EDSP 473
CASE STUDY PROJECT: INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEMPLATE
Virginia Department of Education’s Sample IEP Form
For Use with Students up to Age Thirteen, as Appropriate
COMPLETE ALL COMPONENTS HIGHLIGHTED IN YELLOW
Teacher Candidate Name: Andrea Wheeler
Course: EDSP 473-D01
Date: April 14, 2023
Page 1 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Student Name_Clara___________________________________________________ Date_04/14/23 Page ___of___
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.
_______________________________________________________________________________________________
Clara is a friendly 14-year-old that performs below grade level and presents with moderate delays.
Clara is new to the community and school. She was recently enrolled in school accompanied by no
previous educational records. Therefore, there is no documentation or data of her academic needs,
deficits, goals, or strategies needed to meet grade level expectations. Clara lives with her mother
and father and has no siblings. Both of her parents are employed, her father as a truck driver, and
mother as a pre-school teachers’ assistant. Clara nor her parents were born in the United States.
Her native language is Spanish, but she is bilingual in English and Spanish. Clara can read, write,
and speak English well; however, her parents have limited understanding of the English language.
Wide Range Achievement Test (WRAT)
Reading=.03 Percentile
Arithmetic= .04 Percentile
Vineland Adaptive Behavior Scale
Community Domain=40
Daily Living Skills=50
Socialization=68
Motor Skills=52
Adaptive Behavior Composite Score=48
Clara was given the Stanford-Binet Intelligence Test and received a Full-Scale IQ score of 40,
which places her in the IQ range of moderately impaired or delayed.
Clara was administered the Brigance Inventory of Basic Skills to access her reading and math.
The test showed : Clara is able to recognize 15 words on pre-primer level, knows 12 initial letter
sounds, and can write all the letters in the alphabet. In math Clara is able to rote count to 25,
recognize and write numbers to 30, complete addition facts to 8, knows the values of 3 coins and a
dollar, and can tell time to the nearest half-hour. Clara is fluent in the English language and can
recognize several high-frequency functional and directional words. Clara does have a difficult time
positively expressing how she feels and at times lashes out when she becomes frustrated.
Page 2 of 27
EDSP 473
Clara gets along well with her peers and enjoys being with others. She enjoys playtime with others
in a social setting. Transitioning from one activity to another is challenging for Clara and struggles
following oral directions. She also has a difficult time expressing her feelings to others and has
been known to lash out, especially with authority figures. Clara hopes to one day live apart from
her family and have a job. She enjoys working with food, which could be an area that she would
like to pursue for employment. One day Clara also hopes to be married.
Upon completing the initial evaluation and assessments all indicators lead to Clara having a
moderate learning disability.
In Clara’s best interest she should be placed in the least restrictive environment, in a general
education inclusion classroom for all subjects with her peers. It is recommended that Clara receive
additional support from the special education teacher and be provided in the classroom for 45
minutes per day, five days per week. It is also recommended due to the lack of attention that Clara
be given extended time on assignments and tests. Preferential seating near the center of the room is
recommended during classroom instruction.
Page 3 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued
Student Name_Clara______________________________________ Date _04_/_14_/_23_ Page ___of___
Student ID Number__________________________________
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued.
Page 4 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name_Clara_____________________________________ Date_04_/14_/23 Page ___of___
Student ID Number________________________________ Area of Need__Reading__________________________
# _1_ MEASURABLE ANNUAL GOAL:
When given a Dolch sigh word list, Clara will accurately read 20 words with no more than a
3 second delay, in 3 out of 4 trials before her next annual review.
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.
SHORT TERM OBJECTIVES:
Objective/Benchmark #_1 When given a Dolch sigh word list, Clara will accurately read 20 words
with no more than a 3 second delay, in 3 out of 4 trials by the end of the first reporting period.
Objective/Benchmark #_2 When given a Dolch sigh word list, Clara will accurately read 20 words
with no more than a 3 second delay, in 3 out of 4 trials by the end of the second reporting period.
Objective/Benchmark #_3 When given a Dolch sigh word list, Clara will accurately read 20 words
with no more than a 3 second delay, in 3 out of 4 trials by the end of the third reporting period.
How will progress toward this annual goal be measured? (check all that apply)
____ Classroom
Participation
X Checklist
____ Class work
____ Homework
_X_ Observation
____ 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
Page 5 of 27
EDSP 473
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.
Page 6 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name_Clara___________________________________ Date 04/14/23_ Page ___of___
Student ID Number________________________________ Area of Need:__Math__________________________
# _2_ MEASURABLE ANNUAL GOAL:
When given mixed coins and bills in the amount of $10.00 or less, (real or play money), Clara will
correctly identify their values with 80% Accuracy in 3 out of 4 trials before her next annual
review.
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.
SHORT TERM OBJECTIVES:
Objective/Benchmark # 1_ When given mixed coins and bills in the amount of $10.00 or less, (real or
play money), Clara will correctly identify their values with 70% Accuracy in 3 out of 4 trials by
the end of the first reporting period.
Objective/Benchmark #_2_ When given mixed coins and bills in the amount of $10.00 or less, (real or
play money), Clara will correctly identify their values with 75% Accuracy in 3 out of 4 trials by
the end of the second reporting period.
Objective/Benchmark #_3_ When given mixed coins and bills in the amount of $10.00 or less, (real or
play money), Clara will correctly identify their values with 80% Accuracy in 3 out of 4 trials by
the end of the third reporting period.
How will progress toward this annual goal be measured? (check all that apply)
____ Classroom
Participation
____ Checklist
_X_ Class work
____ Homework
____ Observation
____ Special Projects
X 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
Page 7 of 27
EDSP 473
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.
