New work and Discussions
Sheina18
New-York-City-Board-of-Education-Individualized-Education-Program-Blank-Template.doc|
THIS IEP INCLUDES: FORMCHECKBOX Transitions FORMCHECKBOX Interim Service Plan |
NEW YORK CITY BOARD OF EDUCATION INDIVIDUALIZED EDUCATION PROGRAM
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CONFERENCE INFORMATION CSE Case# - Home District: Service District: Date: / / Type: |
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STUDENT INFORMATION *Age as of the date of the conference |
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Name: |
NYC ID# - - |
Date of Birth / / |
Gender FORMDROPDOWN |
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Age: |
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Phone: ( ) - |
English LAB |
Year |
Spanish LAB |
Year |
Grade FORMDROPDOWN |
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Language(s) Spoken/Mode of Communication FORMDROPDOWN |
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Primary Agency with whom student is involved |
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Name of Contact FORMTEXT |
Phone: ( ) - |
Agency Case# |
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PARENT/GUARDIAN INFORMATION Relationship to Student |
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Name: |
FORMDROPDOWN |
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Address: |
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Phone (Home): ( ) - |
Phone (Work): ( ) - |
Interpreter Required FORMCHECKBOX Yes FORMCHECKBOX No |
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Preferred Language/ Mode of Communication FORMDROPDOWN |
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SPECIAL MEDICAL/PHYSICAL ALERTS (Refer to Health & Physical Development Page for additional details.) |
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The student has FORMCHECKBOX medical conditions and/or FORMCHECKBOX physical limitations which affect his/her FORMCHECKBOX learning FORMCHECKBOX behavior and/or FORMCHECKBOX participation in school activities. |
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The student requires FORMCHECKBOX medication and/or FORMCHECKBOX health care treatment(s) or procedure(s) during the school day. |
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Other alerts: |
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SUMMARY OF RECOMMENDATIONS Eligibility FORMCHECKBOX Yes FORMCHECKBOX No |
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Recommended Services Classification of Disability FORMDROPDOWN |
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FORMDROPDOWN |
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Staffing Ratio |
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FORMDROPDOWN |
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Twelve Month School Year FORMCHECKBOX Yes FORMCHECKBOX No Recommended Services for the Twelve Month School Year |
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FORMDROPDOWN |
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Staffing Ratio |
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FORMDROPDOWN |
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Other Recommendations (Check all that apply) *Details are provided in relevant sections of IEP |
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FORMCHECKBOX Program Accessibility |
FORMCHECKBOX Adaptive Phys. Ed.* |
FORMCHECKBOX Bilingual Instruction |
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FORMCHECKBOX Related Services |
FORMCHECKBOX Assistive Technology |
FORMCHECKBOX Monolingual Services with ESL |
FORMCHECKBOX Monolingual Services without ESL |
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FORMCHECKBOX Special Education Transportation – Comment |
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Students who are blind or visually impaired: |
Students who are deaf or hard of hearing |
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Braille instruction needed FORMCHECKBOX Yes FORMCHECKBOX No |
Language of Instruction |
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Mode of Communication |
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Copy for FORMCHECKBOX CSE FORMCHECKBOX Parent FORMCHECKBOX School FORMCHECKBOX Student FORMCHECKBOX Other Page 1 |
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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CONFERENCE INFORMATION |
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Referral Type: |
FORMCHECKBOX Initial |
FORMCHECKBOX Annual Review |
Conference Type: |
FORMCHECKBOX EPC |
FORMCHECKBOX Annual Review |
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FORMCHECKBOX Triennial |
FORMCHECKBOX Requested Review |
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FORMCHECKBOX CSE Review |
FORMCHECKBOX CPSE Review |
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Attendance at Conference |
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Please note that your signature reflects your participation at the conference and does not necessarily indicate agreement with the Individualized Education Program. |
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Signature/Title |
Role (Indicate if Bilingual) |
Signature/Title |
Role (Indicate if Bilingual) |
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FORMTEXT |
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Parent/Legal Guardian |
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Parent/Legal Guardian |
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District Representative |
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Special Education Teacher Or Related Service Provider |
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General Education Teacher |
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Parent Member (CPSE/CSE) |
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Student |
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Other |
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Education Evaluator |
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School Psychologist |
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Other |
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School Social Worker |
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Other |
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Other |
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Use an asterisk(*) to signify the participant who interprets the instructional implications of evaluation results. Use the letter (T) to signify participation by teleconference. |
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Conference Result |
