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Example IEP

 

Example IEP

 

DATE OF MOST RECENT EVALUATION:______/______/______DATE OF NEXT REEVALUATION:______/______/_____

PURPOSE OF CONFERENCE (Check all that apply)

 

 

  Review of Existing Data

  Reevaluation

  IEP Review/Revision

  Manifestation Determination

  Termination of Placement

 

 

  Initial Eligibility

  Initial IEP

  Transition

  Graduation

  Other (e.g. FBA/BIP)________

 

STUDENT IDENTIFICATION INFORMATION

 

STUDENT’S ADDRESS (Street, City, State, Zip Code)

 

 

STUDENT’S DATE OF BIRTH

 

SIS ID NUMBER

 

 MALE

 FEMALE

ETHNICITY

LANGUAGE/MODE OF COMMUNICATION USED BY STUDENT

CURRENT GRADE LEVEL

ANTICIPATED DATE OF HS GRADUATION

PLACEMENT(To be completed after placement determination)

 

YES    NO      Placement is in Resident School

DISABILITY(S)

 

MEDICAID NUMBER  

 

RESIDENT DISTRICT  

 

SERVING DISTRICT  

 

RESIDENT SCHOOL  

 

SERVING SCHOOL

 

         

 

PARENT/GUARDIAN INFORMATION

 

(1) PARENT’S NAME                               Educational Surrogate Parent  

 

(2) PARENT’S NAME                               Educational Surrogate Parent

 

(1) PARENT’S ADDRESS (Street, City, State, Zip Code)

 

 

(2) PARENT’S ADDRESS (Street, City, State, Zip Code)

 

(1) PARENT’S TELEPHONE NUMBER (include Area Code)

(2) PARENT’S TELEPHONE NUMBER (Include Area Code)

 

(1) LANGUAGE/MODE OF COMMUNICATION USED BY PARENT(S)

 

Yes  No   Interpreter      

(2) LANGUAGE/MODE OF COMMUNICATION USED BY PARENT(S)

 

Yes  No   Interpreter      

 

PARTICIPANTS

 

Signature indicates attendance.  Check appropriate boxes to indicate which meetings were attended.  Anyone serving in a dual role should indicate so on the following lines.  If a required participant participates through written input or is excused from all or part of the IEP meeting, the required excusal and written report, as necessary, is attached.

 

ELIG.

REVIEW

 

IEP

ELIG.

REVIEW

 

IEP

 

 

 

 

 

 

 

 

     

 

 

 

Parent

 

 

 

School Social Worker

 

 

 

     

 

 

 

     

 

 

 

Parent

 

 

 

Speech-Language Pathologist

 

 

 

     

 

 

 

     

 

 

 

Student

 

 

 

Bilingual Specialist

 

 

 

     

 

 

 

     

 

 

 

LEA Representative 

 

 

 

Interpreter

 

 

 

     

 

 

 

     

 

 

 

General Education Teacher

 

 

 

Other (specify)

 

 

 

     

 

 

 

     

 

 

 

Special Education Teacher

 

 

 

Other (specify)

 

 

 

     

 

 

 

     

 

 

 

School Psychologist 

 

 

 

Other (specify)

                   

 

 

If the parent(s) did not attend the IEP meeting, document the attempts to contact the parent(s) prior to the IEP meeting.

 

 

 

 

PROCEDURAL SAFEGUARDS

 

 

Explanation of Procedural Safeguards were provided to/reviewed with the parent(s) on _____________________________________________________

 

Transfer of Rights - Seventeen-year old student informed of his/her rights that will transfer to the student upon reaching age 18.  Yes        NA

 

Parent(s) were given a copy of the:  Evaluation report and eligibility determination              IEP   

 

                                                                District’s behavioral intervention policies      District’s behavioral intervention procedures (initial IEP only)


 

DOCUMENTATION OF EVALUATION RESULTS

 

Complete for initial evaluations, reevaluations, or a review of an independent or outside evaluation.

Considering all available evaluation data, record the team’s analyses of the student’s functioning levels.  Only those areas which were identified as relevant to the current evaluation must be completed.  All other areas should be noted as “Not Applicable”.  Evaluation data may include:  parental input, teacher recommendations, physical condition, social or cultural background, adaptive behavior, record reviews, interviews, observations, testing etc.  Describe the observed strengths and/or deficits in the student’s functioning in the following domains.

