Virginia Department of Education’s Sample IEP Form
For Use with Students up to Age Thirteen, as Appropriate
TABLE OF CONTENTS
The Virginia Department of Education does not require that schools use this sample IEP format; it is
offered as a best practice example. The sample IEP form is divided into two sections. The first section
includes those pages that are the foundation of all IEPs. The second section includes those pages that
will be added to the IEP as needed and sample formats for other purposes.
SECTION 1: Foundation of All IEPs
Cover Page: This page contains general information about the student and documentation of those
individuals who participated in the development of the IEP. (page 3)
Factors for IEP Team Considerations: This form may be used to document the team’s
consideration of the matters that the applicable regulations require the team to consider during the
process of developing the IEP, along with any decisions made by the team regarding these matters.
The documentation of these considerations, while not required, is best practice. However, all
members of the IEP team must be aware of the factors that need to be considered by the IEP team
during the development of the IEP. (page 4)
Present Level of Academic Achievement and Functional Performance (pages 5-6)
Measurable Annual Goals/Progress Reports (page 7)
Services, Accommodations/Modifications (page 8)
Services, Participation in State and Divisionwide Accountability/Assessment System (pages 9-
10)
Services, Least Restrictive Environment, Placement (pages 11-12)
Services, Least Restrictive Environment, Placement-Preschool only (pages 13-14)
Prior Notice (page 15)
Prior Written Notice (page 16)
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 1 of 27
SECTION 2: Additional Forms as Needed
Elementary IEP Process Checklist: Example list that can be used to facilitate the IEP process.
(page 18)
IEP Meeting Notice – Sample (page 19-20)
Consent to Invite Agency Personnel – Sample (page 21)
Cover Page – Medicaid Eligible Students: This page contains general information about the
student and documentation of those individuals who participated in the development of the IEP and
assists in meeting the documentation requirements for Medicaid students for which services are
billed. (pages 22-23)
Measurable Annual Goals/Progress Reports, continued (page 24)
Short-term Objectives and/or Benchmarks: to be used as needed. (page 25)
Progress Report Comments: This page can be used to provide comments on progress report codes.
(page 26)
Extended School Year Services: This page addresses services beyond the normal school year/day, if
needed. (page 27)
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 2 of 27
INDIVIDUALIZED EDUCATION PROGRAM
COVER PAGE
Student Name: Carly________________________________________________________________ Page 3 of 27
Student ID Number_______________________________________________________________________ Grade: 3____
DOB ____/____/____ Age:9______ Disabilities: Cerebral Palsy, Visual and Cognitive Impairments __________
Parent(s) Name_____________________________________________________Email_____________________________
Home Address_____________________________________________________Primary (____)______________________
____________________________________________________ Secondary (____)____________________
Date of IEP meeting…………………...…………………….……………………….....……..………….._____/_____/_____
Date parent notified of IEP meeting………………………………..……………………...………………_____/_____/_____
This IEP will be reviewed no later than ………..…………………….……………..……….……………_____/_____/_____
Most recent eligibility date…………………………….…………………………………….……………._____/_____/_____
Next re-evaluation, including eligibility, must occur before ………..……..…………..…..…………….._____/_____/_____
Copy of IEP given to parent (Name) _____________________________________________ On (Date)_____/_____/_____
IEP Teacher/Manager_________________________________________ Phone Number (____)______________________
The Individualized Education Plan (IEP) that accompanies this document is meant to support the positive process and team
approach. The IEP is a working document that outlines the student’s vision for the future, strengths and needs. The IEP is
not written in isolation. The intent of an IEP is to bring together a team of people who understand and support the student in
order to come to consensus on a plan and an appropriate and effective education for the student. No two teams are alike and
each team will arrive at different answers, ideas and supports and services to address the student’s unique needs. The student
and his/her family members are vital participants, as well as teachers, assistants, specialists, outside service providers, and the
principal. When all team members are present, the valuable information shared supports the development of a rich student
profile and education plan.
PARTICIPANTS INVOLVED:
The list below indicates that the individual participated in the development of this IEP and the placement decision; it
does not authorize consent. Parent consent is indicated on the “Prior Notice” page.
