Name: Jack Reich

Individualized Educational Program (IEP) Blank Form

Name: Student 1 Age: 17 HT: 72” Wt: 145

Educational Placement: General Education Disability (major health problems): None

Present level of performance statement (in physical education)

Student 1 is a 17-year-old student who is currently placed in general education classes and has no
known disabilities. He is currently a senior at Westminster High School, and receiving no
accommodations for his classes. Student 1 is on the Varsity tennis team, and is very skilled at
racket sports. Overall, he is in very athletic, but after assessing Student 1 with the Adapted
Physical Education Assessment Scale - Secondary Level (APEAS II), it became apparent that he
could use improvements in his ability to balance on his right foot, with his eyes closed. The
APEAS II assessment also showed me that, while Student 1 had no problem with his form, while
throwing a ball, he had very low accuracy when throwing at a target. Student 1 is a very nice and
kind person, but he has a tendency to go out of his way to avoid social interactions. Often doing
things by himself and excluding his surrounding peers.

1. Annual Goal & Projected Date (start/stop): (Behavioral and measurable. Remember to
include the level of prompt in all annual goals & benchmarks)
Student 1 will balance independently on his right foot, with his left foot six inches off the
ground, eyes closed, arms crossed, and hands grasping opposite elbows at chest level, for 60
seconds, 4 out of 5 times (80% accuracy) by September 15, 2021.

Benchmarks & Projected Dates (short term behavioral objectives that measure progression
towards annual goal):
1. Student 1 will balance independently on his right foot, with his left foot six inches off the
ground, eyes closed, arms crossed, and hands grasping opposite elbows at chest level, for 15
seconds, 4 out of 5 times (80% accuracy) by December 15, 2020.

2. Student 1 will balance independently on his right foot, with his left foot six inches off the
ground, eyes closed, arms crossed, and hands grasping opposite elbows at chest level, for 30
seconds, 4 out of 5 times (80% accuracy) by March 15, 2021.

3. Student 1 will balance independently on his right foot, with his left foot six inches off the
ground, eyes closed, arms crossed, and hands grasping opposite elbows at chest level, for 45
seconds, 4 out of 5 times (80% accuracy) by June 15, 2021.

Materials/Methods:
 Timer
 Modeling
 Flat hard surface with no obstructions
 Environment free from distracting stimuli
2. Annual Goal: & Projected Date (start/stop): (Behavioral and measurable. Remember to
include the level of prompt in all annual goals & benchmarks)
With a verbal prompt Student 1 will overhand throw a softball, with his dominate hand, 30 feet
away accurately landing inside a designated target that is 18 inches off the ground, 36 inches tall,
and 18 inches wide, 4 out of 5 times (80% accuracy) by September 15, 2021.

Benchmarks & Projected Dates (short term behavioral objectives that measure progression
towards annual goal):
1. With a verbal prompt Student 1 will overhand throw a softball, from 10 feet away accurately,
landing inside a designated target that is 18 inches off the ground, 36 inches tall, and 18 inches
wide, 4 out of 5 times (80% accuracy) by December 15, 2021.

2. With a verbal prompt Student 1 will overhand throw a softball, with his dominate hand, 20
feet away accurately landing inside a designated target that is 18 inches off the ground, 36 inches
tall, and 18 inches wide, 4 out of 5 times (80% accuracy) by March 15, 2021.

3. With a verbal prompt Student 1 will overhand throw a softball, with his dominate hand, 25
feet away accurately landing inside a designated target that is 18 inches off the ground, 36 inches
tall, and 18 inches wide, 4 out of 5 times (80% accuracy) by June 15, 2021.

Materials/Methods:
 Softball
 Modeling
 Target
 Environment free from distracting stimuli

3. Affective or Cognitive Annual Goal & Projected Date (start/stop): (Behavioral and
measurable. Remember to include the level of prompt in all annual goals & benchmarks)
Student 1 will independently give positive feedback to five class mates and high five them using
their names 4 out of 5 times (80% accuracy) September 15, 2021.

Benchmarks & Projected Dates (short term behavioral objectives that measure progression
towards annual goal):
1. Student 1 with a verbal prompt will give positive feedback to 1 class mates and high five them
using their name 4 out of 5 times (80% accuracy) December 15, 2021.

2. Student 1 with a verbal prompt will give positive feedback to 3 class mates and high five them
using their names 4 out of 5 times (80% accuracy) March 15, 2021.

3. Student 1 with a verbal prompt will give positive feedback to 5 class mates and high five them
using their names 4 out of 5 times (80% accuracy) by June 15, 2021.

