Wk 4 Summative Assessment: Individualized Education Programs (IEP) Plan

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- Symbol indicates information that goes into the Student Teacher Accountability Recording System (STARS).

IEP Page 1 of 28 IEP for ___________________________________________________ Date:

SECONDARY

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student Name:_____________________________________________ Date:

Student State ID #: DOB: Age:

Grade: Gender: M F Ethnicity:

Parent(s)/Guardian(s):

Address:

Home Phone: Work/Message Phone:

School: School Phone:

School Address:

For initial IEPs only:

Date parent(s) signed consent form:

Date evaluation completed:

Initial eligibility determination date:

Most Recent Evaluation Date: Next Evaluation Due:

IEP Meeting Purpose:______________________________ Next Annual IEP Date:

Based on assessment and evaluation information and the IEP Team determination of eligibility:

The primary disability is:

Autism Deaf-Blindness Intellectual Disability Emotional Disturbance

Hearing Impairment Deafness Multiple Disabilities Orthopedic Impairment

Other Health Impairment Specific Learning Disability: ___ Dyslexia

Speech or Language Impairment Traumatic Brain Injury Visual Impairment/Blindness

Exceptionality: Gifted Speech Only

The secondary disability is:

Autism Deaf-Blindness Intellectual Disability Emotional Disturbance

Hearing Impairment Deafness Multiple Disabilities Orthopedic Impairment

Other Health Impairment Specific Learning Disability: ___ Dyslexia

Speech or Language Impairment Traumatic Brain Injury Visual Impairment/Blindness

Exceptionality: Gifted

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IEP Page 2 of 28 IEP for ___________________________________________________ Date:

STUDENT PROFILE What do the parent and student envision as the student’s future?

Student/Family Vision Statement: ________________________________________________

______________________________________________________________________________

Employment:

Community Participation:

Recreation & Leisure:

Post-Secondary Training & Learning:

Daily/Independent Living:

Note: Completion of this section requires the IEP team to consider and describe the student’s academic and

functional strengths and concerns as identified by the parent, student, teachers, related service staff, and other

team members. The IEP team must consider additional results from state and district-wide assessments,

transition assessments, initial and most recent psychological educational evaluations, evaluations provided by

the district, parents or guardians, and any extracurricular and non-academic areas that may be affected.

Domain

Information

Provider

Strengths

Concerns / Recommendations

Academic:

-State and district

assessments

-Language assessments

Recreation & Leisure:

(extra-curricular and

non-academic)

Community

Participation:

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IEP Page 3 of 28 IEP for ___________________________________________________ Date:

Domain

Information

Provider

Strengths

Concerns / Recommendations

Jobs and Job

Training:

Transition assessments

Post-Secondary

Training or Learning:

Transition assessments

Independent Living:

Transition Assessments

(if applicable)

Other Areas:

-Health considerations

-Attendance

-Observations

Additional

information

considered by the IEP

team:

-Evaluations provided

by parent(s) or

guardian(s)

-Psychological

Educational

Evaluations and

Eligibility

Determinations

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IEP Page 4 of 28 IEP for ___________________________________________________ Date:

CONSIDERATION OF SPECIAL FACTORS

Is the student visually impaired (including blindness)? YES NO

If YES, is: Instruction in Braille needed Use of Braille needed Both

Does the student have special oral and/or written communication needs? YES NO

(If YES) Describe the needs and planned services that address the needs:

_______________________________________________________________________________

Is the student deaf or hard of hearing? YES NO

(If YES) complete the Addendum for Students who are Deaf or Hard of Hearing Communication

Considerations form. The form is available at http://www.ped.state.nm.us/seo/

Does the student have limited English proficiency? YES NO

If YES, describe the relationship of language needs and planned services:

Does the student have assistive technology needs? YES NO

If YES, describe devices and/or services required:

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IEP Page 5 of 28 IEP for ___________________________________________________ Date:

DISCIPLINE

Does the student exhibit behaviors that impede his or her learning or that of others? YES NO

If YES, the IEP team must consider the following questions, then decide which discipline strategy

is most appropriate for the student.