NAME OF PARTICIPANT POSITION
_Morgan Forehand_____________________________________ _____Teacher________________________
_____________________________________________________ ______Parent/Guardian________________
_____________________________________________________ ______Parent/Guardian________________
_____________________________________________________ ___Guidance Counselor________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 3 of 27
INDIVIDUALIZED EDUCATION PROGRAM
FACTORS FOR IEP TEAM CONSIDERATION
Student Name: Carly_____________________________________________ Date: 09/06/2022Page 4 of 27
Student ID Number___________________________________________
During the IEP meeting, the following factors must be considered by the IEP team. Best practice suggests that the IEP team
document that the factors were considered and any decision made relative to each. The factors are addressed in other sections
of the IEP if not documented on this page (for example: see Present Level of Academic Achievement and Functional
Performance).
1. Results of the initial or most recent evaluation of the student;
Carly has cerebral palsy, visual impairments, and cognitive impairments.
The Woodcock-Johnson Test of Cognitive Abilities was administered with the following results (standard scores): General
Intelligence Ability (64), Long-Term Retrieval (63), Auditory Processing (67), Fluid Reasoning (66), Processing Speed (63),
Short-Term Memory (69), Visual-Spatial Thinking (65), Comprehension Knowledge (61), Reading-Writing (57), and
Quantitative Knowledge (59).
____________________________________________________________________________________________________
__
2. The strengths of the student;
Strong Parental Support, increased reading skills when using pictures; Preferred method is computer tasks
____________________________________________________________________________________________________
__________
3. The academic, developmental, and functional needs of the student;
difficulty with reading, writing, and math. She has some difficulty with articulation and often runs out of breath while
speaking. Carly uses a wheelchair and a walker at school.
____________________________________________________________________________________________________
__________
4. The concerns of the parent(s) for enhancing the education of their child;
Phonemic Awareness
Reading, Writing, Math
Sight Words (Current knowledge is two)
Math symbols and basic number concepts
____________________________________________________________________________________________________
__________
5. The communication needs of the student;
Troubles with articulation and often runs out of breath while speaking
____________________________________________________________________________________________________
__________
6. The student’s needs for benchmarks or short-term objectives;
____________________________________________________________________________________________________
__________
7. Whether the student requires assistive technology devices and services. When considering whether assistive technology is
required, the IEP team may refer to the Virginia Assistive Technology Resource Guide to facilitate the discussions about goals
and objectives, areas of difficulty, and whether AT devices or services are needed, and whether accessible instructional
materials in alternate formats are needed.
Students needs assistive technology as the student was diagnosed with cerebral palsy.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 4 of 27
____________________________________________________________________________________________________
__________
8. In the case of a student whose behavior impedes his or her learning or that of others, consider the use of positive
behavioral interventions, strategies, and supports to address that behavior;
Yes, Carly needs behavioral strategies and interventions to address frustrations when staying on task with assignments and
using writing materials properly.
____________________________________________________________________________________________________
__________
9. In the case of a student with limited English proficiency, consider the language needs of the student as those needs relate
to the student’s IEP;
Carly does not present with any issues in English proficiency.
___________________________________________________________________________________________________
10. In the case of a student who is blind or is visually impaired, provide for instruction in Braille and the use of Braille
unless the IEP team determines after an evaluation of the student’s reading and writing skills, needs, and appropriate reading
and writing media, including an evaluation of the student’s future needs for instruction in Braille or the use of Braille, that
instruction in Braille or the use of Braille is not appropriate for the student. When considering that Braille is not appropriate
for the child the IEP team may use the Functional Vision and Learning Media Assessment for Students who are Pre-Academic
or Academic and Visually Impaired in Grades K-12 (FVLMA) or similar instrument; and
___________________________________________________________________________________________________
11. In the case of a student who is deaf or hard of hearing, consider the student’s language and communication needs,
opportunities for direct communications with peers and professional personnel in the student’s language and communication
mode, academic level, and full range of needs, including opportunities for direct instruction in the student’s language and
communication mode. The IEP team may use the Virginia Communication Plan when considering the student's language and
communication needs and supports that may be needed.