Academic Achievement (Current or past academic achievement data pertinent to current educational performance)

     

 

Functional Performance (Current or past functional performance data pertinent to current functional performance)

     

Cognitive Functioning (Data and other information regarding intellectual ability; how the student takes in information, understands information, and expresses information)

     

Communicative Status (Information regarding communicative abilities (language, articulation, voice, fluency) affecting educational performance)

 

 

 

For ELL students explain ELL STATUS:                Has Linguistic status Changed  YES    NO 

     

Health (Current or past medical difficulties affecting educational performance)

     

Hearing/Vision (Auditory/visual problems that would interfere with testing or educational performance.  Include dates and results of last hearing/vision test)

     

Motor Abilities (Fine and gross motor coordination difficulties, functional mobility, or strength and endurance issues affecting educational performance)

     

 

Social/Emotional Status/Social Functioning (Information regarding how the environment affects educational performance (life history, adaptive behavior, independent functioning, personal and social responsibility, cultural background)

     


ELIGIBILITY DETERMINATION

(ALL DISABILITIES OTHER THAN SPECIFIC LEARNING DISABILITY)

 

DETERMINANT FACTORS

 

 

 

The determinant factor for the student’s suspected disability is:

 

 

Yes

 

No

Lack of appropriate instruction in reading, including the essential components of reading instruction

(Evidence Provided)_______________________________________________________________________

 

 

 

 

 

Yes

 

No

Lack of appropriate instruction in math (Evidence Provided)________________________________________

 

 

 

 

 

 

Yes

 

No

Limited English Proficiency (Evidence Provided):________________________________________________

           

 

If any of the above answers is “yes,” the student is not eligible for services under IDEA and the team must complete Step 1 and 4 below.  If all of the answers are “no,” complete Steps 1-4.

 

COMPLETE FOR STUDENTS SUSPECTED OF HAVING A DISABILITY UNDER IDEA.

STEP 1 - DISABILITY

 

 No Disability Identified  (Complete Step 4 and write “Not Eligible for Special Education Services” in the Disability section of the Conference Summary Report page.)

 

 Disability Identified

Based on the team’s analysis, identify the disability(s):

 

Primary                                                  Secondary

? Autism (O)                                        ?

? Cognitive Disability (A)                    ?

? Deaf/Blindness (H)                          ?

? Deafness (G)                                    ?

? Developmental Delay (3-9) (N)       ?

? Emotional Disability (K)                  ?

? Hearing Impairment (F)                   ?

 

Primary                                                                  Secondary

? Multiple Disabilities (M)                                   ?

? Orthopedic Impairment (C)                            ?

? Other Health Impairment (L)                           ?

? Speech or Language Impairment (I)              ?

? Traumatic Brain Injury (P)                               ?

? Visual Impairment including Blindness (E)  ?

STEP 2 - ADVERSE EFFECTS

 

 No Adverse Effect Identified

(Complete Step 4 and write “Not Eligible for Special Education Services” in the Disability section of the Conference Summary Report page.)

 

 Adverse Effect Identified

For each disability identified, describe how the disability adversely affects the student’s educational performance

 

 

 

 

 

STEP 3 - EDUCATIONAL NEEDS

 

State to what extent the student requires special education and related services to address educational needs.

 

 

 

 

 

STEP 4 - ELIGIBILITY

 

Based on the steps above, the student is entitled to special education and related services.

 

 No (Not Eligible)                                                                             Yes (Eligible)

 

 


 

DOCUMENTATION OF INTERVENTION/EVALUATION RESULTS

(SPECIFIC LEARNING DISABILITY)

(Required as of the 2010-2011 School Year)

 

Complete for initial evaluations, reevaluations, or a review of an independent or outside evaluation when a specific learning disability is suspected. 

 

As part of the evaluation process, relevant behavior noted during observation in the child’s age-appropriate learning environment, including the general education classroom setting for school-age children, and the relationship of that behavior to the child’s academic functioning and educationally relevant medical findings, if any, must be documented.

Problem Identification / Statement of Problem:

Using baseline data, please provide an initial performance discrepancy statement for all identified areas of concern in the relevant domains (academic performance; functional performance; cognitive functioning, communicative status (for ELL students includes an explanation of ELL status and any change in linguistic status); social/emotional status/functioning, motor abilities, health, hearing and vision) including information about the student’s performance discrepancy prior to intervention.  Attach evidence.

 

 

Problem Analysis / STRENGTHS AND WEAKNESSES:

Describe student’s skill strengths and weaknesses in the identified area(s) of concern within the relevant domains.  Attach evidence, including evidence of skills deficit versus performance deficit.

 

Plan Development / Intervention(s):

Describe the previous and current intervention plans (core/Tier 1, supplemental/Tier 2, and intensive/Tier 3) including evidence that the intervention is scientifically based and was implemented with integrity.  Attach plan/evidence.

 

Plan Evaluation / Educational Progress:

Provide documentation of student progress over time as a result of the intervention.  Attach evidence/graphs.

 

 

Plan Evaluation / Discrepancy:

State the current performance discrepancy after intervention, i.e., the difference between a student’s level of performance compared to the performance of peers or scientifically-based standards of expected performance.  Attach evidence.

 

 

Plan Evaluation / Instructional Needs:

Summarize the student’s needs in the areas of curriculum, instruction, and environment.  Include a statement of whether the student’s needs in terms of materials, planning, and personnel required for intervention implementation are significantly different from those of general education peers.  Attach evidence.

