 2) the concerns of
the parents for enhancing the education of their student; 3) the results of the initial or most recent evaluation of the
student; and 4) the academic, developmental, and functional needs of the student.

Provide a statement of the student’s present levels of academic achievement and functional performance,
including 1) how the student’s disability affects the student’s involvement and progress in the general education
curriculum (i.e., the same curriculum as for nondisabled students); or 2) for preschool students, as appropriate,
how the disability affects the student’s participation in appropriate activities.

Martin is able to recognize 1st grade level words at 99% accuracy and 2nd grade level words at 97% accuracy when
he is reading the passage aloud. When Martin read a passage aloud, he can recall the main idea at 100%
accuracy. Martin is able to answer comprehension questions at the 1 st grade level at 100% accuracy. When
reading a passage silently, Martin is able to recall the main idea, detail, vocabulary, and cause and effect at 100%
accuracy. When the teacher reads the passage aloud to the Martin, he recalls detail at 80% accuracy and cause
and effect at 100% accuracy. When Martin reads a passage aloud, his fluency at a 1 st grade level is 52 wprm and
comprehension is 63%. At a 2nd grade level, Martin’s fluency is 53 wpm and comprehension is 50%. The average
fluency at the 2nd grade level is 121 words per minute (wpm). Martin put much effort and concentration into
articulating the words. When reading a passage aloud, Martin’s vocabulary, detail, and sequence are at 50%
accuracy. Martin identifies the cause and effect at 66% accuracy and inference at 43% accuracy. When Martin
reads a passage silently, he is able to answer comprehension questions at the 2 nd grade level at 63% accuracy.
His sequence is at 50% accuracy and inference is at 60% accuracy when he reads the passage silently. When the
teacher reads a passage aloud to Martin, he recalls the main idea and inference at 60% accuracy. He recalls
sequence at 50% accuracy and vocabulary at 0% accuracy.

Martin is able to rote count to 50, count by 10’s to 100, count by 5’s to 100, count by 2’s to 14. He is able to read
and write numbers to 50. When asked to tell time by the hour and half-hour, Martin is able to tell time at 100%
accuracy. He is able to write time in notation form at 100% accuracy. At 96% accuracy, Martin is able to add 25/25
facts (sums to 20) and add facts (sums to 20) using a strategy of counting on his fingers. Martin is about to read
numbers to 99 at 100% accuracy and write numbers to 99 at 99% accuracy. Martin has his daily assignments
done at 96% accuracy and his chapter test scores range from 90%-100% accuracy with an average accuracy of
95%. In 7 minutes and 20 seconds, Martin is able to subtract 25/25 facts (minuends of 20) and subtract facts
(minuends to 20) with 64% accuracy when using a strategy of counting on his fingers. Martine is unable to read
and write numbers at 0% accuracy. When asked to tell time by five-minute intervals and by the minute, Martin tells
the time at 0% accuracy. Martin is able to count coins of different value to 50 at 60% accuracy (He is unable to
count from a quarter to a dime. He always says 25, then 30 instead of 35).

Martin attempts a story or to make a point, illustration supports writing, meaning, and general idea is
recognizable/understandable. Some of Martin’s ideas are clear but some are fuzzy. There is no title when
assigned, no experiments with beginnings, and no transitions or evidence of sequencing haphazard. Martin
communicates feelings with color, size, shape. He is unclear when responding to task and awareness of audience
not present. Martin is unable to recognize words, environmental words used correctly, and attempts at phrases
and functional language. He mimics letters and words across the page. The words stand alone and there is no
evidence of patterns of sentences. Martin’s sense of sentences is not yet present. Martin writes letter strings that
are not words. He attempts to create standard letters and spacing of words. He attempts to write left to right and
top to bottom. Martin is yet to make sense of punctuation and capitalization.