___________________________________________________________________________________________________
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INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE
Student Name_Carly_____________________________________________ Date09/06/2022 Page 6 of 27
Student ID Number_____________________________________________________
The Present Level of Academic Achievement and Functional Performance summarize the results of assessments that identify
the student’s interests, preferences, strengths and areas of need, including assistive technology and/or accessible materials. It
also describes the effect of the student’s disability on his or her involvement and progress in the general education curriculum,
and for preschool children, as appropriate, how the disability affects the student’s participation in appropriate activities. This
includes the student’s performance and achievement in academic areas such as writing, reading, mathematics, science, and
history/social sciences. It also includes the student’s performance in functional areas, such as self-determination, social
competence, communication, behavior and personal management. Test scores, if included, should be self-explanatory or an
explanation should be included, and the Present Level of Academic Achievement and Functional Performance should be
written in objective measurable terms, to the extent possible. There should be a direct relationship among the desired goals,
the Present Level of Academic Achievement and Functional Performance, and all other components of the IEP.
_______________________________________________________________________________________________
Carly loves animals, especially dogs and has very supportive parents. Carly is diagnosed with cerebral palsy, visual and
cognitive impairments. Carly uses a wheelchair and walker at school. She qualifies for adapted curriculum through the
intellectual disability category. Her disabilities lead to the need for a more adaptive classroom and educational plan. Carly has
impulsivity issues when it comes to computer usage and struggles with paper and pencil tasks. She becomes frustrated easily
and crumples the paper. Carly responds very well to having an aide assist with one-on-one assistance in math and when using
manipulatives.
Educationally, Carly qualifies for special education under the intellectual disability (ID) category and is on the adapted
curriculum. She has emerging phonemic awareness, two sight words mastered (I and You), reading skills with visual aide and
can produce sentences with a 10-14 picture/word bank. She can count to 10.
Carly has difficulty with speaking loudly/articulation and can run out of breath while speaking so she requires an
amplifier while in groups and when someone misunderstands or has trouble hearing her. She uses a standard mouse with an
enlarged cursor on a white background with larger sized text. Carly also requires supported seating positions, wheelchair tray,
and adapted tables and chairs.
Carly struggles with reading, writing, and math. Math recall for basic math concepts is low and so is one to one
correspondence. She confuses the addition and subtraction symbols.
The Woodcock-Johnson Test of Cognitive Abilities was administered with the following results (anything under a 69 is
considered a very low cognitive level with the highest being a 110): General Intelligence Ability (64), Long-Term Retrieval
(63), Auditory Processing (67), Fluid Reasoning (66), Processing Speed (63), Short-Term Memory (69), Visual-Spatial
Thinking (65), Comprehension Knowledge (61), Reading-Writing (57), and Quantitative Knowledge (59).
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued
Student Name_Carly_____________________________________________ Date09/06/2022 Page ___of___
Student ID Number__________________________________
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 7 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name:_Carly_____________________________________________ Date: 09/06/2022 Page ___of___
Student ID Number________________________________ Area of Need: All______________
# _____ MEASURABLE ANNUAL GOAL:
1. Carly can identify the difference between addition and subtraction symbols with a 70% accuracy on a list of 20 problems
by the end of the semester, three months.
2. Carly can identify at least 5 sight words with a 75% accuracy in a trial of 3 different samples by the end of the semester,
three months.
3. Carly can count to 20 without error or mixing up more than two numbers by the end of the school year.
4. Carly can at least write her name and the date on a piece of paper twice a week with a minimum of 50% accuracy for the
remainder of the school year.
5. Carly can type a simple sentence without hitting multiple keys with the heel of her hand with a success rate of 60% or
more. Choose from the following sentences: Carly is nine years old. Carly loves dogs. I can do it. I will do it.
The IEP team considered the need for short-term objectives/benchmarks.
Short-term objectives/benchmarks are included for this goal. (Required for students participating in the VAAP)
Short-term objectives/benchmarks are not included for this goal.
How will progress toward this annual goal be measured? (check all that apply)
__X__ Classroom
Participation
____ Checklist
__X__ Class work
____ Homework
___X_ Observation
__X__ Special Projects
____ Tests and Quizzes
____ Written Reports
____ Criterion-referenced
test:_________________________
____ Norm-referenced test:
___________________________
____ Other:
___________________________________
_____
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
IP -The student has demonstrated Insufficient Progress
to meet this annual goal and may not achieve this goal
within the duration of this IEP.
ES - The student demonstrates Emerging Skill but may not
achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction on
this goal.
M -The student has Mastered this annual goal.
* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Student Name:_Carly_____________________________________________ Date: 09/06/2022 Page ___of___
Student ID Number___________________________________
This student will be provided access to general education classes, special education classes, other school services and
activities including nonacademic activities and extracurricular activities, and education related settings:
___ with no accommodations/modifications
_X__ with the following accommodations/modifications
Accommodations/modifications provided as part of the instructional and testing/assessment process will allow the student
equal opportunity to access the curriculum and demonstrate achievement. Accommodations/modifications also provide access
to nonacademic and extracurricular activities and educationally related settings. Accommodations/modifications based solely
on the potential to enhance performance beyond providing equal access are inappropriate.
Accommodations may be in, but not limited to, the areas of time, scheduling, setting, presentation and response including
assistive technology and/or accessible materials. The impact of any modifications listed should be discussed.
ACCOMMODATIONS/MODIFICATIONS (list, as appropriate)
Accommodation(s)/Modification(s) Frequency Location
(name of school
*)
Instructional
Setting
Duration
m/d/y to m/d/y
Portable Amplifier When in large groups School Adapted
classroom
09/06/2022 to
09/06/2023
Standard Mouse with enlarged
cursor
When on the computer School Adapted
classroom
09/06/2022 to
09/06/2023
Supported Seating Positions When completing fine
motor tasks
School Adapted
classroom
09/06/2022 to
09/06/2023
Wheelchair Tray When completing fine
motor tasks
School Adapted
classroom
09/06/2022 to
09/06/2023
Tables at Corrected Height When completing fine
motor tasks
School Adapted
classroom
09/06/2022 to
09/06/2023
* IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the
location of the services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the
parents do not indicate that they will object to any particular school or state that the team should identify a single school.
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Supports for School Personnel: (Describe supports such as equipment, consultation, or training for school staff to meet the
unique needs for the student)
Carly benefits from one on one support due to limits from her disabilities. She benefits from an adapted classroom, tables at
her height, lap desk for wheelchair, sound booster if in large groups, and motivation/redirection to stay on task if working
with manipulatives. Carly is in a wheelchair and uses a walker while at school, so some tasks are limited. She has difficulty
with articulation and runs out of breath occasionally when speaking so she needs an amplifier. Carly would also need
assistance through physical, occupational and speech therapy. Carly qualifies for special education under the intellectual
disability (ID) category and is on the adapted curriculum
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 11 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
Student Name:_Carly_____________________________________________ Date: 09/06/2022 Page ___of___
Student ID Number__________________________________
This student’s participation in state and divisionwide assessments must be discussed annually. During the duration of this IEP:
Will the student be at a grade level or enrolled in a course for which the student must participate in a
state and/or divisionwide assessment? If yes, continue to next question.
Yes No
Based on the Present Level of Academic Achievement and Functional Performance, is this student
being considered for participation in the Virginia Standards of Learning (SOL)Assessments (select
appropriate content area)
Reading Math Science History/Social Science Grade 8 Writing
Yes No
Based on the Present Level of Academic Achievement and Functional Performance, is this student
being considered for participation in the Special Permission Request Virginia Substitute Evaluation
Program (VSEP)? If yes, complete the “VSEP Participation Criteria” for each content area
considered. (Grades 3-8 only)
Reading Math Science History/Social Science Grade 8 Writing
Yes No
Does the student meet the VSEP participation criteria? If yes, determine for specific content area.
Reading Math Science History/Social Science Grade 8 Writing
Special permission for eligible students with disabilities in grades 3-8. refer to VDOE’s
Students with Disabilities: Guidelines for Assessment Participation for guidance.
Yes No
Based on the Present Level of Academic Achievement and Functional Performance, is this student
being considered for participation in the Virginia Alternate Assessment Program (VAAP), which is
based on Aligned Standards of Learning? If yes, complete the “VAAP Participation Criteria”.
Yes No
Does the student meet VAAP participation criteria? Yes No
If “yes” to any of the above, check the assessment(s) chosen and attach (or maintain in student’s educational record) the
assessment page(s), which will document how the student will participate in Virginia’s accountability system and any needed
accommodations and/or modifications.