 

 

 

 

 

Additional Information Necessary for Decision-Making (INCLUDE AS APPROPRIATE):

Report any educationally relevant information necessary for decision-making, including information regarding eligibility exclusionary and inclusionary criteria.  Attach evidence.

 

 

 

     

 

ELIGIBILITY DETERMINATION

(SPECIFIC LEARNING DISABILITY)

(Required as of the 2007-2008 School Year)

 

Complete for initial evaluations, reevaluations, or a review of an independent or outside evaluation when a specific learning disability is suspected. 

DETERMINANT FACTORS

 

 

 

The determinant factor for the student’s suspected disability is:

 

 

Yes

 

No

Lack of appropriate instruction in reading, including the essential components of reading instruction

(Evidence Provided)_______________________________________________________________________

 

 

 

 

 

Yes

 

No

Lack of appropriate instruction in math (Evidence Provided)________________________________________

 

 

 

 

 

 

Yes

 

No

Limited English Proficiency (Evidence Provided)_________________________________________________

           

 

If any of the above answers is “yes,” the student is not eligible for services under IDEA and the team must complete the Eligibility Determination section accordingly.  If all of the answers are “no,” complete the following sections.

EXCLUSIONARY CRITERIA

 

The team determined that the following factors are the primary basis for the student’s learning difficulties.  Document the source of evidence in each area:

 

Yes

 

No

A visual, hearing or motor disability:

 

Yes

 

No

Cognitive Disability:

 

Yes

 

No

Emotional disability:

 

Yes

 

No

Cultural factors:

 

Yes

 

No

Environmental or economic disadvantage:

 

If any of the boxes immediately above is checked “yes,” the student cannot have a primary eligibility of specific learning disability and the team must complete the Eligibility Determination section accordingly.

 

inclusionary CRITERIA

 

 

Educational Progress (Over Time)

 

Evidence in the Documentation of Evaluation Results should support the team’s answer to this question

 

 

Is the student progressing at a significantly slower rate than is expected in any areas of concern? 

(Select One)

 No

 Yes  - The student is progressing at a significantly slower rate than expected

 Yes  - The student is currently making an acceptable rate of progress but only because of the intensity of the intervention that is                 being provided.

 

If yes, in which area(s)?

 

 

 

Discrepancy (At One Point in Time)

Evidence in the Documentation of Evaluation Results should support the team’s answer to this question. 

 

Is the student’s performance significantly below performance of peers or expected standards in any areas of concern?

(Select One)

 No

 Yes  - The student’s performance is significantly discrepant.

 Yes  - The student’s performance is not currently discrepant but only because of the intensity of the intervention that is being                 provided.

 

If yes, in which area(s)?

 

 

 

           

 

ELIGIBILITY DETERMINATION

(SPECIFIC LEARNING DISABILITY)

(Required as of the 2007-2008 School Year)

Instructional Need

Evidence in the Documentation of Evaluation Results should support the team’s answer to this question.

 

Are this student’s needs in any areas of concern significantly different from the needs of typical peers and of an intensity or type that exceeds general education resources?

(Select One)

 No

 Yes  - The student’s instructional needs are significantly different and exceed general education resources.

 

If yes, in which area(s)?

 

 

If any of the boxes in this section (Inclusionary Criteria) are marked “No”, the student does not have a Specific Learning Disability and the team must complete the Eligibility Determination section accordingly. 

 

Optional Criteria

After determining that the criteria in the preceding section are met, the district may choose to use an IQ-achievement discrepancy model. If using this model, complete this section.

 

IQ-Achievement Discrepancy

 Yes   No   NA    Does a severe discrepancy exist between achievement and ability that is not correctable without special                                                     education and related services?  (Please refer to evidence in Documentation of Evaluation Results)

 

If yes, in which area(s)?

 

 

 

ELIGIBILITY DETERMINATION

 

 

 

Step 1:  Disability Adversely Affecting Educational Performance

 

 Yes   No                   Based on the answers to the questions in the “Determinant Factors, Exclusionary Criteria,” and “Inclusionary                                         Criteria,” sections, does the student have a specific learning disability?

 

     

 

If the answer is “no” the student is not eligible for special education services under the category of Specific Learning Disability and the team must complete Step 2 below.

 

If the answer is “yes,” indicate the area below and complete Step 2.

 Basic reading skills

 Reading fluency skills

 Reading comprehension

 Mathematical calculation

 Mathematical problem solving

 Written expression

 Oral expression

 Listening comprehension

 

 

 

Step 2:  Special Education and Related Services

 

 

Specialized instruction is required in order for the student to make progress and reduce discrepancy (Eligible)

 

 

Specialized instruction is not required in order for the student to make progress and reduce discrepancy (Not Eligible)

 

 

 

Each team member must sign below to certify that the report reflects his/her conclusions for specific learning disability.  Any participant who disagrees with the team’s decision must submit a separate statement presenting her/his conclusions.

