IEP-BlankVersion.doc|
|
Services Plan |
PARMA CITY SCHOOL DISTRICT |
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
|
Name |
|
Date of Birth |
|
Grade Level |
|
|
|
Male |
|
Female |
|
|
Student ID Number |
906002314 |
|
|||||||||
|
Student Address |
504 South West Georgia Ave. |
Parent/Guardian |
|
||||||||
|
Parent Address |
504 South West Georgia Ave. |
Home Phone |
229-889-1234 |
Work Phone |
229-883-6789 |
||||||
|
Effective IEP Dates from |
|
to |
|
Meeting Date |
|
|
|
Initial IEP |
|
|
Periodic Review |
|
District of Residence |
|
District of Service |
|
|
Step 1: Discuss future planning |
|
(Family and student preferences and interests) |
|
|
|
Step 2: Discuss present levels of performance |
|
(Description of a child’s strengths and needs and present levels of “academic achievement and functional performance.") |
|
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Annual Goals and Short Term Objectives
|
Step 3: Identify needs that require specially designed instruction |
|
|
|
Step 4: Identify measurable annual goals |
|||
|
Goal # |
1 |
Content area addressed: |
|
|
|
|||
|
Benchmarks or short-term objectives |
|||
|
|
|||
|
Statement of Student Progress (Include how the child’s progress towards annual goals will be measured and how the parents will be informed of the extent to which the child’s progress is sufficient to enable him/her to achieve the goals by the end of the year) |
|||
|
|
|
Step 5: Identify services |
|||||||
|
Service: |
|
Initiation date: |
|
Expected Duration: |
|
Frequency: (how often) |
|
|
(Identify all services needed for the child to attain the annual goal and progress in the general curriculum. Services may include specially designed instruction, related services, supplementary aids, or, on behalf of the child, a statement of program modifications, testing accommodations, or supports for school personnel) |
|||||||
|
|
|
Step 6: Determine least restrictive environment |
|
Determine where services will be provided (Include an explanation of the extent, if any, to which the child will not participate with non-disabled children in the regular classroom) |
|
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Annual Goals and Short Term Objectives
|
Step 3: Identify needs that require specially designed instruction |
|
|
|
Step 4: Identify measurable annual goals |
|||
|
Goal # |
2 |
Content area addressed: |
|
|
|
|||
|
Benchmarks or short-term objectives |
|||
|
|
|||
|
Statement of Student Progress (Include how the child’s progress towards annual goals will be measured and how the parents will be informed of the extent to which the child’s progress is sufficient to enable him/her to achieve the goals by the end of the year) |
|||
|
|
|
Step 5: Identify services |
|||||||
|
Service: |
|
Initiation date: |
|
Expected Duration: |
|
Frequency: (how often) |
|
|
(Identify all services needed for the child to attain the annual goal and progress in the general curriculum. Services may include specially designed instruction, related services, supplementary aids, or, on behalf of the child, a statement of program modifications, testing accommodations, or supports for school personnel) |
|||||||
|
|
|
Step 6: Determine least restrictive environment |
|
Determine where services will be provided (Include an explanation of the extent, if any, to which the child will not participate with non-disabled children in the regular classroom) |
|
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Annual Goals and Short Term Objectives
|
Step 3: Identify needs that require specially designed instruction |
|
|
|
Step 4: Identify measurable annual goals |
|||
|
Goal # |
3 |
Content area addressed: |
|
|
|
|||
|
Benchmarks or short-term objectives |
|||
|
|
|||
|
Statement of Student Progress (Include how the child’s progress towards annual goals will be measured and how the parents will be informed of the extent to which the child’s progress is sufficient to enable him/her to achieve the goals by the end of the year) |
|||
|
|
|
Step 5: Identify services |
|||||||
|
Service: |
|
Initiation date: |
|
Expected Duration: |
|
Frequency: (how often) |
|
|
(Identify all services needed for the child to attain the annual goal and progress in the general curriculum. Services may include specially designed instruction, related services, supplementary aids, or, on behalf of the child, a statement of program modifications, testing accommodations, or supports for school personnel) |
|||||||
|
|
|
Step 6: Determine least restrictive environment |
|
Determine where services will be provided (Include an explanation of the extent, if any, to which the child will not participate with non-disabled children in the regular classroom) |
|
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Annual Goals and Short Term Objectives
|
Step 3: Identify needs that require specially designed instruction |
|
|
|
Step 4: Identify measurable annual goals |
|||
|
Goal # |
4 |
Content area addressed: |
|
|
|
|||
|
Benchmarks or short-term objectives |
|||
|
|
|||
|
Statement of Student Progress (Include how the child’s progress towards annual goals will be measured and how the parents will be informed of the extent to which the child’s progress is sufficient to enable him/her to achieve the goals by the end of the year) |
|||
|
|
|
Step 5: Identify services |
|||||||
|
Service: |
|
Initiation date: |
|
Expected Duration: |
|
Frequency: (how often) |
|
|
(Identify all services needed for the child to attain the annual goal and progress in the general curriculum. Services may include specially designed instruction, related services, supplementary aids, or, on behalf of the child, a statement of program modifications, testing accommodations, or supports for school personnel) |