___ SOL Assessments Reading Math Science History/Social Science Grade 8 Writing
___ Virginia Substitute Evaluation Program (VSEP) Reading Math Science History/Social Science Grade 8 Writing
_X__ Virginia Alternate Assessment Program (VAAP)
Divisionwide Assessment (list):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
*Refer to Students with Disabilities: Guidelines for Assessment Participation for additional guidance on the assessment programs.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
(continued)
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Student Name_Carly_____________________________________________ Date09/06/2022 Page ___of___
Student ID Number__________________________________
PARTICIPATION IN STATEWIDE ASSESSMENTS
Test
Assessment Type*
(SOL, VSEP,VAAP) Accommodations*
*
If yes, list accommodation(s)
Reading _VAAP________________________
Not Assessed at this Grade Level
Yes No On Computer; Mouse and
Cursor; Adaptive Seating
Math _VAAP________________________
Not Assessed at this Grade Level
Yes No On Computer; Mouse and
Cursor; Adaptive Seating
Science _VAAP________________________
Not Assessed at this Grade Level
Yes No On Computer; Mouse and
Cursor; Adaptive Seating
History/SS
_VAAP________________________
Not Assessed at this Grade Level
Yes No On Computer; Mouse and
Cursor; Adaptive Seating
Writing _______________________________________
Not Assessed at this Grade Level
Yes No
* Students with disabilities are expected to participate in all content area assessments that are available to students without
disabilities. The IEP Team determines how the student will participate in the accountability system.
** Accommodation(s) must be based upon those the student generally uses during classroom instruction and assessment,
including assistive technology and/or accessible materials. For the accommodations that may be considered, refer to VDOE’s
Students with Disabilities: Guidelines for Assessment Participation for guidance.
Divisionwide Assessment (list):
____None____________________________________________________________________________________________
____________________________________________________________________________________________________
___________________________________________________________________________________________________
EXPLANATION FOR NON-PARTICIPATION IN REGULAR STATE OR DIVISION-WIDE ASSESSMENTS
If an IEP team determines that a student must take an alternate assessment instead of a regular state assessment, explain in the
space below why the student cannot participate in this regular assessment; why the assessment selected is appropriate for the
student, including that the student meets the criteria for the alternate assessment; and how the student’s nonparticipation in the
regular assessment will impact the child’s promotion; or other matters. Refer to the VDOE’s Students with Disabilities:
Guidelines for Assessment Participation for guidance.
Alternate/Alternative Assessments Participation Criteria is attached or maintained in the student’s educational record
Carly is not recommended for standardized/district testing and recommended for VAAP due to the following characteristics
listed from the Guidelines for Participation released by the VDOE: communication difficulties, uneven learning patterns in all
domains, multiple disabling conditions along with an cognitive disability, motor impairments resulting in the use of a
wheelchair, difficulty learning new tasks and maintaining skills, and individualized methods of accessing information. Carly
qualifies for special education under the intellectual disability (ID) category and is on the adapted curriculum.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 13 of 27
Student Name:_Carly_____________________________________________ Date: 09/06/2022 Page ___of___
Student ID Number ___________________________________
Least Restrictive Environment (LRE)
When discussing the least restrictive environment and placement options, the following must be considered:
To the maximum extent appropriate, the student is educated with children without disabilities.
Special classes, separate schooling or other removal of the student from the regular educational environment occurs only
when the nature or severity of the disability is such that education in regular classes with the use of supplementary aids
and services cannot be achieved satisfactorily.
The student’s placement should be as close as possible to the child’s home and unless the IEP of the student with a
disability requires some other arrangement, the student is educated in the school that he or she would attend if he or she
did not have a disability.
In selecting the LRE, consideration is given to any potential harmful effect on the student or on the quality of services that
he/she needs.
The student with a disability shall be served in a program with age-appropriate peers unless it can be shown that for a
particular student with a disability, the alternative placement is appropriate as documented by the IEP.
Free Appropriate Public Education (FAPE)
When discussing FAPE for this student, it is important for the IEP team to remember that FAPE may include, as appropriate:
Educational Programs and Services
Proper Functioning of Hearing Aids
Assistive Technology and/or accessible
materials
Transportation
Nonacademic and Extracurricular Services and Activities
Physical Education
Extended School Year Services (ESY)
Length of School Day
SERVICES :
Identify the service(s), including frequency, duration and location that will be provided to or on behalf of the student in order
for the student to receive a free appropriate public education. These services are the special education services and as
necessary, the related services, supplementary aids and services based on peer-reviewed research to the extent practicable,
assistive technology and/or accessible materials, supports for personnel*, accommodations and/or modifications* and
extended school year services* the student will receive that will address area(s) of need as identified by the IEP team. Address
any needed transportation and physical education services including accommodations and/or modifications. * These services
are listed on the “Accommodations/Modifications” page and “Extended School Year Services” page, as needed.