1. Are positive behavioral interventions, strategies, and accommodations included in the IEP?

YES NO

2. Are behavioral goals (with short-term objectives or benchmarks) when appropriate, included

in the IEP? YES NO

3. Does a Functional Behavioral Assessment (FBA) need to be conducted?

YES NO

If YES to FBA, responsibility assigned to:

Which of the following discipline provisions is most appropriate for this student?

Check only one

The student will follow the school-wide discipline plan.

The student requires the modifications described in this IEP under Annual Goals and/or

Instructional Accommodations.

The student requires a Behavioral Intervention Plan. (Attach BIP to this IEP)

In regards to the BIP and/or FBA, who will inform administrators and teachers?

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IEP Page 6 of 28 IEP for ___________________________________________________ Date:

PRESENT LEVELS OF ACADEMIC ACHIEVEMENT

Please document the student’s present levels of academic achievement for areas of identified need (e.g.,

reading, written language, mathematics, transition). This information is not for transition planning.

Specify each instrument or source and report the results.

Identified Area of Need:_____________________________ Student/Parent Input

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IEP Page 7 of 28 IEP for ___________________________________________________ Date:

PRESENT LEVELS OF FUNCTIONAL PERFORMANCE

Please document the student’s present levels of functional performance for identified areas of need (eg.,

social/emotional, behavior, life skills, energy level, sustained attention, memory function, impulse,

processing speed, and motor skills).

Identified Area of Need:_____________________________ Student/Parent Input

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IEP Page 8 of 28 IEP for ___________________________________________________ Date:

EXTENDED SCHOOL YEAR (ESY)

Does the student exhibit severe or substantial regression that is not recoupable within a reasonable

period in one or more of the critical areas addressed in the annual measurable goals?

(In addition to regression/recoupment, consider the following factors: severity of the disability,

behavioral skills, critical learning period, learned material, potential for generalization and

maintenance, emerging skills that are at risk for loss, medical conditions and family circumstances.)

YES NO

(REQUIRED): If YES, attach documentation to the ESY ADDENDUM that demonstrates the

substantial regression and recoupment periods

PARTICIPATION IN STATE MANDATED ASSESSMENTS

Special Education Standardized⎯No Accommodations

Special Education—Allowable Accommodations

Specify the necessary accommodations:

This list of allowable accommodations can be found at http://www.ped.state.nm.us/seb

Alternate Assessment ⎯ Attach ALTERNATE ASSESSMENT ADDENDUM and supporting

documents

PARTICIPATION IN DISTRICT-WIDE ASSESSMENTS

Standardized⎯No Accommodations

Special Education—Allowable Accommodations

Specify the necessary accommodations:

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IEP Page 9 of 28 IEP for ___________________________________________________ Date:

MEASURABLE POST-SECONDARY GOALS

(Required by age 14 or sooner if needed)

Measurable post-secondary goals describe what the student will do after exiting high school. These

goals will address the following specific areas: education/training, employment and independent living

(the latter if appropriate).

Measurable Post-Secondary Goal(s) for Education/Training:

Transition Assessment(s) used to identify goal:

•

Measurable Post-Secondary Goal(s) for Employment:

Transition Assessment(s) used to identify goal:

•

Measurable Post-Secondary Goal(s) for Independent Living (If Appropriate):

Transition Assessment(s) used to identify goal:

•

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IEP Page 10 of 28 IEP for ___________________________________________________ Date:

GRADUATION OPTIONS

The student’s planned course of study meets the requirements for:

Standard Option Modified Option Ability Option

For the Modified Option:

Explain why the Standard Option was rejected:

Note: The team is responsible for documenting progress on achieving the Employability and Career

Development Standards with Benchmarks and Performance Standards on the IEP goals/objectives

pages.

For the Ability Options:

Explain why the Standard and Modified Option were rejected:

_____________________________________________________________________________

For all Graduation Options:

Projected date of graduation:

Is the student on target with graduation requirements? YES NO

If NO, what are the concerns? (Required credits, graduation exam, attendance, behavior concerns,

need for academic support)

______________________________________________________________________________

What is the plan for addressing these concerns?

Services for Gifted Students Only: Describe diverse learning opportunities, alternative

coursework, and flexible instructional arrangements unique to the student's capabilities.