Martin is able to produce all sounds in conversation at 90% accuracy. He is able to state and use plural forms
containing, -z, s, ez-endings, possessives and third-person singular, and past tense containing -t, d, ed-endings.
Martin is able to use comparative and superlative forms correctly with words ending in -er and -est. Martian has

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rational vocabulary (describing how 2 items are alike, apple-orange) and grammatic understanding (Show me a
picture of, “The leaves had fallen to the ground). Martin is unable to understand parts of vocabulary categories
(tools, transportation). He struggles with oral vocabulary (verbally defining a target word), repeating short
directions, and grammatic completion (Today, Jon is writing. Yesterday, he _______). Martin needs help with using
plurals involving the -vz-ending (leaves, calves, knives), irregular plurals (feet, children, women), past tense ending
with -t (dropped, roped), irregular past tense verbs (cut, caught, fed), and irregular adjectives (better, best).
Martin travels with classmates and teachers to locations more than 50 miles from school, such as on a field trip and
runs errands to various locations around the school building. He is able to use small electric equipment in the
classroom (tape player) and puts books and supplies in their proper place when finished using them. Martin is able to
use electrical outlets safely, cares for minor injuries at school (paper cuts or nose bleeds) and describes general
safety standards for the community (Do not accept money or food from strangers). He participates in organized
programs for a sport of hobby and with others in games or other fun activities without needing encouragement.
Martin is able to cut food into bite-sized pieces and cleans under his fingernails. Martin struggles with looking at
others’ faces when they are talking and speaking clearly and distinctly. He is unable to keep score when playing
games, write his own address including zip code, and write down assignments as a reminder. Martin needs help with
dusting furniture, blowing/wiping nose with tissue or handkerchief, and covering mouth when sneezing or coughing.
Martin struggles with controlling his anger when another person breaks the rules in games or other fun activities and
struggles controlling disappointment when favorite activity is canceled. Martin is unable to work on one school activity
for at least 15 minutes. He struggles working independently and asking for help only when necessary.

Martin appears to be a happy 2nd grader. He smiles, gives hugs, and share stories (more on a one-to-one basis than
on a group). He appears to try but doesn’t always stay on task to finish. He is a fun student to work with. Martin is
easily distracted from task by ordinary classroom stimuli (minor movement, noises).

How the student’s disability affects his involvement in the general curriculum: When comparing Martin’s
reading scores, he reads the best when he can read it independently in a quiet room. He struggles to oral read or
listen to someone else read. Math is an area that can frustrate Martin due to the areas of need that Martin has in
math. Martin is often easily distracted by any movement or activity happening in the classroom throughout the day.
Martin is able to do small activities throughout the classroom and school, but needs help doing self-care (like
blowing/wiping nose) and controlling his emotions.

* Remember to address:
 Strengths & needs using academic achievement (skill based assessment) AND functional performance
 Transition strengths and needs including the student’s preferences and interests (must be in the student’s IEP by age 16)

Consideration of Special Factors

Is the student limited English proficient? ☐ Yes ☒ No

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If the answer to this question is “yes”, please explain the language needs of the student as these needs relate to the
student’s IEP.
       

Are there any special communication needs? ☒ Yes ☐ No

If the answer to this question is “yes”, please explain the communication needs of the student, and in the case of a
student who is deaf or hard of hearing, consider the student’s language and communication needs, opportunities for direct
communications with peers and professional personnel in the student’s language and communication mode, academic
level, and full range of needs, including opportunities for direct instruction in the student’s language and communication
mode.
       

Does the student require Braille? ☐ Yes ☒ No

If the answer to this question is “yes”, what instruction in Braille and use of Braille will be provided?
       

Does the student’s behavior impede his or her learning or that of others? ☒ Yes ☐ No
If yes, what strategies are required to appropriately address this behavior, including positive behavioral interventions and
supports?
       

Does the student require Assistive Technology Devices and Services? ☒ Yes ☐ No
If yes, what device or service will be provided?
       