 Yes

 No

     

 

 Yes

 No

     

 Yes

 No

     

 

 Yes

 No

     

 Yes

 No

     

 

 Yes

 No

     

 Yes

 No

     

 

 Yes

 No

     


 

DATA CHART

(OPTIONAL)

 

REPORT OF PERFORMANCE (READING, WRITING, MATH)

 

Insert a data chart that displays the student’s performance in reading, writing, and/or math relative to his/her peer group.  Data charts may be provided for other areas, as well.

 

 

REPORT OF PERFORMANCE

(INSERT DATA CHART)

 

 

 

 

REPORT OF PERFORMANCE

(INSERT DATA CHART)

 

 

 

 


 

PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

 

Complete for initial IEPs and annual reviews.

When completing this page, include all areas from the following list that are impacted by the student’s disability: academic performance, social/emotional status, independent functioning, vocational, motor skills, and speech and language/communication.  This may include strengths/weaknesses identified in the most recent evaluation.

Student’s Strengths

Parental Educational Concerns/Input       

Student’s Present Level of Academic Achievement (Include strengths and areas needing improvement)

Student’s Present Levels of Functional Performance (Include strengths and areas needing improvement)

Describe the effect of this individual’s disability on involvement and progress in the general education curriculum and the functional implications of the student’s skills. 

  • For a preschool child, describe the effect of this individual’s disability on involvement in appropriate activities. 
  • By age 14½, describe the effect of this individual’s disability on the pursuit of post-secondary expectations (living, learning, and working).

 

SECONDARY TRANSITION

 

Complete for students age 14½ and older, and when appropriate for students younger than age 14½.  Post-school outcomes should guide the development of the IEP for students age 14½ and older.

 

Age-Appropriate Transition Assessments

Transition Assessments

(Including student and family survey/interview)

Assessment Type

Responsible Agency/Person

Date Conducted

Report

Attached

Goal #

EMPLOYMENT                                          None needed

 

 

 

 

 

 

EDUCATION                                              None needed

                                                                

 

 

 

 

 

TRAINING                                                  None needed

 

 

 

 

 

INDEPENDENT LIVING SKILLS               None needed

 

 

 

 

 

 

 

POST-SECONDARY OUTCOMES (address by age 14½ )

Indicate and project the desired appropriate measurable post-secondary outcomes/goals as identified by the student, parent and IEP team.  Goals are based upon age appropriate transition assessments related to employment, education and/or training, and where appropriate, independent living skills.

Employment (e.g., competitive, supported shelter, non-paid employment as a volunteer or training capacity, military): AND

 

Post-Secondary Education (e.g., community college, 4-year university, technical/vocational/trade school): AND/OR

 

 

 

Post-Secondary Training (e.g., vocational or career field, vocational training program, independent living skills training, apprenticeship, OJT, job corps): AND

 

 

 

 

IF APPLICABLE, Independent Living (e.g., independent living, health/safety, self-advocacy/future planning, transportation/mobility, social relationships, recreation/leisure, financial/income needs):

 

COURSE OF STUDY (address by age 14½)

Identify a course of study that is a long-range educational plan or multi-year description of the educational program that directly relates to the student's anticipated post-school goals, preferences and interests as described above

 

Year 1 – Age 14/15

Year 2 – Age 15/16

Year 3 – Age 16/17

Year 4 – Age 17/18

Extended – Age 18-21

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 2

 

 

 

 


 

transition Services (address by age 141/2)

 

Please include, if appropriate, needed linkages for outside agencies, (e.g., DMH, DRS, DSCC, PAS, SASS, SSI, WIC, DHCFS, etc.)

 

INSTRUCTION (e.g., tutoring, skills training, prep for college entrance exam, accommodations, adult basic ed.)

 

 

 

 

(If none, indicate “none”)

Provider Agency and Position

 

 

Goal #(s) if appropriate

 

Date/Year to be Addressed

 

 

Date/Year Completed

 

 

RELATED SERVICES (e.g., transportation, social services, medical services, technology, support services)

 

 

 

 

(If none, indicate “none”)

Provider Agency and Position

 

 

Goal #(s) if appropriate

 

Date/Year to be Addressed

 

 

Date/Year Completed

 

 

COMMUNITY EXPERIENCES (e.g., job shadow, work experiences, banking, shopping, transportation, tours of post-secondary settings)

 

 

 

 

(If none, indicate “none”)

Provider Agency and Position

 

 

Goal #(s) if appropriate

 

Date/Year to be Addressed

 

 

Date/Year Completed

 

 

DEVELOPMENT OF EMPLOYMENT AND OTHER POST-SCHOOL ADULT LIVING OBJECTIVES (e.g., career planning, guidance counseling, job try-outs, register to vote, adult benefits planning)

 

 

 

 

(If none, indicate “none”).