Has student taken and passed the NM High School Competency Exam (NMHSCE – ends after 2013-

14) or Standards Based Assessment (SBA)/High School Graduation Assessment (HSGA)?

YES NO

If NO, what is the plan of action______________________________________________________

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IEP Page 11 of 28 IEP for ___________________________________________________ Date:

Identify the scores for each subtest. If the student has taken the exit exam, and is on the Modified or

Ability Option, indicate the targeted proficiency level.

• Students on

Standard Option must

meet the 175 NMHSCE

cut score or the State’s

cut score of 2272.5 on

the SBA/HSGA

• A Proficiency Level

must be determined by

the IEP team for all

students on Career

Readiness or Ability

Options

Does the student need to retake any subtest(s) of the Standards Based Assessment (SBA)/ High

School Graduation Assessment (HSGA)? If YES, identify the subtest(s).

If the student is on the Modified or Ability Option, what additional information did the IEP team use

to determine the targeted proficiency levels?

Subtest

Date test

taken

Scores Proficiency

Level

Passed

Science

Social Studies

Math

Reading

Language Arts

Written Composition

(Standard Option: 3.0)

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IEP Page 12 of 28 IEP for ___________________________________________________ Date:

Students in 12th grade who completed four years of high school and continue to have educational

and transition needs may receive a Conditional Certificate of Transition in the form of a

continuing or transition IEP. This is not a program of study and does not end a student's right to a

Free Appropriate Public Education (FAPE).

Is this a Continuing or Transition IEP?

The student’s program and instruction have been appropriate

The student has maintained realistic efforts to meet IEP goals

The student has successfully completed four or more years of high school

The student can participate equitably in all graduation activities

Projected date of graduation for the student:

*Describe how this graduation program of study aligns with the student’s post-secondary goals and

the state standards with benchmarks____________________________________________________

_____________________________________________________________________

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IEP Page 13 of 28 IEP for ___________________________________________________ Date:

COURSE OF STUDY

Course of Study (required by 14 years of age, or sooner if appropriate). IEP team must document

all courses and other educational experiences that will help the student reach her/his measurable

post- secondary goals.

School

Year

Proposed Courses Selected for High School Program

(Including elective classes, work study, independent study)

Yr. 1

Yr. 2

Yr. 3

Yr. 4

Ages

18-21

Specify planned

activities by

each projected

year

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IEP Page 14 of 28 IEP for ___________________________________________________ Date:

INSTRUCTIONAL ACCOMMODATIONS AND/OR MODIFICATIONS

The IEP team has determined that the identified accommodations and/or modifications are

appropriate in the following areas: ___________________________________________________

_______________________________________________________________________________

*Please, be specific about the required accommodations and/or modifications.

Environment:___________________________

_______________________________________

Instructional Material:___________________

_______________________________________

Assignments/Homework: _________________

_______________________________________

Testing: (in classroom) ___________________

_______________________________________

Behavior Supports:______________________

_______________________________________

____________________________________

Instructional Presentation Mode: __________

_______________________________________

Instructional Strategies: __________________

_______________________________________

Student Response Mode:__________________

_______________________________________

Other:_________________________________

_______________________________________

Grades will be determined by: ____________

_______________________________________

Grades will be based on: __________________

_______________________________________

In case of a failing grade: _________________

_______________________________________

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IEP Page 15 of 28 IEP for ___________________________________________________ Date:

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IEP Page 16 of 28 IEP for ___________________________________________________ Date:

ANNUAL MEASURABLE GOALS IN IDENTIFIED AREAS OF NEED ACADEMIC ACHIEVEMENT

The measurable annual goals must align with the student’s needs and reflect how they must support

the student’s post-secondary goals.

IDENTIFIED AREA OF NEED: Math Reading Written Language

Behavior Problem Solving Processing Skills Communication Skills

Reference from New Mexico’s Content Standards with Benchmarks (2012-13) or Common Core

State Standards (starting 2013-14) with Benchmarks and Expanded Grade Band Expectations

(EGBE):

______________________________________________________________________________

ANNUAL GOAL: (direction of change, the behavior, present level, ending level and timeframe for achieving the

goal)

Date Initiated ____________

______________________________________________________________________________

Objectives are not required in accordance with 34 CFR §300.320, with one exception: students with

disabilities who take alternate assessments aligned to alternate academic achievement standards or the

EGBE.