Physical Education: ☒ Regular ☐ Not Required ☐ Adaptive:

Refer to Goals/Goals & Objectives        

Hearing Aid Maintenance: ☒ Not Applicable ☐ Yes: Personnel Responsible for Monitoring:       
Describe the monitoring process/frequency necessary for maintenance:
       

Assessment
☒ Student will be taking state and district-wide assessments with or without accommodations.
☐ Student will be taking state and district-wide alternate assessments (The alternate assessment is for students working
in the alternate achievement standards) (Annual goal and short term objectives required)
a. Does the student meet the significant cognitive disability criteria? (If no, student is not eligible to take the
alternate assessment) ☐ Yes ☐ No
b. Explain the reason why the student cannot participate in the regular assessment.
       
c. Explain the reason why the alternate assessment selected is appropriate for this student.
       
☐ No state and/or district-wide assessments are required at this student’s grade level during the course of this annual
IEP.

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Educational Goals and Objectives/Benchmarks

Provide a statement of measurable annual goals, including academic and functional goals designed to 1) meet the
student’s needs that result from the disability, 2) enable the student to be involved in and make progress in the general
education curriculum, and 3) meet each of the student’s other educational needs that result from the disability.
Measurable Annual Goal # 1
Martin will be able to read a short story (5-10 Proc. Date Prog. Comments:
pages), at a 2nd grade level, at a reading level of 95 Code/s Code
WPM in five minutes or less, by the end of the 8
school year.
2

Measurable Annual Goal # 2

Martin will add two-digit numbers to 100 with 100% 6
accuracy in 8 of 10 trials.
1

Measurable Annual Goal # 3

Martin will be able to read the clock, in 5-minute 2
increments 80% correctly, by the end of the first
half of the year. By the end of the year, he should 6
be able to read the clock, in 15-minute increments
95% correctly.

Measurable Annual Goal # 4

Martin will be able to make his way up to counting
2
up to $50 with $1, $5-, and $10-dollar bills within
one school year. He will correctly count the money
88% of the time. 3

Procedure Codes (Complete at IEP meeting) Progress Codes Reporting Frequency to Parents
1. Teacher-made tests 6. Work Samples P= Progress being made ☒ Quarterly Reports
2. Observations 7. Portfolios I= Insufficient Progress to meet goal ☐ Trimester Reports ☐ Other:      
3. Weekly tests 8. Oral Tests X= Not addressed this Reporting Period Reporting Method to Parents
4. Unit tests 9. Data Response M=Met goal ☒ Conferences ☐ Report Card
5. Student Conferences 10. Other: ☒ Goal Page Copy ☐ Other:      

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Educational Goals and Objectives/Benchmarks

Provide a statement of measurable annual goals, including academic and functional goals designed to 1) meet the
student’s needs that result from the disability, 2) enable the student to be involved in and make progress in the general
education curriculum, and 3) meet each of the student’s other educational needs that result from the disability.
Measurable Annual Goal # 5
Martin will understand the difference between Proc. Date Prog. Comments:
different language arts aspects. He will be able to Code/s Code
read a sentence and understand what part of the 2
sentence go with the correct language term.
6

Short Term Instructional Objectives or Benchmarks Proc. Date Prog. Comments:

(Required for students who take alternate Code/s Code
assessment.)

Procedure Codes (Complete at IEP meeting) Progress Codes Reporting Frequency to Parents
1. Teacher-made tests 6. Work Samples P= Progress being made ☒ Quarterly Reports
2. Observations 7. Portfolios I= Insufficient Progress to meet goal ☐ Trimester Reports ☐ Other:      
3. Weekly tests 8. Oral Tests X= Not addressed this Reporting Period Reporting Method to Parents
4. Unit tests 9. Data Response M=Met goal ☒ Conferences ☐ Report Card
5. Student Conferences 10. Other: ☒ Goal Page Copy ☐ Other:      

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Accommodations and Modifications

Accommodations/Modifications/Supplementary Aides and Frequency Location Duration

Services
1. Extra time on tests As often as GenEd Length of IEP
needed classroom

2. Shorter reading assignments During reading GenEd Length of IEP

class classroom

Statement of the program modifications or supports for Frequency Location Duration

school personnel (as appropriate):
                         
                         
                         

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State/District-wide Assessment Accommodations

☒ Student will be taking the assessment without accommodations.

☐ Student will be taking the assessment with the accommodations.