Service(s) Frequency **School/location
Instructional
Setting
(classroom)
Duration
m/d/y to m/d/y
Portable Amplifier When in groups School/Classroom 09/06/2022 to 09/06/2023
Standard Mouse with enlarged
cursor
When using
computer
School/Classroom 09/06/2022 to 09/06/2023
Supported Seating Positions When completing
tasks that are fine
motor
School/Classroom 09/06/2022 to 09/06/2023
Wheelchair Tray When needed School/Classroom 09/06/2022 to 09/06/2023
Tables at Corrected Height When completing
tasks at a desk
School/Classroom 09/06/2022 to 09/06/2023
Transportation to School Daily To School/Classroom 09/06/2022 to 09/06/2023
Physical Therapy Twice a Week School/Classroom 09/06/2022 to 09/06/2023
Speech Pathologist Twice a Week School/Classroom 09/06/2022 to 09/06/2023
Occupational Therapy Twice a week School/Classroom 09/06/2022 to 09/06/2023
** IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the
location of the services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the
parents do not indicate that they will object to any particular school or state that the team should identify a single school.
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SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name_Carly_____________________________________________ Date 09/06/2022 Page ___of___
Student ID Number ___________________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 15 of 27
Extended School Year Services (ESY): (see attached summary sheet as a means to document discussion)
The IEP team determined that the student needs ESY services.
The IEP team determined that the student does not need ESY services. Describe.
The IEP team will determine and/or address ESY services at a later date. Addressed by date:______________
Explain:
PLACEMENT
No single model for the delivery of services to any population or category of children with disabilities is acceptable for
meeting the requirement for a continuum of alternative placements. All placement decisions shall be based on the individual
needs of each student. The team may consider placement options in conjunction with discussing any needed supplementary
aids and services, accommodations/modifications, assistive technology and/or accessible materials, and supports for school
personnel. In considering the placement continuum options, check those the team discussed. Then, describe the placement
selected in the PLACEMENT DECISION section below. Determination of the Least Restrictive Environment (LRE) and
placement may be one or a combination of options along the continuum.
PLACEMENT CONTINUUM OPTIONS CONSIDERED: (check all that have been considered):
general education class(es)
special class(es)
special education day school
state special education program / school
Public residential facility
Private residential facility
Homebound
Hospital
Other ____________________________
Based upon identified services and the consideration of least restrictive environment (LRE) and placement continuum
options, describe in the space below the placement. Additionally, summarize the discussions and decision around LRE and
placement. This must include an explanation of why the student will not be participating with students without disabilities in
the general education class(es), programs, and activities. Attach additional pages as needed.
Explanation of Placement Decision:
Carly requires an adapted classroom to make progress with academic achievement and functional skills. Carly qualifies for
special education under the intellectual disability (ID) category and is on the adapted curriculum.
Carly requires one on one assistance in the classroom to maintain focus and impulsivity issues. Carly benefits from
supported seating positions when completing tasks using fine motor skills; adaptions which include but are not limited to a
wheelchair tray, adapted chairs and tables at the corrected height. Carly also is significantly behind her grade level peers
which would put her struggling even more in a general education classroom setting.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE AND PARENT CONSENT
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Student Name_Carly_____________________________________________ Date 09/06/2022 Page ___of___
Student ID Number___________________________________
PRIOR NOTICE
The school division proposes to implement this IEP. This proposed IEP will allow the student to receive a free appropriate
public education in the least restrictive environment. This decision is based upon a review of current records, current
assessments and the student’s performance as documented in the Present Level of Academic Achievement and Functional
Performance. Other options considered, if any, and the reason(s) for rejection are attached or can be found in the Placement
Decision section of this IEP. Additionally, other factors, if any that are relevant to this proposal are attached. Parent and adult
student rights are explained in the Procedural Safeguards. If you, the parent(s) and adult student, need another copy of the
Procedural Safeguards or need assistance in understanding this information please contact
________________________________ at (___) ____________ or e-mail ________________________________ or
________________________________ at (___) ____________ or e-mail ________________________________ .
____ Parent(s) initials here indicate that the parent(s) has read the above prior notice and attachments, if any, before giving
permission to implement this IEP.
PARENT/ADULT STUDENT CONSENT: Indicate your response by checking the appropriate space and sign below.
___ I give permission to implement this IEP.
___ I do not give permission to implement this IEP.
____________________________________________________ ____/____/____
Parent Signature Date
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 17 of 27