Provider Agency and Position

 

 

Goal #(s) if appropriate

 

Date/Year to be Addressed

 

 

Date/Year Completed

 

 

APPROPRIATE ACQUISITION OF DAILY LIVING SKILLS AND/OR

FUNCTIONAL VOCATIONAL EVALUATION (e.g., self-care, home repair, home health, money, independent living, / job and career interests, aptitudes and skills)

 

Provider Agency and Position

 

 

Goal #(s) if appropriate

 

Date/Year to be Addressed

 

 

Date/Year Completed

 

 

LINKAGES TO AFTER GRADUATION SUPPORTS/SERVICES (e.g. DRS, DMH, DSCC, PAS, SASS, SSI, WIC, DHCFS, CILs)

 

Provider Agency and Position

 

 

Goal #(s) if appropriate

 

Date/Year to be Addressed

 

 

Date/Year Completed

 

 

home-based support services program

 Yes

 No

 

The student has a developmental disability and may become eligible for the program after reaching age 18 and

 when no longer receiving special education services.

 

 

 

 

 

If yes, complete the following statements:

 

 

Plans for determining the student’s eligibility for home-based services:

 

 

Plans for enrolling the student in the program of home-based services:

 

 

 

 

Plans for developing a plan for the student’s most effective use of home-based services after reaching age 18 and when no longer receiving special education services:

 

 

 

 

 

       

 

 

Page 2 of 2


 

FUNCTIONAL BEHAVIORAL ASSESSMENT (AS APPROPRIATE)

 

Complete when gathering information about a student’s behavior to determine the need for a Behavioral Intervention Plan.  When used in developing a Behavioral Intervention Plan, the Functional Behavioral Assessment must be reviewed at an IEP meeting and should be attached to the IEP. 

The Functional Behavioral Assessment must include data collected through direct observation of the target behavior.  Attach documentation of data collection.

 

Participant/Title

 

Participant/Title

 

 

 

 

 

 

 

 

 

 

Student’s Strengths – Include a description of behavioral strengths (e.g., ignores inappropriate behavior of peers, positive interactions with staff, accepts responsibility, etc.)

     

Operational Definition of Target Behavior – Include a description of the frequency, duration and intensity of the behavior.

     

Setting – Include a description of the setting in which the behavior occurs (e.g., physical setting, time of day, persons involved.)

     

Antecedents – Include a description of the relevant events that preceded the target behavior.

     

Consequences – Include a description of the result of the target behavior (e.g. removed from classroom and did not complete assignment.  What is the payoff for the student?)

     

Environmental Variables – Include a description of any environmental variables that may affect the behavior (e.g., medication, weather, diet, sleep, social factors.)

     

Hypothesis of Behavioral Function - Include a hypothesis of the relationship between the behavior and the environment in which it occurs.

     

 

 


 

BEHAVIORAL INTERVENTION PLAN (AS APPROPRIATE)

 

Complete when the team has determined a Behavioral Intervention Plan is needed.

 

Student’s Strengths – Describe student’s behavioral strengths

     

Target Behavior

Is this behavior a  Skill Deficit or a Performance Deficit

 

Skill Deficit:  The student does not know how to perform the desired behavior.

Performance Deficit:  The student knows how to perform the desired behavior, but does not consistently do so.

 

     

Hypothesis of Behavioral Function – Include hypothesis developed through the Functional Behavioral Assessment (attach completed form).  What desired thing(s) is the student trying to get?  OR What undesired thing(s) is the student trying to avoid?

     

Summary of Previous Interventions Attempted – Describe any environmental changes made, evaluations conducted, instructional strategy or curriculum changes made or replacement behaviors taught.

     

Replacement Behaviors – Describe which new behaviors or skills will be taught to meet the identified function of the target behavior (e.g. student will slap his desk to replace striking out at others).  Include description of how these behaviors/skills will be taught.

     

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BEHAVIORAL INTERVENTION PLAN (AS APPROPRIATE)

Behavioral Intervention Strategies and Supports

  Environment – How can the environment or circumstances that trigger the target behavior be adjusted?

     

  Instruction and/or Curriculum – What changes in instructional strategies or curriculum would be helpful?

     

  Positive Supports – Describe all additional services or supports needed to address the student’s identified needs that   

                                     contribute to the target behavior.

     

Motivators and/or Rewards – Describe how the student will be reinforced to ensure that replacement behaviors are more motivating than the target behavior.

     

Restrictive Disciplinary Measures – Describe any restrictive disciplinary measures that may be used with the student and any conditions under which such measures may be used (include necessary documentation and timeline for evaluation.)

     

Crisis Plan – Describe how an emergency situation or behavior crisis will be handled.

     

Data Collection Procedures and Methods – Describe expected outcomes of the interventions, how data will be collected and measured, timelines for and criteria to determine success or lack of success of the interventions.

     

Provisions For Coordination with Caregivers – Describe how the school will work with the caregivers to share information, provide training to caregivers if needed, and how often this communication will take place.