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FORMCHECKBOX Initiate Service |
FORMCHECKBOX Modify Service |
FORMCHECKBOX Change Recommended Service |
FORMCHECKBOX No Change |
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Indicate Modifications |
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Initiation, Duration and Review of IEP |
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Projected Date of Initiation of IEP / / |
Projected Date of Review of IEP / / |
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Duration of Services |
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Contacts with Parent/Legal Guardian |
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Date Notice of Meeting Sent / / |
Date IEP and Notice of Recommendation |
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Date of Follow-up (if any) / / |
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FORMCHECKBOX Given to Parent / / |
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Type of Follow-up FORMCHECKBOX Letter FORMCHECKBOX Telephone |
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FORMCHECKBOX Sent to Parent / / |
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Page 2
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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ACADEMIC PERFORMANCE AND LEARNING CHARACTERISTICS Describe the student’s present levels of academic achievement, language development, cognitive development and learning style in English and the other than English language for LEP students. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.
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PRESENT PERFORMANCE: |
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READING and WRITING |
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MATH |
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Area |
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Test/Evaluation |
Score |
Instructional Level |
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Area |
Date |
Test/Evaluation |
Score |
Instructional Level |
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Decoding |
/ / |
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Computation |
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Reading Comprehension |
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Problem Solving |
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Listening Comprehension |
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Writing |
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ACADEMIC MANAGEMENT NEEDS (Environmental modifications and human/material resources) |
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Page 3
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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ACADEMIC PERFORMANCE AND LEARNING CHARACTERISTICS Describe the student’s present levels of academic achievement, language development, cognitive development and learning style in English and the other than English language for LEP students. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.
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PRESENT PERFORMANCE: |
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ACADEMIC MANAGEMENT NEEDS (Environmental modifications and human/material resources) |
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Page 3-1
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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ACADEMIC PERFORMANCE AND LEARNING CHARACTERISTICS Describe the student’s present levels of academic achievement, language development, cognitive development and learning style in English and the other than English language for LEP students. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.
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PRESENT PERFORMANCE: |
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ACADEMIC MANAGEMENT NEEDS (Environmental modifications and human/material resources) |
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Page 3-2
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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SOCIAL/EMOTIONAL PERFORMANCE Describe the student’s strengths and weaknesses in the area of social and emotional development in English and the other than English language for LEP students. Consider the degree and quality of the student’s relationships with peers and adults, feelings about self and social adjustment to school and community environments. Discuss how the student’s disability affects his/her involvement and progress in a general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities. |
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PRESENT PERFORMANCE:
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BEHAVIOR AND THE INSTRUCTIONAL PROCESS |
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FORMCHECKBOX Behavior is age appropriate |
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Describe present levels of support including personnel responsible for providing behavioral support |
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FORMCHECKBOX Behavior does not seriously interfere with instruction and can be addressed by the FORMCHECKBOX general education and/or FORMCHECKBOX special education classroom teacher. |
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FORMCHECKBOX Behavior seriously interferes with instruction and requires additional adult support. |
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FORMCHECKBOX Behavior requires highly intensive supervision. |
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SOCIAL/EMOTIONAL MANAGEMENT NEEDS (Environmental modifications and human/materials resources)
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A behavior intervention plan has been developed FORMCHECKBOX Yes FORMCHECKBOX No |
Page 4
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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SOCIAL/EMOTIONAL PERFORMANCE Describe the student’s strengths and weaknesses in the area of social and emotional development in English and the other than English language for LEP students. Consider the degree and quality of the student’s relationships with peers and adults, feelings about self and social adjustment to school and community environments. Discuss how the student’s disability affects his/her involvement and progress in a general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities. |
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PRESENT PERFORMANCE:
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BEHAVIOR AND THE INSTRUCTIONAL PROCESS |
