final

___Huang Le ____________

__Anytown School District __________

__________________________________

Student

Resident District

IEP Meeting Date

__ Anytown School District __________

__________________________________

Gender: _X_ M ___ F Grade: _____

Attending District

Annual IEP Review Date

___xx/xx/xx_______________

__ Anytown School ___________

__________________________________

Date of Birth (mm/dd/yy)

Attending School

Amendment Date

__111-111-111______________________

__________________________________

__________________________________

Secure Student Identifier (SSID)

Case Manager

Most Recent (re)Evaluation Date

__AU Autism Spectrum Disorder ______

_SI Speech/Language Impairment ___

__________________________________

Primary Disability Code & Category

Secondary Disability Code & Category – OPTIONAL

Re-Evaluation Due Date

_Huang Le _____

__Duyi Le __________

__An Liu ______________

Student

Parent/Guardian/Surrogate

Parent/Guardian/Surrogate

__________________________________

____________________________________

__Dr. Susan Jones __________

Special Education Teacher / Provider

Special Education Teacher / Provider

District Representative

_Mr. Franklin________________________

____________________________________

___Dr. John Smith _________________

General Education Teacher

General Education Teacher

Individual Interpreting Instructional Implications of Evaluations

_N/A ___________________________

Denay Gonzales, Speech/Language Pathologist

Shiri Ali, BCBA, Autism Specialist________

Agency Representative, if appropriate

Other

Other

__________________________________ ____________________________________ ____________________________________ Other Other Other

NOTE: If required team member participates through written input or is excused from all or part of the IEP meeting, attach documentation of parent’s and district’s agreement to participate by written input or excuse.

A district provided interpreter was used for this meeting: YES ( NO ( Name _______________________________________________

A. Does the student exhibit behavior that impedes his/her learning or the learning of others? 34 CFR 300.324(a)(2)(i)

___X__ YES

____ NO

If YES, the IEP addresses the use of positive behavioral interventions and supports, and other strategies, to address that behavior(s).

B. Does the student have limited English Proficiency? 34 CFR 300.324(a)(2)(ii)

_____ YES English Language Proficiency Level____________

__X__ NO

If YES, the IEP team must consider the language needs of the student as those needs relate to the student’s IEP.

C. Is the student blind or visual impaired? 34 CFR 300.324(a)(2)(iii)

_____ YES

__X__ NO

If YES, Braille needs are addressed in the IEP, or an evaluation of reading/writing needs is completed and a determination is made that Braille is not appropriate.

D. Does the student have communication needs? 34 CFR 300.324(a)(2)(iv)

__X__ YES

_____ NO

If YES, the IEP addresses communication supports, services, and/or instruction.

E. Is the student deaf or hard of hearing? 34 CFR 300.324(a)(2)(iv)

_____ YES

__X__ NO

If YES, the IEP addresses the student’s language and communication needs, opportunities for direct communication with peers and

professional personnel in the student’s language and communication mode, academic level, and full range of needs, including opportunities for direct instruction in the student’s language and communication mode.

F. Does the student need assistive technology devices or services? 34 CFR 300.324(a)(2)(v)

_____ YES

__ __ NO

If YES, the IEP addresses assistive technology devices or services.

G. Does the student require one or more specialized formats (braille, large print, audio, and/or digital text) of educational materials because blindness or other disability prevents effective use of standard print materials? 34 CFR 300.210(b)(3); 300.172(b)(4)

_____ YES

__X__ NO

If YES, alternate format(s) is/are identified in the IEP.

Student’s overall strengths, interests, and preferences: 34 CFR 300.324 (a)(1)(i)

Input from parent(s) in the areas of academic achievement and functional performance, including concerns for enhancing the education of their child:

34 CFR 300.324(a)(1)(ii)

Present level of academic achievement (i.e. reading, writing, mathematics, etc), including most recent performance on State or district-wide assessments:

· Strengths of the student

· Needs of the student

· How the student’s disability affects involvement and progress in the general education curriculum 34 CFR 300.320(a)(1); 300.324(a)(iii)

Narrative and supporting data:

Present level of functional performance (not limited to, but may include communication, social skills, behavior, organization, fine/gross motor skills, self-care, self-direction, etc), including the results of initial or most recent formal or informal assessments/observations:

· Strengths of the student

· Needs of the student

· How the student’s disability affects involvement and progress in the general education curriculum 34 CFR 300.320(a)(1)

Narrative and supporting data:

Results of age-appropriate transition assessments, including student’s preferences, interests, needs and strengths (PINS)

34 CFR 300.320(b)(1); 34 CFR 300.43(a)(2)

Transition planning has begun for Huang at an early stage. We are focusing on independent classroom skills that will be prerequisites for a formal transition plan to be assessed when he enters the 9th grade.

Training

Education

Employment

Independent living skills (where appropriate)

Transition Services/Activities: Transition Services include instruction, related services, community experiences, the development of employment and other post-school adult living objectives, and if appropriate, acquisition of daily living skills and provision of a functional vocational evaluation. 34 CFR 300.43

TBD by IEP Team

Course of Study: (designed to assist the student in reaching the post-secondary goals) 34 CFR 300.320(b)(2)

TBD by IEP Team

Agency Participation: To the extent appropriate, with consent of the parents or adult student, the school district must invite a representative of any participating agency likely to be responsible for providing or paying for transition services.