OBJECTIVE or BENCHMARK: ___________________________________________

______________________________________________________________________________

__________________________________________________________ ✓ if Transition Activity

Criteria for Mastery: ____________________________________________________________

Anticipated Date of Mastery: _____________ Position/Agency Responsible: _______________

Methods of Measurement: ________________________________________________________

Progress Documentation: (Note date and progress for each progress period) ___________________________

______________________________________________________________________________

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IEP Page 17 of 28 IEP for ___________________________________________________ Date:

ANNUAL MEASURABLE GOALS IN IDENTIFIED AREAS OF NEED FUNCTIONAL PERFORMANCE

The measurable annual goals must align with the student’s needs and reflect how they must support

the student’s post-secondary goals.

IDENTIFIED AREA OF NEED: Social/Emotional Life Skills Energy Level

Sustained Attention Memory Function Impulse Processing Speed

Motor Skills

Reference from New Mexico’s Content Standards with Benchmarks (2012-13) or Common Core

State Standards (starting 2013-14) with Benchmarks and Expanded Grade Band Expectations

(EGBE):

ANNUAL GOAL: (direction of change, the behavior, present level, ending level and timeframe for achieving the

goal)

Date Initiated ____________

______________________________________________________________________________

Objectives are not required in accordance with 34 CFR §300.320, with one exception: students with

disabilities who take alternate assessments aligned to alternate academic achievement standards or the

EGBE.

OBJECTIVE or BENCHMARK : ___________________________________________

______________________________________________________________________________

__________________________________________________________ ✓ if Transition Activity

Criteria for Mastery: ____________________________________________________________

Anticipated Date of Mastery: ___________ Position/Agency Responsible: _________________

Methods of Measurement: ________________________________________________________

Progress Documentation: (Note date and progress for each progress period) _______________________

______________________________________________________________________________

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IEP Page 18 of 28 IEP for ___________________________________________________ Date:

TRANSITION SERVICES/INTERAGENCY LINKAGES

The IEP team must include activities/strategies designed to assist the student in reaching his/her

measurable post-secondary and annual goals.

Student Needs

Activities/Strategies

Person/Agency

Responsible

Timeframe

Date of

Completion for

each activity

Instruction:

(Career

Development

Activities)

Related Services:

(Transference of

skills into other

settings)

Community

Experiences:

*field trips,

business partners

Employment/

Post-Secondary:

Independent/

Daily

Living Skills:

(if appropriate)

Functional

Vocational

Assessments:

(if appropriate)

Does the student need involvement from any additional outside agencies to complete a successful

transition?

YES NO

If YES, list the agencies to contact ___________________________________________________

________________________________________________________________________________

If NO, explain ____________________________________________________________________

_________________________________________________________________________________

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IEP Page 19 of 28 IEP for ___________________________________________________ Date:

MEDICAL/SIGNIFICANT HEALTH INFORMATION

MEDICATION:________________________________________________________________

______________________________________________________________________________

SIGNIFICANT HEALTH INFORMATION:

Does the student require an individualized health plan or school health services as a related service?

YES NO:

If YES, attach the health plan to the IEP and/or indicate on the Schedule of Services.

Does the student require an emergency evacuation plan? YES NO

If YES, attach the emergency evacuation plan, including the person(s) responsible to the IEP.

Physical Education: Regular Regular, with accommodations Adapted

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IEP Page 20 of 28 IEP for ___________________________________________________ Date:

MOBILITY

Does the student require assistance to move in and around the school?

YES NO:

If YES, describe the assistance to be provided:

TRANSPORTATION

Does the student require transportation as a related service?

YES NO:

If YES, what accommodations and supports are required in order for the student to be transported

with typically developing peers in the Least Restrictive Environment (LRE)?

Does the student require any of the following:

▪ Wheelchair lift: YES NO

▪ Security device(s) such as harnesses, tethers, braces, brackets, restraints, seatbelts, vests:

YES NO

If YES, please describe the security device(s) the student requires:

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IEP Page 21 of 28 IEP for ___________________________________________________ Date:

SCHEDULE OF SERVICES

If this IEP spans between two school years, please complete this page twice, separating the services to be

delivered in each school year.