|||||||
|
|
|
Step 6: Determine least restrictive environment |
|
Determine where services will be provided (Include an explanation of the extent, if any, to which the child will not participate with non-disabled children in the regular classroom) |
|
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Annual Goals and Short Term Objectives
|
Step 3: Identify needs that require specially designed instruction |
|
|
|
Step 4: Identify measurable annual goals |
|||
|
Goal # |
5 |
Content area addressed: |
|
|
|
|||
|
Benchmarks or short-term objectives |
|||
|
|
|||
|
Statement of Student Progress (Include how the child’s progress towards annual goals will be measured and how the parents will be informed of the extent to which the child’s progress is sufficient to enable him/her to achieve the goals by the end of the year) |
|||
|
|
|
Step 5: Identify services |
|||||||
|
Service: |
|
Initiation date: |
|
Expected Duration: |
|
Frequency: (how often) |
|
|
(Identify all services needed for the child to attain the annual goal and progress in the general curriculum. Services may include specially designed instruction, related services, supplementary aids, or, on behalf of the child, a statement of program modifications, testing accommodations, or supports for school personnel) |
|||||||
|
|
|
Step 6: Determine least restrictive environment |
|
Determine where services will be provided (Include an explanation of the extent, if any, to which the child will not participate with non-disabled children in the regular classroom) |
|
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Annual Goals and Short Term Objectives
|
Step 3: Identify needs that require specially designed instruction |
|
|
|
Step 4: Identify measurable annual goals |
|||
|
Goal # |
6 |
Content area addressed: |
|
|
|
|||
|
Benchmarks or short-term objectives |
|||
|
|
|||
|
Statement of Student Progress (Include how the child’s progress towards annual goals will be measured and how the parents will be informed of the extent to which the child’s progress is sufficient to enable him/her to achieve the goals by the end of the year) |
|||
|
|
|
Step 5: Identify services |
|||||||
|
Service: |
|
Initiation date: |
|
Expected Duration: |
|
Frequency: (how often) |
|
|
(Identify all services needed for the child to attain the annual goal and progress in the general curriculum. Services may include specially designed instruction, related services, supplementary aids, or, on behalf of the child, a statement of program modifications, testing accommodations, or supports for school personnel) |
|||||||
|
|
|
Step 6: Determine least restrictive environment |
|
Determine where services will be provided (Include an explanation of the extent, if any, to which the child will not participate with non-disabled children in the regular classroom) |
|
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Annual Goals and Short Term Objectives
|
Step 3: Identify needs that require specially designed instruction |
|
|
|
Step 4: Identify measurable annual goals |
|||
|
Goal # |
7 |
Content area addressed: |
|
|
|
|||
|
Benchmarks or short-term objectives |
|||
|
|
|||
|
Statement of Student Progress (Include how the child’s progress towards annual goals will be measured and how the parents will be informed of the extent to which the child’s progress is sufficient to enable him/her to achieve the goals by the end of the year) |
|||
|
|
|
Step 5: Identify services |
|||||||
|
Service: |
|
Initiation date: |
|
Expected Duration: |
|
Frequency: (how often) |
|
|
(Identify all services needed for the child to attain the annual goal and progress in the general curriculum. Services may include specially designed instruction, related services, supplementary aids, or, on behalf of the child, a statement of program modifications, testing accommodations, or supports for school personnel) |
|||||||
|
|
|
Step 6: Determine least restrictive environment |
|
Determine where services will be provided (Include an explanation of the extent, if any, to which the child will not participate with non-disabled children in the regular classroom) |
|
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Annual Goals and Short Term Objectives
|
Step 3: Identify needs that require specially designed instruction |
|
|
|
Step 4: Identify measurable annual goals |
|||
|
Goal # |
8 |
Content area addressed: |
|
|
|
|||
|
Benchmarks or short-term objectives |
|||
|
|
|||
|
Statement of Student Progress (Include how the child’s progress towards annual goals will be measured and how the parents will be informed of the extent to which the child’s progress is sufficient to enable him/her to achieve the goals by the end of the year) |
|||
|
|
|
Step 5: Identify services |
|||||||
|
Service: |
|
Initiation date: |
|
Expected Duration: |
|
Frequency: (how often) |
|
|
(Identify all services needed for the child to attain the annual goal and progress in the general curriculum. Services may include specially designed instruction, related services, supplementary aids, or, on behalf of the child, a statement of program modifications, testing accommodations, or supports for school personnel) |
|||||||
|
|
|
Step 6: Determine least restrictive environment |
|
Determine where services will be provided (Include an explanation of the extent, if any, to which the child will not participate with non-disabled children in the regular classroom) |
|
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Special Factors
Based on discussions of the information provided regarding relevant special factors and other considerations as noted below, the following is applicable and incorporated into the IEP.
