10
Special Education Department
Individualized Education Program (IEP)
Student Name: Student Data/Cover Sheet (Form A-1) IEP Meeting Date:
Student ID: DOB:
Demographic Information
Student Number:
Student Name:
Birthdate:
Gender:
Grade:
Student Address:
Home Phone:
City, State, Zip:
Parent 1 Name:
Parent 1 Relationship:
Parent 1 Address:
Home Phone:
City, State, Zip:
Work Phone:
Parent 1 Email:
Parent 2 Name:
Parent 2 Relationship:
Parent 2 Address:
Home Phone:
City, State, Zip:
Work Phone:
Parent 2 Email:
Primary Language of Home:
Primary Language Survey Date:
Primary Language Survey Results:
Language of Instruction:
Home District:
Attendance District:
Service Coordinator:
Home School:
Attending School:
Vision Screened On:
Results:
Hearing Screened On:
Results:
Meeting Date:
Anticipated Duration of IEP:
To
Re-evaluation Due:
Current Evaluation:
Special Education Primary Category #1:
Special Education Eligibility Category #2:
Special Education Eligibility Category #3:
For Students with SLD only, the following area(s) of eligibility was/were previously determined:
Level of Services: (A)
Type: of Meeting:
Date Meeting Notice Sent to the Parent(s):
Date Procedural Safeguards given to the Parent(s):
Special Education Department
Individualized Education Program (IEP)
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)
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Section 1: Current IEP Information
Goal Number Written:
Summarize special education services the student is receiving:
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:
Section 3: Present Level of Academic Achievement
READING
WRITING
MATH
Parent’s Input on Student’s Current Academic Achievement:
Current Classroom-Based Data:
State and District Assessments:
Section 4: Functional Performance
Social Emotional and Behavior:
Parent’s Input and Student’s Current Functional Achievement:
Summary of Work Habits:
Section 5: Summary of Educational Needs
Special Education Department
Individualized Education Program (IEP)
ADDITIONAL DOCUMENTATION/CONSIDERATION OF SPECIAL FACTORS
Considered Not Included
Needed
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[Grab your reader’s attention with a great quote from the document or use this space to emphasize a key point. To place this text box anywhere on the page, just drag it.]For a student whose behavior impedes his/her learning, or that of
others, positive behavior interventions, strategies, and supports have
been considered.
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Proficiency
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Visually Impaired Child
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with Peers in the Child’s Language and Communication Mode
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Special Education Department
Individualized Education Program (IEP)
Skill Area:
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Skill Area:
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Skill Area:
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Special Education Department
Individualized Education Program (IEP)
ACCOMODATIONS
Date given to Genera Ed. Teacher: Service Coordinator:
Accommodations do not change now much of the curriculum the student is expected to learn. It only changes how students access and express knowledge on a daily basis. Accommodations are changes in how a student accesses information and demonstrates learning. Accommodations do not substantially change the instructional level, content, or performance criteria. The changes are made in order to provide a student with equal access to learning and equal opportunity to show what he or she knows and can do. Students with disabilities who qualify in one academic area are eligible for accommodations in other areas to the extent that their disability would affect performance in those areas.
Accommodations
Type
Location
Legend for Type and Location Fields
Type:
1 = Class work / assignments 2 = Assessments / tests 3 = Both class work / assignments / assessments.
Location:
A = All Subjects B = Language Arts / English C = Reading D = Spelling E = Math
F = Science G = Social Studies H = Health I = Electives J = Physical Ed.
K = Lunch L = Transition / Vocation M = Library N = Title 1 Special / Exploratory
Parental Communication
How will the parent be informed of their child’s academic progress and the extent to which that profess is sufficient to enable the child to achieve annual goals by the end of the year?
IEP Team Consideration for Extended School Year
Consideration for eligibility: IEP team considered ESY eligibility in the areas of regression and recoupment factors and essential skills at a critical stage of development.
Eligible for ESY:
Written explanation as to why ESY is or is not needed:
Special Education Department
Individualized Education Program (IEP)
ASSESSMENT
Rationale: Students with disabilities will participate in usual district assessments unless indicated by this form. Only those accommodations that are provided for instruction and are required by the IEP should be provided for assessment. All students will be assessed at grade level, other than the few who must be provided alternative assessments.
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
Special Education Department
Individualized Education Program (IEP)
SPECIAL EDUCATION SERVICES TO BE PROVIDED
Special Education Program(s) Necessary to Meet Special Education Goals and Objectives during the school calendar year.
**The child is in need of specially designed instruction in the following areas:
Special Education Services
Instructional Setting / Location
Start Date
Frequency
Provider
Duration / End Date
RELATED SERVICES
Educationally Relevant Related Services Are Listed Below
Special Education Services
Instructional Setting / Location
Start Date
Frequency
Provider
Duration / End Date
Clarification:
SUPPLEMENTARY AIDS / ASSISTIVE TECHNOLOGY AND SERVICE FOR STUDENTS
Educationally Relevant Supplementary Aides / Assistive Technology and Services Are Listed Below.
SUPPORTS FOR SCHOOL PERSONNEL
Supports For School Personnel Are Listed Below
Clarification:
LEAST RESTRICTIVE ENVIRONMENT
Provide an explanation of the extent, if any, to which the student will NOT participate with non-disabled students in the general curricular, extracurricular and 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):
Reason for Different Services School:
Rationale
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