34 CFR 300.321(b)(3)

TBD by IEP Team

Transfer of Rights 34 CFR 300.320(c), 300.520

The student and parent were informed of his/her rights under Part B of IDEA that will transfer to the student at the age of majority:

· X YES

· Date student was informed: __________

· Date anticipated transfer will occur: __________

The district must also provide written notice of the transfer of rights to the student and the parent when the student reaches the age of majority.

Graduation 34 CFR 300.102(a)(3)(i)-(iii)

Anticipated Graduation Date: __________

· With Regular Diploma

· With Modified Diploma

· With Extended Diploma

· With Alternative Certificate

Standard Assessment or

Alternate Assessment

(select one)

Accessibility Supports

(includes all accommodations, designated supports, and/or universal tools the team identifies as necessary for statewide assessments)

Modified

Cut Scores

(Only available for standard assessment with or without accommodations)

* Explanation

State why student cannot participate in standard assessment and why particular alternate assessment selected is appropriate for student.

( Standard: English Language Arts / Literacy

( Without accessibility supports

( With accessibility supports

( Alternate: Extended Assessment*

( Standard: Mathematics

( Without accessibility supports

( With accessibility supports

( Alternate: Extended Assessment*

( Standard: Science

( Without accessibility supports

( With accessibility supports

( Alternate: Extended Assessment*

( Standard: Social Sciences

( Standard without accessibility supports

( Standard with accessibility supports

Standard Assessment

Accessibility Supports

(includes all accommodations, designated supports, and/or universal tools the team identifies as necessary for statewide assessments)

Exemption Decisions

(identify appropriate domains)

Due to the nature of some students’ disabilities, an IEP team might exempt the student from responding to a particular domain

*Explanation

Statement why student cannot participate in select domains

( English Language Proficiency Assessment (ELPA)

( Without accessibility supports

( With accessibility supports

( *Listening

( *Reading

( *Writing

( *Speaking

( Kindergarten Assessment (KA)

( Without accessibility supports

( With accessibility supports

( *Early Literacy

( *Early Math

( *Approaches to Learning

Standard Assessment or

Alternate Assessment

(select one)

Accessibility Supports

(includes all accommodations, designated supports, and/or universal tools the team identifies as necessary for statewide assessments)

* Explanation:

State why student cannot participate in standard assessment and why particular alternate assessment selected is appropriate for student.

( Standard District Assessment: ______________

( Without accessibility supports

( With accessibility supports

( Alternate District Assessment: ______________

( Without accessibility supports

( With accessibility supports

( Standard District Assessment: ______________

( Without accessibility supports

( With accessibility supports

( Alternate District Assessment: ______________

( Without accessibility supports

( With accessibility supports

( Standard District Assessment: ______________

( Without accessibility supports

( With accessibility supports

( Alternate District Assessment: ______________

( Without accessibility supports

( With accessibility supports

Goal Area: 34 CFR 300.320(a)(2)(i)

Annual Measurable Goal (including conditions and frequency):

Objectives (if needed):

Related Content Standard(s), if applicable:

How progress will be measured:

How progress will be reported, including frequency: 34 CFR 300.320(a)(3)(i)

Progress Towards Goal 34 CFR 300.320(a)(3)(ii)

Date of Progress: ___/___/___

Narrative and supporting data:

Date of Progress: ___/___/___

Narrative and supporting data:

Date of Progress: ___/___/___

Narrative and supporting data:

Specially Designed Instruction

34 CFR 300.39

Anticipated Amount & Frequency

Anticipated Location

Starting Date

Ending Date

Provider

Role Responsible for Monitoring

Related Services

34 CFR 300.34

Anticipated Amount & Frequency

Anticipated Location

Starting Date

Ending Date

Provider

Role Responsible for Monitoring

Supplementary Aids/Services; Accommodations

34 CFR 300.320(a)(4)(i)-(iii)

Anticipated Amount & Frequency

Anticipated Location

Starting Date

Ending Date

Provider

Role Responsible for Monitoring

Supplementary Aids/Services; Modifications

34 CFR 300.320(a)(4)(i)-(iii)

Anticipated Amount & Frequency

Anticipated Location

Starting Date

Ending Date

Provider

Role Responsible for Monitoring

Program Modifications/ Supports for School Personnel

34 CFR 300.320(a)(4)(i)-(iii)

Anticipated Amount & Frequency

Anticipated Location

Starting Date

Ending Date

Provider

Role Responsible for Monitoring

Describe the extent (including amount), if any, to which the child will not participate with nondisabled children in the regular classroom and in extracurricular and other nonacademic activities:

Provide explanation justifying the removal, if any:

EXTENDED SCHOOL YEAR (ESY) SERVICES 34 CFR 300.106; OAR 581-015-2065

Criteria/Inquiry:

Does the student experience regression on his/her IEP goals and objectives?

( Yes ( No ( More information needed

Explanation:

Does the student experience a prolonged recoupment period of time to relearn previously learned skills?

( Yes ( No ( More information needed

Explanation:

Other factors considered by the team:

Decision:

Does the student require ESY services?

( Yes (described below, including goals to be addressed) ( No ( To be determined by _______________________

Specially Designed Instruction

34 CFR 300.39

Anticipated Amount & Frequency

Anticipated Location

Starting Date

Ending Date

Provider

Role Responsible for Monitoring

Related Services

34 CFR 300.34

Anticipated Amount & Frequency

Anticipated Location

Starting Date

Ending Date

Provider

Role Responsible for Monitoring