      

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GOALS AND OBJECTIVES/BENCHMARKS

 

Complete for initial IEPs and annual reviews.  (Anyone responsible for implementing the IEP (e.g., goals and objectives/benchmarks, accommodations, modifications and supports) must be notified of her/his specific responsibilities.)

 

reporting on goals

 

The progress on annual goals will be measured by the short-term objectives/benchmarks.  Check the methods that will be used to notify parents of the student’s progress on annual goals and if the progress is sufficient to achieve the goals by the end of the IEP year:

 

  Report cards

  Progress reports

  Parent conference

  Other (specify) __________________________

 

 

current academic achievement and functional performance

 

 

Results of the initial or most recent evaluation and results on district-wide assessments relevant to this goal; performance in comparison to general education peers and standards.

 

 

 

goals and objectives/benchmarks

 

 

The goals and short-term objectives or benchmarks shall  meet the student’s educational needs that result from the student’s disability, including involvement in and progress in the general curriculum, or for preschool students, participation in appropriate activities.

 

Goal Statement #____of_____       

 

Indicate Goal Area:        Academic        Functional         Transition                        Illinois Learning Standard:   #___________

 

Title(s) of Goal Implementer(s)      

 

 

 

 

 

                 

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

     

 

Evaluation

Criteria

Evaluation

Procedures

Schedule for

Determining Progress

Dates Reviewed/

Extent of Progress (Optional)

 

% Accuracy

 

 

Observation Log

 

 

Daily

 

 

 /

# of attempts

 

 

Data Charts

 

 

Weekly

 

 

Other (specify)

 

 

Tests

 

 

Quarterly

 

 

 

 

Other (specify)

 

 

Semester

 

 

 

 

Other (specify)

 

 

 

 

 

 

                               
 

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

     

 

Evaluation

Criteria

Evaluation

Procedures

Schedule for

Determining Progress

Dates Reviewed/

Extent of Progress (Optional)

 

% Accuracy

 

 

Observation Log

 

 

Daily

 

 

 /

# of attempts

 

 

Data Charts

 

 

Weekly

 

 

Other (specify)

 

 

Tests

 

 

Quarterly

 

 

 

 

Other (specify)

 

 

Semester

 

 

 

 

Other (specify)

 

 

 

 

 

 

                               
 

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

     

 

Evaluation

Criteria

Evaluation

Procedures

Schedule for

Determining Progress

Dates Reviewed/

Extent of Progress (Optional)

 

% Accuracy

 

 

Observation Log

 

 

Daily

 

 

 /

# of attempts

 

 

Data Charts

 

 

Weekly

 

 

Other (specify)

 

 

Tests

 

 

Quarterly

 

 

 

 

Other (specify)

 

 

Semester

 

 

 

 

Other (specify)

 

 

 

 

 

 

                               
 

 

EDUCATIONAL ACCOMMODATIONS AND SUPPORTS

Complete for initial IEPs and annual reviews.  (Anyone responsible for implementing the educational accommodations must be notified of her/his specific responsibilities).

 

TRANSITION

 Yes

 No

 NA

Consideration of service needs, goals, and support/services is required (by age 14 ½ , the team must address transition

service needs).  If yes, complete the “Transition Services” section of the IEP.

 

 Yes

 No

 NA

Consideration of “Home-Based Support Services Program for Mentally Disabled Adults” for eighteen-year-old student is

required.  If yes, complete the “Home-Based Support Services Program” section of the IEP.

 

CONSIDERATION OF SPECIAL FACTORS

Check the boxes to indicate if the student requires any supplementary aids and/or services due to the following factors.  For any box checked “yes,” specify the special factors in the “Supplementary Aids, Accommodations and Modifications” section listed below.

 Yes

 No

 

assistive technology devices and services

 Yes

 No

 

communication needs

 Yes

 No

 

deaf/hard of hearing – languages and communication needs

 Yes

 No

 

limited English proficiency – language needs

 Yes

 No

 

blind/visually impaired – provision of Braille instruction

 Yes

 No

 

behavior impedes student’s learning or that of others.  If yes, the team must consider strategies, including positive behavioral interventions and supports to address behavior.  This may include a Functional Behavioral Assessment and/or a Behavioral Intervention Plan.  If, so attach any completed forms.

 

 

 

 

linguistic and cultural accommodations

 Yes

 No

 

The student requires accommodations for the IEP to meet her/his linguistic and cultural needs.

 

If yes, specify any needed accommodations:

     

 Yes

 No

 

Special education and related services will be provided in a language or mode of communication other

 

than or in addition to English.  If yes, specify any needed accommodations:

 

 

 

 

SUPPLEMENTARY AIDS, ACCOMMODATIONS, AND MODIFICATIONS

             

Specify what aids, accommodations, and modifications are needed for the child to make progress toward annual goals, to progress in the general education curriculum, participate in extracurricular and other non-academic activities, and to be educated and participate with other children with disabilities and/or nondisabled children (e.g., accommodations for daily work, environmental accommodations, moving from class to class, etc.).  Supplementary aids, accommodations, and modifications must be based upon peer-review research to the extent practicable.