Based on discussions of the information provided regarding relevant special factors and other considerations as noted below, the following is applicable and incorporated into the IEP. |
Incorporated into IEP |
||
|
Behavior: In the case of a student whose behavior impedes his or her learning or that of others. |
|
|
|
|
Limited English proficiency (LEP) |
|
|
|
|
Children/students with visual impairments (See IEP page FORMTEXT ) |
|
|
|
|
Communication |
|
|
|
|
Deaf or hard of hearing |
|
|
|
|
Assistive technology services and devices |
|
|
|
Other Considerations
|
Physical education |
|
|
|
|
Extended school year services |
|
|
|
|
Beginning at age 14…transition service needs which focus on the student's courses of study (See IEP page FORMTEXT ) |
|
|
|
|
Transition services statement, no later than age 16 (See IEP page FORMTEXT ) |
|
|
|
|
Testing and assessment programs, including proficiency tests (See IEP page FORMTEXT ) |
|
|
|
|
Transfer of rights beginning at least one year before the student reaches the age of majority under state law (Ohio law is age 18) |
|
|
|
|
Relevant Information/Suggestions (e.g., medical information, other information): |
|
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Statewide and District Testing
|
Student Name |
|
Student Grade (when scheduled to take this test) |
|
Student ID |
|
|
School Year |
|
IEP Meeting Date |
|
|
|
|
Areas of Assessment |
Grade Level of Test to be Administered |
STATEWIDE TESTING |
DISTRICTWIDE TESTING |
|||||
|
|
|
Will Take Test without IEP Accommodations |
Will Take Test with IEP Accommodations |
Will Participate in Alternate Assessment |
Grade Level of Test to be Administered |
Will Take Test without Accommodations |
Will Take Test with Accommodations |
Will Participate in Alternate Assessment |
|
Reading |
|
|
|
|
|
|
|
|
|
Writing |
|
|
|
|
|
|
|
|
|
Math |
|
|
|
|
|
|
|
|
|
Science |
|
|
|
|
|
|
|
|
|
Citizenship |
|
|
|
|
|
|
|
|
|
Technology |
|
|
|
|
|
|
|
|
|
ITAC |
|
|
|
|
|
|
|
|
|
Excused from the consequences associated with not passing the test (Graduation Test) in the following area(s) of assessment: |
|||||||
|
|
|||||||
|
Met participation requirements |
|
Yes |
|
No |
Date |
|
|
|
|
|
Area of Assessment |
List Accommodations to Assessment |
Area of Assessment |
List Accommodations |
|
Reading |
|
Other (Specify) |
|
|
Writing |
|
Other (Specify) |
|
|
Math |
|
Other (Specify) |
|
|
Science |
|
Other (Specify) |
|
|
Citizenship |
|
Other (Specify) |
|
|
Accommodation Codes |
|
|
|
|
|
1 - computer |
4 - calculator |
7 - spell checker |
10 - shortened test sessions |
13 - frequent breaks |
|
2 - word bank |
5 - oral admission (except reading test) |
8 - small group |
11 - monitor on task / focus |
14 - other (list above) |
|
3 - reference card |
6 - extended time |
9 - read / clarify directions |
12 - scribe |
|
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
|
Name |
|
IEP summary for effective dates FORMTEXT |
|
Date of next IEP review |
|
|
IEP Team Meeting Participants |
||||||
|
Check on of the following: |
This IEP team meeting was a: |
MACROBUTTON CheckIt ( Face to Face Meeting |
MACROBUTTON CheckIt ( Video Conference |
MACROBUTTON CheckIt ( Telephone Conference / Conference Call |
||
|
|
|
|
|
|
|
|
|
|
|