Activities with typically

developing peers

Regular Education Services

Lunch/Breakfast

Library

Computer Lab

Assemblies

Electives

Extracurricular activities

Other _______________

Accommodations Needed

Subject: YES NO

Special Education &

Related Services

Minutes

per Day/

Week/

Month/

Semester

/Year

Start

Date

Ending

Date

Service

Provider (s)

Location

Time in

Regular

Setting

Time in

Special

Education

Setting

Time Totals

Supplementary Aids and

Services

Minutes

per Day/

Week/

Month/

Semester

/Year

Start

Date

Ending

Date

Service

Provider (s)

Location

Time in

Regular

Setting

Time in

Special

Education

Setting

Time Totals

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IEP Page 22 of 28 IEP for ___________________________________________________ Date:

LEVEL OF SERVICE

X = The total number of hours per week of special education service

Y = The total number of hours in a typical school week, (excluding lunch and recess)

Level of service = X divided by Y (express as percent)

Example: X = 6 hrs./wk Y = 30 hrs./wk. 6 divided by 30 = .2 (20%) = Level 2 (moderate)

10% or less of school day (Level 1-minimum) 11% - 49% of the school day (Level 2-moderate)

50%-or more of the school day (Level 3-

extensive)

approaching a full school day (Level 4-maximum)

LEAST RESTRICTIVE ENVIRONMENT (LRE)

(This statement should provide the rationale for removal from general education.)

Decisions regarding placement are based on the individual needs of students and must begin with the

consideration of the general education setting. The purpose of this section is to document the rationale

with respect to each academic or functional area that is necessary to educate the student in the general

education setting.

If the student will be included in the general education setting for more than 80% of the time, no

rationale is required. Items 1 through 3 of this section of the IEP need not be completed or included

in the student’s IEP.

If the student will not be included in the general education setting for more than 80% of the time,

complete items 1 through 3 below (REQUIRED):

1. Explain why supplementary aids and services are not adequate to meet the student’s needs in the

general education class [34 CFR §300.320 (a)(4), and 34 CFR §300.114 (a)(2)(ii)]:

2. Explain how placement in a special education setting will be more advantageous in meeting

student’s needs [34 CFR §300.320 (a)(4)(iii)]:

3. Explain why placement in a general education setting is reduced or limited and what is being done

to reintegrate the student back to a general education setting [34 CFR §300.320 (a)(5)]:

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IEP Page 23 of 28 IEP for ___________________________________________________ Date:

SETTING

a = Total number of hours per week in Special Education setting

b = Total number of hours in a typical week (excluding, lunch and recess)

Setting = a divided by b (express as a percent)

Example: 1) 2 hrs./wk. 2) 30 hrs./wk. 2 divided by 30 = .06 (6%) = Setting 1

In regular classroom 80% of the school day, or more (Setting 1)

In regular classroom 40% to 79% of the day (Setting 2)

In regular class less than 40% of the day (Setting 3)

Other setting: Public/Private Separate Schools, RTC, Homebound/Hospital (Setting 4)

Is the student's program and related services provided in his or her neighborhood school?

YES NO:

(If NO) explain

Identify the school site that the student will be attending:

*Note: Review placement decisions at least once a year, as part of the annual review process.

IEP PROGRESS DOCUMENTATION

Inform parents of their child’s progress toward annual goals in the IEP and the extent to which that

progress is sufficient to enable the child to achieve the goals by the end of the year. Progress reports

are required at least as often as parents of non-disabled children receive reports.

Describe the process to ensure that the child’s parents regularly receive reports of progress toward

annual goals: _____________________________________________________________________

_____________________________________________________________________

Reporting schedule to inform parents about progress on annual measurable goals:

Monthly Quarterly Semester Other

AGE OF MAJORITY

will reach the age of majority (18 in New Mexico) on (date)

The student and parent/guardian were informed annually on (date) _____________of the student’s

rights upon reaching the age of majority beginning at age 14.

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IEP Page 24 of 28 IEP for ___________________________________________________ Date:

MEETING PARTICIPANTS

Signature signifies attendance and participation in the development of the IEP.