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FORMCHECKBOX Behavior is age appropriate |
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Describe present levels of support including personnel responsible for providing behavioral support |
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FORMCHECKBOX Behavior does not seriously interfere with instruction and can be addressed by the FORMCHECKBOX general education and/or FORMCHECKBOX special education classroom teacher. |
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FORMCHECKBOX Behavior seriously interferes with instruction and requires additional adult support. |
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FORMCHECKBOX Behavior requires highly intensive supervision. |
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SOCIAL/EMOTIONAL MANAGEMENT NEEDS (Environmental modifications and human/materials resources)
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A behavior intervention plan has been developed FORMCHECKBOX Yes FORMCHECKBOX No |
Page 4-1
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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HEALTH AND PHYSICAL DEVELOPMENT Describe the student’s health and physical development including the degree or quality of the student’s motor and sensory development, health, vitality and physical skills or limitations which pertain to the learning process, behavior and participation in physical education or other school activities. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.
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PRESENT PERFORMANCE:
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MEDICAL/HEALTH CARE NEEDS |
PHYSICAL NEEDS |
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During the school day, the student requires: |
The student FORMCHECKBOX does FORMCHECKBOX does not have mobility limitations. |
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Medication FORMCHECKBOX Yes FORMCHECKBOX No |
(if yes, functionality describe the limitations(s).) |
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(if yes, functionality describe the limitations(s).) |
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The student requires: |
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Treatment(s) or other health procedure(s) FORMCHECKBOX Yes FORMCHECKBOX No (If yes, functionally describe the condition for which treatment(s) or procedure(s) are required) |
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Accessible program FORMCHECKBOX Yes FORMCHECKBOX No |
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Adaptive Physical Education FORMCHECKBOX Yes FORMCHECKBOX No |
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Health as a related service FORMCHECKBOX Yes FORMCHECKBOX No |
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(If yes indicate staffing ratio: FORMDROPDOWN |
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(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required) |
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Assistive Technology Device(s) FORMCHECKBOX Yes FORMCHECKBOX No |
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Assistive Technology Service(s) FORMCHECKBOX Yes FORMCHECKBOX No |
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(If assistive technology device(s) or service(s) are required, specify in management needs.) |
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HEALTH/PHYSICAL MANAGEMENT NEEDS (Environmental modifications, human/material resources or specialized equipment)
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Page 5
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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HEALTH AND PHYSICAL DEVELOPMENT Describe the student’s health and physical development including the degree or quality of the student’s motor and sensory development, health, vitality and physical skills or limitations which pertain to the learning process, behavior and participation in physical education or other school activities. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.
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PRESENT PERFORMANCE:
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MEDICAL/HEALTH CARE NEEDS |
PHYSICAL NEEDS |
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During the school day, the student requires: |
The student FORMCHECKBOX does FORMCHECKBOX does not have mobility limitations. |
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Medication FORMCHECKBOX Yes FORMCHECKBOX No |
(if yes, functionality describe the limitations(s).) |
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(if yes, functionality describe the limitations(s).) |
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The student requires: |
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Treatment(s) or other health procedure(s) FORMCHECKBOX Yes FORMCHECKBOX No (If yes, functionally describe the condition for which treatment(s) or procedure(s) are required) |
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Accessible program FORMCHECKBOX Yes FORMCHECKBOX No |
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Adaptive Physical Education FORMCHECKBOX Yes FORMCHECKBOX No |
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Health as a related service FORMCHECKBOX Yes FORMCHECKBOX No |
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(If yes indicate staffing ratio: FORMDROPDOWN |
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(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required) |
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Assistive Technology Device(s) FORMCHECKBOX Yes FORMCHECKBOX No |
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Assistive Technology Service(s) FORMCHECKBOX Yes FORMCHECKBOX No |
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(If assistive technology device(s) or service(s) are required, specify in management needs.) |
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HEALTH/PHYSICAL MANAGEMENT NEEDS (Environmental modifications, human/material resources or specialized equipment)
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Page 5-1
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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HEALTH AND PHYSICAL DEVELOPMENT Describe the student’s health and physical development including the degree or quality of the student’s motor and sensory development, health, vitality and physical skills or limitations which pertain to the learning process, behavior and participation in physical education or other school activities. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.