*Teams must consider if the accommodations are approved for the applicable test administration.

*List the accommodations the student will be taking for each test/test area.
(Only those accommodations identified for instruction on the goal pages can be considered for state and district-wide
testing. The accommodations selected for use must relate to the student’s disability.)

State Assessment Accommodations

Smarter Balanced Smarter Balanced Dakota STEP

ELA (Gr 3-8 & 11): Math (Gr 3-8 & 11): Science (Gr 5, 8 & 11):
_____________ _____________ _____________
_____________ _____________ _____________
_____________ _____________ _____________
_____________ _____________ _____________
_____________ _____________ _____________

Test: Test:       Test:      

           
           
           
           

* NSCS Alt Assessment and D-STEP Alt Science

Accommodations for both instruction and assessment must be documented.

District-wide Assessment Accommodations

Test:       Test:       Test:      

           
           
           
           

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Special Education Services

Description of services Frequency Location Duration

Basic Reading Skills Daily for 15 minutes/75 mins weekly School District length of IEP
Math Problem Solving 2x a week/10 min sessions/ (20 mins weekly) School District length of IEP
                  
                  
                  
                  
                  

Related Service to be Provided Frequency Location Duration

3x weekly/20-minute
☒ Speech/Language Therapy sessions (60 minutes School District Length of IEP
weekly)
☐ Occupational Therapy
☐ Physical Therapy
☐ Transportation (Specify when, how
often, where, distance, costs, etc.)
☐ Counseling Services
(Including rehabilitation counseling)
2x weekly/15-minute
☒ Audiological Services sessions (30 minutes School District Length of IEP
weekly)
☐ Interpreting Services
☐ Medical Services
(Diagnostic Services only)
☐ Orientation and Mobility
☐ Parent Counseling/Training
☐ Psychological Services
☐ Recreation Therapy
☐ School Nurse/Health Services
☐ Social Work Services (in schools)
☐ Other

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Least Restrictive Environment

The IEP Team must ensure that, to the maximum extent appropriate, students with disabilities are educated with
nondisabled peers, including extracurricular services and activities.

Continuum of Alternative Placements Continuum of Alternative Placements (Ages 3-5)

☒ 0100 General Classroom with Modifications 80-100% ☐ 0310 Early Childhood Setting-10 hrs.+/week
☐ 0110 Resource Room 40-79% services in Reg EC program
☐ 0120 Self-Contained Classroom 0-39% ☐ 0315 Early Childhood Setting-10 hrs.+/week
☐ 0130 Separate Day School services in other location
☐ 0140 Residential Facility ☐ 0325 Early Childhood Setting-Less than 10hrs/wk.
☐ 0150 Home/Hospital services in Reg EC program
☐ 0330 Early Childhood Setting-Less than 10hrs/wk.
services in other location
☐ 0335 Special Education Class
☐ 0345 Separate School
☐ 0355 Residential Facility
☐ 0365 Home
☐ 0375 Service Provider Location

Participation with Non-Disabled Peers

Program Options Non-Academic Extracurricular
☒ Art ☒ Counseling ☐ Athletics
☐ Industrial Technology ☒ Meals ☐ Clubs
☒ Music ☐ Employment Referrals ☐ Groups
☐ Vocational Education ☒ Recess ☐ Recreation
☐ Family & Consumer Science ☒ Health Services ☐ Other       
☒ Other PE, Library ☐ Other       

Comments:        

Justification for Placement--An explanation of the extent, if any, to which the student will not participate with
non-disabled students in regular classes and non-academic activities.
(Please use accept/reject format for each alternative placement considered.)

☒ The team addressed the potential harmful effects of the special education placement.

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Extended School Year

Extended School Year Services: ☐ needed ☒ not needed ☐ to be determined by (Date)       

Beginning Date Ending Date Minutes

Goal(s) # *Type of Service **Based on
mm/dd/yy mm/dd/yy Per Week

* Instruction, related services (specify), other (list)

** Regression/Recoupment, Emerging Skills, or Maintenance of Critical Life Skills

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