MACROBUTTON CheckIt ( Participated |
|
MACROBUTTON CheckIt ( Participated |
|
MACROBUTTON CheckIt ( Participated |
|
|
|
MACROBUTTON CheckIt ( Excused |
|
MACROBUTTON CheckIt ( Excused |
|
MACROBUTTON CheckIt ( Excused |
|
|
Parent |
|
Parent |
|
Special Education Teacher/Provider |
|
|
|
|
MACROBUTTON CheckIt ( Participated |
|
MACROBUTTON CheckIt ( Participated |
|
MACROBUTTON CheckIt ( Participated |
|
|
|
MACROBUTTON CheckIt ( Excused |
|
MACROBUTTON CheckIt ( Excused |
|
MACROBUTTON CheckIt ( Excused |
|
|
Regular Education Teacher |
|
District Representative |
|
Child/Student |
|
|
|
|
MACROBUTTON CheckIt ( Participated |
|
MACROBUTTON CheckIt ( Participated |
|
MACROBUTTON CheckIt ( Participated |
|
|
|
MACROBUTTON CheckIt ( Excused |
|
MACROBUTTON CheckIt ( Excused |
|
MACROBUTTON CheckIt ( Excused |
|
|
Other Titles |
|
Other Titles |
|
Other Titles |
|
|
|
|
MACROBUTTON CheckIt ( Participated |
|
MACROBUTTON CheckIt ( Participated |
|
MACROBUTTON CheckIt ( Participated |
|
|
|
MACROBUTTON CheckIt ( Excused |
|
MACROBUTTON CheckIt ( Excused |
|
MACROBUTTON CheckIt ( Excused |
|
|
Other Titles |
|
Other Titles |
|
Other Titles |
|
Summary of special education services: FORMTEXT
|
Initial IEP MACROBUTTON CheckIt ( I give consent to initiate special education and related services specified in this IEP.* MACROBUTTON CheckIt ( I give consent to initiate special education and related services specified in this IEP except for ____________________________________________________________** FORMTEXT ** MACROBUTTON CheckIt ( I do not give consent for special education services at this time.** Parent Signature ____________________________________ Date: FORMTEXT ________________ * This IEP serves as prior written notice if there is agreement. ** If there is not agreement, the district must provide prior written notice to the parents. |
|
Parent Notice of Procedural Safeguards / Copy of the IEPMACROBUTTON CheckIt ( I have received a copy of the parent notice of procedural safeguards for the current year. MACROBUTTON CheckIt ( Parent has requested and received a copy of the IEP Parent Signature ___________________________________________________ Date: FORMTEXT ____________________________________________________________ Note: The student receives notice of procedural safeguards at least one year prior to his/her 18th birthday. Student Signature _____________________________ Date: FORMTEXT ______________ |
|
Last MFE Date: ____________________________________________ Next MFE Due By: __________________________________________ |
|
|
|
|
|
|
|
Consent for Change in Placement MACROBUTTON CheckIt ( I give consent for the change of placement as identified in this IEP* MACROBUTTON CheckIt ( I give consent for the special education and related services specified in this IEP except for _____________________________________________ ** MACROBUTTON CheckIt ( I do not give consent for a change of placement as identified in this IEP. MACROBUTTON CheckIt ( I revoke consent for Special Education service Signature: _______________________________________ Date: ___________ * This IEP serves as prior written notice if these is agreement. ** If there is not an agreement, the district must provide prior written notice to the parents.