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PRESENT PERFORMANCE:
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MEDICAL/HEALTH CARE NEEDS |
PHYSICAL NEEDS |
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During the school day, the student requires: |
The student FORMCHECKBOX does FORMCHECKBOX does not have mobility limitations. |
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Medication FORMCHECKBOX Yes FORMCHECKBOX No |
(if yes, functionality describe the limitations(s).) |
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(if yes, functionality describe the limitations(s).) |
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The student requires: |
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Treatment(s) or other health procedure(s) FORMCHECKBOX Yes FORMCHECKBOX No (If yes, functionally describe the condition for which treatment(s) or procedure(s) are required) |
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Accessible program FORMCHECKBOX Yes FORMCHECKBOX No |
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Adaptive Physical Education FORMCHECKBOX Yes FORMCHECKBOX No |
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Health as a related service FORMCHECKBOX Yes FORMCHECKBOX No |
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(If yes indicate staffing ratio: FORMDROPDOWN |
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(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required) |
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Assistive Technology Device(s) FORMCHECKBOX Yes FORMCHECKBOX No |
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Assistive Technology Service(s) FORMCHECKBOX Yes FORMCHECKBOX No |
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(If assistive technology device(s) or service(s) are required, specify in management needs.) |
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HEALTH/PHYSICAL MANAGEMENT NEEDS (Environmental modifications, human/material resources or specialized equipment)
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Page 5-2
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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HEALTH AND PHYSICAL DEVELOPMENT Describe the student’s health and physical development including the degree or quality of the student’s motor and sensory development, health, vitality and physical skills or limitations which pertain to the learning process, behavior and participation in physical education or other school activities. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.
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PRESENT PERFORMANCE:
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MEDICAL/HEALTH CARE NEEDS |
PHYSICAL NEEDS |
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During the school day, the student requires: |
The student FORMCHECKBOX does FORMCHECKBOX does not have mobility limitations. |
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Medication FORMCHECKBOX Yes FORMCHECKBOX No |
(if yes, functionality describe the limitations(s).) |
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(if yes, functionality describe the limitations(s).) |
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The student requires: |
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Treatment(s) or other health procedure(s) FORMCHECKBOX Yes FORMCHECKBOX No (If yes, functionally describe the condition for which treatment(s) or procedure(s) are required) |
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Accessible program FORMCHECKBOX Yes FORMCHECKBOX No |
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Adaptive Physical Education FORMCHECKBOX Yes FORMCHECKBOX No |
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Health as a related service FORMCHECKBOX Yes FORMCHECKBOX No |
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(If yes indicate staffing ratio: FORMDROPDOWN |
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(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required) |
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Assistive Technology Device(s) FORMCHECKBOX Yes FORMCHECKBOX No |
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Assistive Technology Service(s) FORMCHECKBOX Yes FORMCHECKBOX No |
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(If assistive technology device(s) or service(s) are required, specify in management needs.) |
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HEALTH/PHYSICAL MANAGEMENT NEEDS (Environmental modifications, human/material resources or specialized equipment)
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Page 5-3
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
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ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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Methods of Measurement |
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Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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COMMENTS: |
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ANNUAL GOAL:
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Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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Methods of Measurement |
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Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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COMMENTS: |
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EXPLANATION OF CODING SYSTEM |
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METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
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1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
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*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
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1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
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For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
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Use a Y (Yes) or N (No) in the appropriate column
Page 6
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
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ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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Methods of Measurement |