Materials/Methods:
 Modeling
 Verbal Prompt
 Right Foot Balance Rubric

Student Name: ____________________________ Date: _______________________

Level of Mastery: ___________________________ Score: _______/20

Mastery Levels: Levels of Prompts:

Grand Master (Rudimentary) = 0-5 points PP = Physical prompt
Arch Master (Emerging) = 6-10 points VP = Verbal prompt
Supreme Master (Functional) = 11-15 points MP = Modeling Prompt
Ultimate Master (Mastery) = 16-20 points

Skill Level of Grand Master Arch Master Supreme Ultimate Score

Prompt (Rudimentary) (Emerging) Master Master
(Circle (Functional) (Mastery)
one) 6-10 Points
0-5 Points 10-15 Points 15-20 Points
Arms Arms were Arms were Arms were Arms were
crossed, PP used 3 times used 2 times used 1 time to not used to
and hands VP to maintain to maintain maintain maintain
grasping MP balance balance balance balance
opposite
elbows 1 Point 2 Points 3 Points 4 Points
Right foot Hopped 3 Hopped 2 Hopped 1 Right foot
firmly PP time to time to time to did not
planted on VP maintain maintain maintain move
the ground MP balance balance balance

1 Point 2 Points 3 Points 4 Points

Left foot Left foot Left foot Left foot Left foot
remains in PP tapped ground tapped tapped ground stayed in air
the air VP 3 time to ground 2 time 1 time to
MP maintain to maintain maintain
balance balance balance
1 Point 2 Points 3 Points 4 Points
Eyes Eyes opened 3 Eyes opened Eyes opened Eyes
stayed PP time 2 time 1 time remained
closed VP closed
MP
1 Point 2 Points 3 Points 4 Points
Time, in Caught self Caught self Caught self 60 seconds
seconds, PP from falling at from falling from falling or greater
that VP 15 to 29 at 30 to 44 at 45 to 59
student MP seconds seconds seconds
balanced 1 Point 2 Points 3 Points 4 Points
Total Score (out of 20):
Notes/Additional Comments:
Data
This data chart tracks the annual goal for Student 1 maintaining balance on his right foot
with his eyes closed. Student 1 demonstrated his balancing on the flat black asphalt
basketball courts at Fulton Middle School, between 10:00 and 10:30 AM. The length of
time he balanced, the level of prompt used, and the quality of his balancing which uses
the right foot balancing rubric, is all recorded.

Date Time Balanced Level of Points Received Mastery Level

(Seconds) Prompts (Based on rubric) (Based on rubric)
09/26/20 12 PP 4 Grand Master
10/01/20 26 PP 7 Arch Master
10/20/20 32 MP 8 Arch Master
11/18/20 38 MP 10 Arch Master
12/15/20 44 VP 13 Supreme Master
01/18/21 42 MP 14 Supreme Master
02/15/21 55 VP 15 Ultimate Master
02/27/21 46 VP 12 Supreme Master
03/15/21 52 VP 16 Ultimate Master
04/10/21 57 VP 18 Ultimate Master
05/18/21 60 VP 18 Ultimate Master
06/01/21 60 VP 20 Ultimate Master
Average Rubric Score 13(12.91) Supreme Master

Mastery Levels: Levels of Prompts:

Grand Master (Rudimentary) = 0-5 points PP = Physical prompt
Arch Master (Emerging) = 6-10 points VP = Verbal prompt
Supreme Master (Functional) = 11-15 points MP = Modeling Prompt
Ultimate Master (Mastery) = 16-20 points

The above chart shows Student 1’s progression on balancing on his right foot in seconds.
It also includes the level of prompt used each day to help Student 1 perform at his highest
level. The chart also includes how well he performed and maintained balance with assists
before completely having to catch himself. How many assists and how long he balanced
before catching himself from falling, were converted into a point value, based on a right
foot balancing rubric. The points can then be used to calculate the level of mastery for
Student 1’s right foot balancing.

Type of Prompts
As seen on the chart, physical, verbal, and modeling prompts were all used with Student
1 throughout his trials. He initially needed a physical prompt to begin, but soon got used
to beginning with a modeling prompt. The goal was to get Student 1 to begin with a
verbal prompt, and about half way through, a verbal prompt was all that was needed.

Teacher Notes
Taking a look at the data chart, you can see that Student 1 initially had difficulties
performing the task. He would either get distracted and start talking, or just giving up.
Once he got used to the trial, and started to stay focus, he quickly became much better.
There was some fluctuation throughout his trials, but the more he was verbally motivated
the better he did. Even though he had his off days, Student 1 showed that he is motivated
to get better, and managed to continually increase his results.