     

 

Supports for school personnel

 Yes

 No

Program trainings and/or supports for school personnel are needed for the student to advance appropriately toward attaining

 

the annual goals, participate in the general curriculum, and be educated and participate with other students in educational activities.  If yes, specify what trainings and/or supports are needed, including when appropriate, the information that clarifies when the trainings and/or supports will be provided, by whom, in what location, etc.

 

 

 

 

 

 


 

ASSESSMENT

 

CLASSROOM-BASED ASSESSMENTS

 

 Yes

 No

Student requires accommodations to participate in classroom-based assessments.

 Yes

 No

Student requires alternate assessment/methods to participate in classroom-based assessments

 

DISTRICT-WIDE ASSESSMENTS

 

 

District does not administer district-wide assessments

 

 

 

District does not administer district-wide assessments at this grade level: _________

 

       

Student will:

 

Participate in the entire district-wide assessment with no accommodations

 

Participate in the entire district-wide assessment with accommodations

 

Participate in part(s) of the district wide assessment (specify)

 

Participate in the district-wide alternate assessment

 

 

STATE ACADEMIC ASSESSMENTS

The State academic assessments are the Illinois Standards Achievement Test (ISAT) at grades 3-8 and the Prairie State Achievement Exam (PSAE) at grade 11, Illinois Measure of Annual Growth in English (IMAGE) in grades 3-8 and 11 (for English Language Learner (ELL) students), and Illinois alternate Assessment  (IAA) in grades 3-8 and 11.

 

State academic assessments are not administered at this grade level __________

Student will:

 

Participate in the ISAT/PSAE/IMAGE with no accommodations

 

Participate in the ISAT/PSAE/IMAGE with accommodations

 

Participate in the IAA

 

If the student will participate in the IAA, the following were met:

 

The ISAT/PSAE/IMAGE is not appropriate (specify)

 

The IAA participation guidelines were met

 

The alternate assessment selected is appropriate for the student (explain)

 

 

STATE ASSESSMENT OF LANGUAGE PROFICIENCY

The State assessment of language proficiency is Assessing Comprehension and Communication in English State to State (ACCESS) in grades K-12

 Yes

 No

 ENGLISH LANGUAGE LEARNER (ELL).  If “NO”, skip to next section

Student will:

 

participate in the ACCESS with no accommodations

 

participate in the ACCESS with accommodations

 

ASSESSMENT ACCOMMODATIONS

If the student is participating in any of the above assessment(s) with accommodations, specify the needed accommodations (e.g., extended time, alternate setting, auditory testing) necessary to measure the student’s academic achievement and functional performance.  The accommodations should be appropriate for that particular assessment and reflective of those already identified for the student in the Supplementary Aids, Accommodations, and Modifications section.

     


EDUCATIONAL SERVICES AND PLACEMENT

 Initiation Date:______/_______/______     Duration Date: ______/_______/_______

 

PARTICIPATION IN GENERAL EDUCATION CLASSES

The IEP must address all content areas, classes, and specify if the student will participate in general physical education.

General Education with No Supplementary Aids

(Specify content areas, classes, whether or not the child will participate in general physical education, and extracurricular and other nonacademic activities.)

Minutes Per Week in Setting

(Optional)

 

 

 

 

 

 

 

General Education with Supplementary Aids (as specified in the Supplementary Aids section)

(Specify content areas, classes, whether or not the child will participate in general physical education, and extracurricular and other nonacademic activities with supports, if applicable.)

Minutes Per Week in Setting

(Optional)

 

 

 

 

 

 

 

 

Special Education and Related Services within the General Education Classroom

(Specify content areas and classes in which the child will participate with the provision of special education and related services. List each special education and related service that will be provided during each class. )

Minutes Per Week in Setting

 

 

 

 

 

 

 

 

 

 

PARTICIPATION IN SPECIAL EDUCATION CLASSES/services

The IEP must address all special education and related services.

Special Education Services – Outside General Education

 

Minutes Per Week in Setting

 

 

 

 

 

 

 

A.

 

Related Services – Outside General Education

 

Minutes Per Week in Setting

 

 

 

 

 

 

 

 

 

B.

 

 

Educational Environment (EE) Calculation (Ages 3-5)

_________ 1. Minutes spent in regular early childhood program

_________ 2. Minutes spent receiving special education and                         related services outside regular early childhood                         (A+B)

 

 

Educational Environment (EE) Calculation (Ages 6-21)

_________ 1. Total Bell to Bell Minutes

_________ 2. Total Number of Minutes Outside of the                         General Education Setting (A+B)

       

 

EDUCATIONAL services and placement

 

EDUCATIONAL ENVIRONMENT CONSIDERATIONS

To the maximum extent appropriate, all students shall be educated and participate with students who are non-disabled.  Provide an explanation of the extent, if any, to which the student will not participate in general education classes and activities.