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Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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COMMENTS: |
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ANNUAL GOAL:
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Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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Methods of Measurement |
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Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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COMMENTS: |
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EXPLANATION OF CODING SYSTEM |
|||||||||
|
METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
||||||
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|
||||||
|
1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
|||||
|
*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
|
||||||||
|
|
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
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For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
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|
Use a Y (Yes) or N (No) in the appropriate column
Page 6-1
|
Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
||||||
|
ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
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/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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Methods of Measurement |
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Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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COMMENTS: |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL:
|
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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|
Methods of Measurement |
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Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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COMMENTS: |
|||||||||
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|||||||||
|
EXPLANATION OF CODING SYSTEM |
|||||||||
|
METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
||||||
|
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|
|
|
||||||
|
1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
|||||
|
*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
|
||||||||
|
|
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
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For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
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|
|
Use a Y (Yes) or N (No) in the appropriate column
Page 6-2
|
Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
||||||
|
ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
|||||||||
|
|
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
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|
Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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|
COMMENTS: |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL:
|
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
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|
Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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|
COMMENTS: |
|||||||||
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|
|||||||||
|
EXPLANATION OF CODING SYSTEM |
|||||||||
|
METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
||||||
|
|
|
|
|
||||||
|
1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
|||||
|
*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
|
||||||||
|
|
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
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|
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|
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|
For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
|
|
|
|
|
|
|
|
Use a Y (Yes) or N (No) in the appropriate column
Page 6-3
|
Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
||||||
|
ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
|||||||||
|
|
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
|
|
|
|
|
|
|
|
|
|
Report of Progress |
|
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|
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|
|
|
|
|
|
Progress Toward Annual Goal |
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|
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|
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|
Reasons for not Meeting Annual Goal |
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|
COMMENTS: |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL:
|
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
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|
Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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|
|
COMMENTS: |
|||||||||
|
|
|||||||||
|
EXPLANATION OF CODING SYSTEM |
|||||||||
|
METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
||||||
|
|
|
|
|
||||||
|
1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
|||||
|
*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
|
||||||||
|
|
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
|
|
|
|
|
|
|
|
Use a Y (Yes) or N (No) in the appropriate column
Page 6-4
|
Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
||||||
|
ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
|||||||||
|
|
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
|
|
|
|
|
|
|
|
|
|
Report of Progress |
|
|
|
|
|
|
|
|
|
|
Progress Toward Annual Goal |
|
|
|
|
|
|
|
|
|
|
Reasons for not Meeting Annual Goal |
|
|
|
|
|
|
|
|
|
COMMENTS: |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL:
|
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
|
|
|
|
|
|
|
|
|
|
Report of Progress |
|
|
|
|
|
|
|
|
|
|
Progress Toward Annual Goal |
|
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|
|
|
|
|
|
|
|
Reasons for not Meeting Annual Goal |
|
|
|
|
|
|
|
|
|
COMMENTS: |
|||||||||
|
|
|||||||||
|
EXPLANATION OF CODING SYSTEM |
|||||||||
|
METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
||||||
|
|
|
|
|
||||||
|
1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
|||||
|
*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
|
||||||||
|
|
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
|
|
|
|
|
|
|
|
Use a Y (Yes) or N (No) in the appropriate column
Page 6-5
|
Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
||||||
|
ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
|||||||||
|
|
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
|
|
|
|
|
|
|
|
|
|
Report of Progress |
|
|
|
|
|
|
|
|
|
|
Progress Toward Annual Goal |
|
|
|
|
|
|
|
|
|
|
Reasons for not Meeting Annual Goal |
|
|
|
|
|
|
|
|
|
COMMENTS: |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL:
|
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
|
|
|
|
|
|
|
|
|
|
Report of Progress |
|
|
|
|
|
|
|
|
|
|
Progress Toward Annual Goal |
|
|
|
|
|
|
|
|
|
|
Reasons for not Meeting Annual Goal |
|
|
|
|
|
|
|
|
|
COMMENTS: |
|||||||||
|
|
|||||||||
|
EXPLANATION OF CODING SYSTEM |
|||||||||
|
METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
||||||
|
|
|
|
|
||||||
|
1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
|||||
|
*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
|
||||||||
|
|
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
|
|
|
|
|
|
|
|
Use a Y (Yes) or N (No) in the appropriate column
Page 6-6
|
Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
||||||
|
ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
|||||||||
|
|
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
|
|
|
|
|
|
|
|
|
|
Report of Progress |
|
|
|
|
|
|
|
|
|
|
Progress Toward Annual Goal |
|
|
|
|
|
|
|
|
|
|
Reasons for not Meeting Annual Goal |
|
|
|
|
|
|
|
|
|
COMMENTS: |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL:
|
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
|
|
|
|
|
|
|
|
|
|
Report of Progress |
|
|
|
|
|
|
|
|
|
|
Progress Toward Annual Goal |
|
|
|
|
|
|
|
|
|
|
Reasons for not Meeting Annual Goal |
|
|
|
|
|
|
|
|
|
COMMENTS: |
|||||||||
|
|
|||||||||
|
EXPLANATION OF CODING SYSTEM |
|||||||||
|
METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
||||||
|
|
|
|
|
||||||
|
1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
|||||
|
*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
|
||||||||
|
|
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
|
|
|
|
|
|
|
|
Use a Y (Yes) or N (No) in the appropriate column
Page 6-7
|
Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
||||||
|
ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
|||||||||
|
|
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
|
|
|
|
|
|
|
|
|
|
Report of Progress |
|
|
|
|
|
|
|
|
|
|
Progress Toward Annual Goal |
|
|
|
|
|
|
|
|
|
|
Reasons for not Meeting Annual Goal |
|
|
|
|
|
|
|
|
|
COMMENTS: |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
|
|
ANNUAL GOAL:
|
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
|
|
Methods of Measurement |
|
|
|
|
|
|
|
|
|
|
Report of Progress |
|
|
|
|
|
|
|
|
|
|
Progress Toward Annual Goal |
|
|
|
|
|
|
|
|
|
|
Reasons for not Meeting Annual Goal |
|
|
|
|
|
|
|
|
|
COMMENTS: |
|||||||||
|
|
|||||||||
|
EXPLANATION OF CODING SYSTEM |
|||||||||
|
METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
||||||
|
|
|
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1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
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*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
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1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
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For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
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Use a Y (Yes) or N (No) in the appropriate column
Page 6-8
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
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ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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Methods of Measurement |
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Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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COMMENTS: |
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ANNUAL GOAL:
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Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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Methods of Measurement |
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Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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COMMENTS: |
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EXPLANATION OF CODING SYSTEM |
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METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
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1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
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*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
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1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
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For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
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Use a Y (Yes) or N (No) in the appropriate column
Page 6-9
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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ANNUAL GOALS AND SHORT-TERM OBJECTIVES There will be reports of progress per year using the coding system shown below. |
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/ |
/ |
/ |
/ |
/ |
/ |
/ |
/ |
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ANNUAL GOAL: |
Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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Methods of Measurement |
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Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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COMMENTS: |
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/ |
/ |
/ |
/ |
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ANNUAL GOAL:
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Progress |
1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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Methods of Measurement |
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Report of Progress |
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Progress Toward Annual Goal |
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Reasons for not Meeting Annual Goal |
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COMMENTS: |
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EXPLANATION OF CODING SYSTEM |
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METHODS OF MEASURMENT |