Signature Role Date

Student

Parent/Guardian

LEA Representative

Special Education Teacher

Regular Education Teacher

Qualified evaluator of test results,

(if appropriate)

Interpreter (as appropriate)

Participating Agencies

Related Services Provider

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IEP Page 25 of 28 IEP for ___________________________________________________ Date:

PARENT RIGHTS

I have had the opportunity to participate in the development of this Individualized Education Program

(IEP) and the recommended services and setting for my child. The information presented to me was

in an understandable manner. I have received a copy of “Parent and Child Rights in Special

Education” as part of an initial IEP meeting. (Parent Initials)

CASE MANAGER

_______________________________________________is responsible for ensuring that everyone

involved in implementing this IEP has access to necessary information and is informed of his/her

specific responsibilities for providing the accommodations/modifications the student requires to

benefit from his/her educational program.

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IEP Page 26 of 28 IEP for ___________________________________________________ Date:

PRIOR WRITTEN NOTICE OF PROPOSED ACTIONS

Federal and State Legislation require that the public agency provide the parent/guardian with

notification a reasonable amount of time before actions occur that would initiate or change the

identification, the evaluation, the educational services and setting, or the provision of a free

appropriate public education for this student. If the student is under 18 the parent/guardian is provided

a copy of this notice. If the student is 18 years of age or over and does not have a legal guardian, it is

his/her right to accept or refuse these proposed actions.

An IEP meeting was held on _____________________ to discuss special education services for this

student. The IEP team reviewed and discussed the following input/ data and information: (Please

check all that apply.)

Student input Developmental case history

Parent input Hearing screening: (date)

Teacher input Vision screening: (date)

Classroom performance Previous IEP/evaluation: (date)

Classroom observation Language dominance

School records Functional vision evaluation

Developmental screening Counseling evaluation

Achievement test: (name/date)

Speech/Language evaluation: (name/date)

Occupational therapy evaluation: (name/date)

Physical therapy evaluation: (name/date)

Psychological evaluation: (name/date)

Intellectual assessment: (name/date)

Medical information:

Other:

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IEP Page 27 of 28 IEP for ___________________________________________________ Date:

Federal regulations and state rules require that all public agencies have a “continuum of

alternative service and setting options" available as needed in order to meet the needs of children

with disabilities for special education and related services.

At this IEP meeting, the public agency and/or the parent(s)/guardian(s) proposed the following

items and options:

All Items Proposed

All Options Considered

Proposed

(√)

Reject

(√)

Reason for Acceptance or Rejection

(Must include a description of each

evaluation procedure, assessment,

record or report used as a basis for the

proposed or refused action)

#1 Regular Education classroom

with Special Education services

specified as:

(Setting 1: 80% or more of the day in

regular classroom)

#2 Regular Education classroom

combined with Special Education

classroom and services provided

specified as:

(Setting 2: 40% to 79% of the day in

regular class setting)

#3 Regular Education classroom

combined with Special Education

classroom and services provided

specified as:

(Setting 3: less than 40% of the day

in the regular class setting)

#4 Special Education services

provided all day or approaching a

full day (Setting 4) specified as:

(Other setting: public/private

separate schools, RTC,

homebound/hospitals)

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IEP Page 28 of 28 IEP for ___________________________________________________ Date:

lTo the Parent/Guardian:s

For initial provision of special education services, informed written consent from the

parent(s)/guardian is required.

Please sign below if you give consent for the school district to proceed with the action(s) indicated

on the Prior Written Notice of Proposed actions.

(Parent/Guardian Signature) (Date)

For assistance in understanding your procedural safeguards/due process rights, you may contact:

School District

Contacts

New Mexico Public

Education

Department

Parent Advocacy

Support

Parent Liaison

Dispute Resolution

Coordinator

Special Education

Bureau

Phone: 505-827-1457

Fax: 505-954-0001

Secondary
INDIVIDUALIZED EDUCATION PROGRAM (iep)
present levels of FUNCTIONAL PERFORMANCE
Annual Measurable Goals in identified Areas of need

IEP PROGRESS DOCUMENTATION
AGE OF MAJORITY
PARENT RIGHTS