Standard 2: Individualized Education Plan – Part 1
Special Education Department
Individualized Education Program (IEP)
Student Name: Student Data/Cover Sheet (Form A-1) IEP Meeting Date:
John Tevin 10/11/2023
Demographic Information
Student Number: Student (Pseudo) Birthdate: Gender: Grade:
Name: 10-23-2014 Male 2
7345920 John Tevin
Student Address: Home Phone:
3500 West Camelback Road Do not complete
City, State, Zip:
Phoenix, Arizona 85017
Parent 1 (Pseudo) Name: Parent 1 Relationship:
Susanne Tevin Mother
Parent 1 Address: Home Phone:
Do not complete. Do not complete.
City, State, Zip: Work Phone:
Do not complete. Do not complete.
Parent 1 Email:
Do not complete.
Parent 2 (Pseudo) Name: Parent 2 Relationship:
James Tevin Father
Parent 2 Address: Home Phone:
Do not complete. Do not complete.
City, State, Zip: Work Phone:
Do not complete. Do not complete.
Parent 2 Email:
Do not complete.
Primary Language of Home: Primary Language Survey Date: Language of Instruction:
English Primary Language Survey Results: English
Home District:Rosedale school district Service Coordinator:
Attendance District:
Home School: Almondale Attending School: Almondale
Vision Screened On: Results: Hearing Screened On: Results:
09/28/2023 No glasses 9/29/2023 Good hearing
Meeting Date: Anticipated Duration of IEP: Re-evaluation Due:
From: To: Current Evaluation:
Special Education Primary Category 1: Reading
Special Education Eligibility Category 2:Writing
Special Education Eligibility Category 3:Math
For Students with SLD only, the following area(s) of eligibility was/were previously determined:
Level of Services: (A) Speech B
Type of Meeting: IEP
Date Meeting Notice Sent to the Date Procedural Safeguards given to the
Parent(s):10/09/2023 Parent(s): 10/09/2023
This page will not need to be completed because it is a signature page.
Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: Student Data/Cover Sheet (Form A-2) IEP Meeting Date:
Student ID: DOB:
The following persons participated in the conference and/or the development of the IEP. Additionally, parents have
been given a copy of their rights regarding the student’s placement in special education and understand that they
have the right to request a review of their child’s IEP at any time.
Position/Relation to Student Participant Date (MM/DD/YY)
If during the IEP year the student turns 16, if the student is not present at the IEP meeting, the service coordinator
must review the IEP with the student and obtain the student’s signature and the date of this review.
Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: John Student Data/Cover Sheet (Form B) IEP Meeting Date:
Student ID: DOB: 10-23-2014
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
(PLAAFP)
Section 1: Current IEP Information
Summarize special education services the student is receiving: Writing and reading and
Matgh
Section 2: Evaluation Information
Areas of Eligibility:
Special Education Primary Category:
Special Education Eligibility Category 2:
Special Education Eligibility Category 3:
For students with SLD only, the following area(s) of eligibility was previously determined:
State and District Assessment Scores:
Section 3: Present Level of Academic Achievement and Functional Performance
A. Cognitive (academic performance in content areas, e.g., ELA/Reading/Writing, Math, Science, Social
Studies, Technology and Fine Arts, as applicable)
B. Physical (gross motor, fine motor, vision, and hearing)
C. Oral Language and Communication
D. Social and Emotional Behavior
E. Adaptive
Current Classroom-Based Data:
Family’s Input on Student’s Current Performance:
Summary of Work Habits:
Section 4: Summary of Educational Needs and General Accommodations
Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: John Tevin
Considerations Form (Form C) IEP Meeting
Date:10/31/2023
Student ID DOB:
ADDITIONAL DOCUMENTATION/CONSIDERATION OF SPECIAL FACTORS
Considered
Not Needed Included
Individual Transition Plan ☐ ☒
Statement of Transfer of Parental Rights at Age of Majority ☐ ☒
Statement of Positive Behavior Interventions, Strategies, and Supports ☐ ☒
Considered for a Student Whose Behavior Impedes his or her Learning,
or That of Others
Statement of Language Needs in the Case of a Child with Limited ☐ ☒
English Proficiency
Statement of Provisions of Instruction in Braille and User of Braille for ☒ ☐
a Visually Impaired Child
Statement of the Language of Needs, Opportunities for Direct ☐ ☐
Communication with Peers in the Child’s Language, and
Communication Mode
Statement of Required Assistive Technology Devices and Services ☒ ☐
Statement of Communication Needs for a Child with a Disability ☐ ☒
Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: Accommodations (Form F) IEP Meeting Date:
Student ID: DOB:
ASSESSMENTS
(Rationales for the accommodations that are being chosen specific to assessments.)
Rationale:
State Assessments
Standard Accommodation(s):
District Assessments
Standard Accommodation(s):
CURRENT STATE STANDARDIZED TEST (i.e., AIMS, PSSA) RESULTS
Testing Area Test Results Grade Semester Year
Reading
Writing
Math
Science
LEAST RESTRICTIVE ENVIRONMENT (LRE)
Provide an explanation of the extent, if any, to which the student will NOT participate with non-
disabled students in the general curricular, extracurricular, nonacademic activities, and program
options. §300.347(a) (4):
Consider any potential harmful effects of this placement for the child or on the quality of
services that he or she needs §300.552 (a-b):