REPORT OF PROGRESS |
PROGRESS TOWARD GOAL |
REASONS FOR NOT MEETING GOAL |
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1. Teacher made Materials 2. Standardized Tests 3. Class Activities 4. Portfolio(s) 5. Teacher/Provider Observations |
6. Performance Assessment Task 7. Check Lists 8. Verbal Explanations 9. Other (specify) |
1. Not applicable during this grading period 2. No progress made 3. Little progress made 4. Progress made; goal not yet met 5. Goal met |
A. Anticipate meeting goal B. Do not anticipate meeting goal (Note reason) C. Goal met |
1. More time needed 2. Excessive absence or lateness 3. Assignments not completed 4. Other (specify) |
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*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time. |
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1st |
2nd |
3rd |
4th |
5th |
6th |
7th |
8th |
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The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP: |
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For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened: |
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Use a Y (Yes) or N (No) in the appropriate column
Page 6-10
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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SCHOOL ENVIRONMENT AND SERVICE RECOMMENDATIONS |
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GENERAL EDUCATION ENVIRONMENT |
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Area of Instruction |
Language of Instruction Communication Mode |
Periods per week |
Supplementary Aids and Services |
Program Modifications and Supports for School Personnel |
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FORMDROPDOWN |
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FORMDROPDOWN |
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FORMDROPDOWN |
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FORMDROPDOWN |
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FORMDROPDOWN |
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FORMDROPDOWN |
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FORMDROPDOWN |
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FORMDROPDOWN |
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FORMDROPDOWN |
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SPECIAL CLASS ENVIRONMENT |
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Area of Instruction |
Language of Instruction Communication Mode |
Periods per week |
Special Class Staffing Ratio |
Supports |
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FORMDROPDOWN |
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FORMDROPDOWN |
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FORMDROPDOWN |
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FORMDROPDOWN |
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Reason for Non–Participation in General Education Environment
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Page 7
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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OTHER PROGRAMS/SERVICES CONSIDERED AND REASONS FOR REJECTION |
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Provide an explanation of the programs/services considered and the reason for rejection. Specify why the student can not achieve the goals of his/her IEP within a general education program with the assistance of supplementary aids and services. |
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Second Language Instruction: If the student is exempt from second language instruction, explain why:
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Page 8
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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PARTICIPATION IN SCHOOL ACTIVITIES, RELATED SERVICE RECOMMENDATIONS AND PARTICPATION IN ASSESSMENTS |
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PARTICIPATION IN SCHOOL ACTIVITIES |
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If the student cannot participate in lunch, assemblies, trips and/or other school activities with non-disabled students, indicate the activity and reason(s) for non-participation. |
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RELATED SERVICE RECOMMENDATIONS |
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Status |
Related Service |
Language of Service |
Location** |
Sessions/Week |
Duration |
Group Size |
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FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
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FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
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FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
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FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
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FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
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FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
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FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
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FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
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FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
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FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
FORMDROPDOWN |
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*Indicate status of recommendation: Indicate; Continue; Modify; or Terminate. |
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**Indicate whether service is provided outside the general education classroom. |
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PARTICIPATION IN ASSESSMENTS |
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FORMCHECKBOX The student will participate in state and local assessments. |
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FORMCHECKBOX Without Accommodations FORMCHECKBOX With Accommodations |
FORMCHECKBOX The student WILL NOT PARTICIPATE in state and local assessments. Reason for non-participation: (see page 9-1) |
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Describe accommodations, if any, that will be used consistently throughout the student’s educational program: |
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Page 9