Yes

No

Special education classes, separate schooling, or removal from the regular education environment is required because the nature or severity of the student’s disability is such that education in general classes with the use of supplementary aids and services cannot be achieved satisfactorily.

Explain:________________________________________________________________________________________________________

Yes

No

Will participate in nonacademic activities with nondisabled peers and have the same opportunity to participate in extracurricular activities as nondisabled peers?

If no, explain:____________________________________________________________________________________________________

Yes

No

Will attend the school he or she would attend if nondisabled?

If no, explain:____________________________________________________________________________________________________

PLACEMENT CONSIDERATIONS

 

       

When determining the placement, consider any potentially harmful effect either on the student or the quality of services that he/she needs.  After determining the student’s placement, complete the “Placement” section on this cover sheet.

Yes    NA       For a child who is deaf, hard or hearing, blind or visually impaired, parents have been informed of existence of the Illinois School                                       for the Deaf or the Illinois School for the Visually Impaired, and other local schools that provide similar services.

 

Placement Options CONSIDERED

 

POTENTIALLY HARMFUL EFFECT/ REASONS REJECTED

TEAM ACCEPTS PLACEMENT

     

 

 

 Yes     No

     

 

 

 Yes      No

     

 

 

 Yes      No

 

TRANSPORTATION

Check all that apply

 Yes

 No

Special transportation is required to and from schools and/or between schools.

 

 Yes

 No

Special transportation is required in and around school buildings.

 

 Yes

 No

Specialized equipment (such as special or adapted buses, lifts, and ramps) is required.

 

Please explain and/or detail transportation plan:


Extended school year SERVICES

 Yes

 No

Extended school year services are needed.  The IEP team must document the consideration of the need for extended school year services and the basis for the determination.

 

If yes, the IEP must indicate the type, amount and duration of services to be provided. 

special education

SERVICE(s)

LOCATION

amount/frequency of services

initiation of services

Duration of Services

Goal(s) Addressed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

         

 

MANIFESTATION DETERMINATION (AS APPROPRIATE)

 

Complete when determining whether a student’s behavior was a manifestation of her/his disability. 

Disability:

     

Incident(s) that Resulted in Disciplinary Action

     

The Student’s IEP and Placement (include a review of all relevant information in the child’s file, including the child’s IEP)

 

Observations of the Student (include a review of staff observations regarding the student’s behavior)

     

Information provided by the Parents (include a review of any relevant information provided by the parent(s)

     

Based upon the above information, the team has determined that:

 Yes

 No

The conduct was caused by or had a direct and substantial relationship to the student’s disability.

 Yes

 No

The conduct was the direct result of the school district’s failure to implement the IEP.

If “Yes” to either of the above, the behavior must be considered a manifestation of the student’s disability.

Check the appropriate box:

 

 

The student’s behavior WAS NOT a manifestation of her/his disability.  The relevant disciplinary procedures applicable to students without disabilities may be applied to the student in the same manner in which they are applied to students without disabilities.  If the district initiates disciplinary procedures applicable to all students, the district shall ensure that the special education and disciplinary records of the student with a disability are transmitted for consideration by the person or persons making the final determination regarding the disciplinary action.

 

 

 

The student’s behavior WAS a manifestation of her/his disability.  The team must review and revise the student’s IEP as appropriate and the district must take appropriate action.  A functional behavior analysis will or has been completed.  The behavior intervention plan shall be completed or modified/reviewed as required to address behavior.

 

 


 

ADDITIONAL NOTES/INFORMATION


REPORT OF PROGRESS ON ANNUAL GOALS (OPTION 1)

 

Specify the extent to which the student’s progress is sufficient to enable the student to achieve the goals by the end of the IEP year.  Districts may use this page to report on student progress OR may use the option two page that would include data charts to indicate a student’s progress.

 

Student’s Name

                Type of Report

 

Date

Report Card

  1     2     3     4   Quarter

 

 

Staff Name

Progress Report

  1     2     3     4   Quarter

 

 

Title

Parent Conference

 

 

 

GOAL NUMBER

MEASURABLE ANNUAL GOAL

REPORT OF PROGRESS:

ADDITIONAL
COMMENTS

Completed

Making Expected Progress

 

Not Making Expected Progress

 

 

 

 

 

 

 

 

                 

 


REPORT OF PROGRESS ON ANNUAL GOALS (OPTION 2)

 

Specify the extent to which the student’s progress is sufficient to enable the student to achieve the goals by the end of the IEP year.  Districts may use this page to report on student progress OR may use the option one page.

 

Student’s Name

                Type of Report

 

Date

Report Card

  1     2     3     4   Quarter

 

 

Staff Name

Progress Report

  1     2     3     4   Quarter

 

 

Title

Parent Conference

 

 

 

GOAL NUMBER

MEASURABLE ANNUAL GOAL

REPORT OF PROGRESS

(INSERT DATA CHARTS)

 

 

 

 

 

 

 

 

 

           

 

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