|
|
Attendance OnlyMACROBUTTON CheckIt ( I am signing to show my attendance / participation at the IEP team meeting but I do not agree with the special education and related services specified in this IEP. Signature: _______________________________________ Date: ___________ |
|
|
|
Reason for Placement in Separate Facility (If applicable) Having considered the continuum of services and the needs of the student, this IEP team has decided that placement in a separate facility is appropriate because: |
|
PROGRESS REPORT |
|
Progress Codes: M = Mastered AP = Making Adequate Progress NP = Not Making Progress NI = Goal/Objective Not Yet Introduced |
|
Parents: This form is used to report on your child’s progress on the goals and objectives listed on his/her IEP. Should you have any questions, please do not hesitate to contact your child’s special education teacher. |
|
|
|
Student: |
|
School Year: |
|
|
GOALS |
OBJECTIVES |
PROGRESS CODE |
COMMENTS |
|||
|
|
|
1 |
2 |
3 |
4 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Homeroom Teacher: |
|
Special Education Teacher: |
|
|
Related Service Providers: |
|
INDIVIDUALIZED EDUCATION PROGRAM
Discuss and Document a Statement of Needed Transition Services
|
Name of Student |
|
Date |
|
Person(s) Responsible for Coordinating Transition Services |
|
|
|
|
|
|
|
|
|
Write a statement of transition service needs that focus on the student’s courses of study during his/her secondary school experiences (beginning at age 14 or younger, if appropriate). |
|||||
|
|
|
For 16 years and older |
COMPLETED AFTER IEP DEVELOPMENT |
||
|
Employment and Post-Secondary Long-term Outcome: |
|
||
|
Current Year Activities and Services |
Responsible Person/Provider |
Initiation/Duration (Specify Date) |
Goals/Objectives that Support Activities/Services |
|
|
|
|
|
|
Post-school / Adult Living Long-Term Outcome: |
|
||
|
Current Year Activities and Services |
Responsible Person/Provider |
Initiation/Duration (Specify Date) |
Goals/Objectives that Support Activities/Services |
|
|
|
|
|
|
Community Participation Long-Term Outcome: |
|
||
|
Current Year Activities and Services |
Responsible Person/Provider |
Initiation/Duration (Specify Date) |
Goals/Objectives that Support Activities/Services |
|
|
|
|
|
|
Functional Vocational Evaluation |
|
Needed |
|
Not Needed |
Date Completed |
|
PARENT INVITATION
|
Date: |
|
Written Notice Number: |
|
|
To: |
|
||
|
From: |
|
I am inviting you to attend a meeting to discuss the educational needs of:
|
|
|
|
|
Student’s Full Name |
|
Date of Birth |
PURPOSE FOR MEETING (Check all which apply):
|
|
To determine if a child has a suspected disability |
|
To discuss transition from early childhood to school-age programs |
|
|
|
To develop an evaluation plan |
|
To discuss transition from school-age to post-secondary programs / activities |
|
|
|
To determine eligibility for services as a child with a disability |
|
To discuss disciplinary matters |
|
|
|
To develop, review, and/or revise the student’s IEP |
|
At your request to discuss: |
|
|
|
To determine reevaluation needs |
|
Other: |
|
This conference has been scheduled as a (check on):
|
MACROBUTTON CheckIt ( |
Face to face meeting |
MACROBUTTON CheckIt ( |
Video Conference |
MACROBUTTON CheckIt ( |
Telephone Conference / Conference Call |
|
Date: |
|
Time: |
|
Location: |
|
Other persons who have been invited to attend this meeting include:
|
|
Regular Education Teacher |
|
Student |
|
Other |
|
|
Speech and Language Pathologist |
|
School Psychologist |
|
|
|
|
Special Education Teacher |
|
District Representative |
|
|
You are welcome to bring any information, including formal or informal test results, work samples, etc., to the meeting. You may bring someone who has knowledge or special expertise regarding your child or someone to assist you at the meeting.
|
If you would like to schedule the conference at a different time, date, or location, or if you require an interpreter, |
|||
|
please contact: |
|
at |
|
|
( ( ( ( ( ( ( ( ( ( ( ( ( ( |
Call or complete and return to the student’s school.
|
Name of Student |
|
Birth Date |
|
|
MACROBUTTON CheckIt ( |
I will attend / participate |
||
|
MACROBUTTON CheckIt ( |
Another/Others will accompany me (optional) |
||
|
MACROBUTTON CheckIt ( |
I will not attend / participate |
|
I would like this meeting rescheduled for the following suggested date and time: |
|
A bilingual or sign language interpreter is requested.
|
MACROBUTTON CheckIt ( Yes |
MACROBUTTON CheckIt ( No |
If Yes, specify language/mode of communication |
|
|
Parent Signature |
|
Date |
|
Page ____ of ____
1
Page ____ of ____