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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PARTICIPATION IN SCHOOL ACTIVITIES, RELATED SERVICE RECOMMENDATIONS AND PARTICPATION IN ASSESSMENTS (Cont.) |
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FORMCHECKBOX The student will participate in Alternative Assessment. |
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Reason for participation in Alternative Assessment |
In addition to Alternative Assessment, describe how the student will be assessed: |
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PROMOTION |
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Promotion: FORMCHECKBOX Standard Criteria FORMCHECKBOX Modified Criteria* |
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*Describe the modified promotion criteria: |
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Page 9-1
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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TRANSITION |
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LONG TERM ADULT OUTCOMES |
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(Beginning at age 14 or younger if appropriate, state long term outcomes based on the student’s preferences, needs and interests.) |
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Community Integration: FORMDROPDOWN FORMDROPDOWN |
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Post-Secondary Placement: FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN |
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Independent Living: FORMDROPDOWN FORMDROPDOWN |
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Employment: FORMDROPDOWN FORMDROPDOWN |
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DIPLOMA OBJECTIVES |
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FORMCHECKBOX Regents Diploma FORMCHECKBOX Advanced Regents Diploma FORMCHECKBOX Local Diploma FORMCHECKBOX IEP Diploma |
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Expected High School Completion Date / Credits Earned As of Date / / |
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TRANSITION SERVICES |
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(Required for students 15 years of age and older) |
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Instructional Activities |
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Responsible Party: FORMCHECKBOX Parent FORMCHECKBOX School FORMCHECKBOX Student FORMCHECKBOX Agency |
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FORMCHECKBOX Fall FORMCHECKBOX Spring FORMCHECKBOX Summer |
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Community Integration |
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Responsible Party: FORMCHECKBOX Parent FORMCHECKBOX School FORMCHECKBOX Student FORMCHECKBOX Agency |
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FORMCHECKBOX Fall FORMCHECKBOX Spring FORMCHECKBOX Summer |
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Post High School |
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Responsible Party: FORMCHECKBOX Parent FORMCHECKBOX School FORMCHECKBOX Student FORMCHECKBOX Agency |
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FORMCHECKBOX Fall FORMCHECKBOX Spring FORMCHECKBOX Summer |
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Page 10
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Student: |
NYC ID# - - |
CSE Case# - |
Date of Conference: / / |
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TRANSITION SERVICES |
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(Required for students 15 years of age and older) |
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Independent Living |
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Responsible Party: FORMCHECKBOX Parent FORMCHECKBOX School FORMCHECKBOX Student FORMCHECKBOX Agency |
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FORMCHECKBOX Fall FORMCHECKBOX Spring FORMCHECKBOX Summer |
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Community Integration |
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Responsible Party: FORMCHECKBOX Parent FORMCHECKBOX School FORMCHECKBOX Student FORMCHECKBOX Agency |
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FORMCHECKBOX Fall FORMCHECKBOX Spring FORMCHECKBOX Summer |
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FORMCHECKBOX Acquisition of Daily Skills FORMCHECKBOX Functional Vocational Assessment |
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Responsible Party: FORMCHECKBOX Parent FORMCHECKBOX School FORMCHECKBOX Student FORMCHECKBOX Agency |
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FORMCHECKBOX Fall FORMCHECKBOX Spring FORMCHECKBOX Summer |
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Page 10-1
NEW YORK CITY BOARD OF EDUCATION
STUDENT ACCOMMODATION PLAN
(SUMMER SCHOOL)
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Name: |
NYC ID# - - |
Date of Birth / /
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Gender: |
Date of Conference / / |
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Home School |
Grade: |
CSE Case# - |
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Date of Plan / / |
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Name of Guardian –Relationship - |
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Address |
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Phone (Home) ( ) - |
Phone (Work) ( ) - |
Interpreter Required FORMCHECKBOX Yes FORMCHECKBOX No |
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Preferred Language/Mode of Communication: |
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1. Describe INSTRUCTIONAL/BEHAVIORAL adaptations, modifications or accommodations to be provided including any testing modifications: |
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AREA |
Adaptations. Modifications, Accommodations (INSTRUCTIONAL / BEHAVIORAL |
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2. List/describe any PHYSICAL/MEDICAL accommodations to be provided: |
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(Does not include INSTRUCTIONAL/BEHAVIORAL interventions.) |
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a. |
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b. |
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c. |
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3. Participants (Name/Title): |
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