Page 8 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name_Clara_______________________________________ Date_04/14/23 Page ___of___
Student ID Number________________________________ Area of Need:_Social Skills/Behavioral_______________
# _3__ MEASURABLE ANNUAL GOAL:
When given a list of preferred self-calming strategies, Clara will utilize these strategies to
demonstrate self-regulation skills when she becomes frustrated within the classroom in 4 out of 5
recorded trials before the next annual review.
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.
SHORT TERM OBJECTIVES:
Objective/Benchmark #_1_ When given a list of preferred self-calming strategies, Clara will utilize
these strategies to demonstrate self-regulation skills when she becomes frustrated within the
classroom in 1 out of 5 recorded trials by the first reporting period.
Objective/Benchmark #_2_ When given a list of preferred self-calming strategies, Clara will utilize
these strategies to demonstrate self-regulation skills when she becomes frustrated within the
classroom in 2 out of 5 recorded trials by the second reporting period.
Objective/Benchmark #_3_ When given a list of preferred self-calming strategies, Clara will utilize
these strategies to demonstrate self-regulation skills when she becomes frustrated within the
classroom in 3 out of 5 recorded trials by the third reporting period.
How will progress toward this annual goal be measured? (check all that apply)
_X_ Classroom Participation
____ Checklist
____ Class work
____ Homework
_X_ Observation
____ Special Projects
____ Tests and Quizzes
____ Written Reports
____ Criterion-referenced test:_________________________
____ Norm-referenced test: ___________________________
_X_ Other: Data collection_______________________
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*
Page 9 of 27
EDSP 473
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.
Page 10 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Student Name__Clara_____________________________________________ Date_04/14/23 _ 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
Reading Services 45 minutes daily,
225 minutes per
week.
Rivermont School General
Education
Classroom,
Inclusion Setting.
04/14/2023-
04/13/2023
Frequent Breaks Daily Rivermont School General
Education
Classroom,
Inclusion Setting.
04/14/2023-
04/13/2023
Visual and Verbal Cues and
reminders for transitioning between
classes and/or activities.
Daily Rivermont School General
Education
Classroom,
Inclusion Setting.
04/14/2023-
04/13/2023
Quiet and calming area within the
classroom to utilize as a coping
Daily Rivermont School General
Education
04/14/2023-
04/13/2023
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 11 of 27
EDSP 473
strategy when frustrated. Classroom,
Inclusion Setting.
Checking for Understanding Daily Rivermont School General
Education
Classroom,
Inclusion Setting.
04/14/2023-
04/13/2023
Preferential Seating Daily Rivermont School General
Education
Classroom,
Inclusion Setting.
04/14/2023-
04/13/2023
Extended Time for Quizzes and Tests Daily Rivermont School General
Education
Classroom,
Inclusion Setting.
04/14/2023-
04/13/2023
* 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.
Supports for School Personnel: (Describe supports such as equipment, consultation, or training for school staff to meet the unique
needs for the student)
All school personal should be aware of Clara’s language deficit. They should realize that Clara may become frustrated and offer
preferred coping strategies if this should happen. School personnel working directly with Clara should use visual and verbal
cues and frequent reminders prior to transition of classrooms or activities. Clara will have the ability to move to a quiet location
within the classroom should she need to utilize the area for a coping strategy in order to de-escalate and return to baseline.
Personnel should check for understanding frequently, allow breaks if needed, and preferential seating should be used. Clara will
also be given additional time for all quizzes and tests.
Page 12 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
Student Name_Clara____________________________________ Date 04/14/23_ 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
___ Virginia Alternate Assessment Program (VAAP)
Divisionwide Assessment (list):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
*Refer to Students with Disabilities: Guidelines for Assessment Participation for additional guidance on the assessment programs.
Page 13 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
(continued)
Student Name: Clara__________________________________________ Date 04/14/23_ Page ___of___
Student ID Number__________________________________
PARTICIPATION IN STATEWIDE ASSESSMENTS
Test
Assessment Type*
(SOL, VSEP,VAAP) Accommodations** If yes, list accommodation(s)
Reading __SOL__________________________
Not Assessed at this Grade Level
Yes No
Extended Time, frequent
breaks
Math _SOL________________________________
Not Assessed at this Grade Level
Yes No
Extended Time, frequent
breaks
Science _SOL_______________________________
Not Assessed at this Grade Level
Yes No
Extended Time, frequent
breaks
History/SS _SOL________________________________
Not Assessed at this Grade Level
Yes No
Extended Time, frequent
breaks
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):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
___________________________________________________________________________________________________
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 particular 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
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Page 14 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name_Clara_____________________________________________ Date_04/14/23__ 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
Reading Services 5 times per week Rivermont School 04/14/2023-04/13/2023
Math Services 5 times per week Rivermont School 04/14/2023-04/13/2023
Speech Services 3 times per week Rivermont School 04/14/2023-04/13/2023
** 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.
Page 15 of 27
EDSP 473
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name__Clara_____________________________________ Date_ 04/14/23_ Page ___of___
Student ID Number ___________________________________
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):
X 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:
Upon completion of the evaluation process, it suggests that Clara has moderate learning disabilities.
Based on this diagnosis it is recommended by the IEP team that Clara be placed in the least restrictive
environment, in a general education inclusion classroom for all subjects with her peers. Additional
support from the special education teacher will be provided in the classroom for 45 minutes per day, five
days per week.
Page 16 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE AND PARENT CONSENT
Student Name___Clara________________________________________ Date_04/14/2023_ 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
TEACHER CANDIDATE REFLECTION ON PROFESSIONAL LEARNING AND ETHICAL PRACTICE:
Using the prompts in the IEP Assignment Instructions, reflect on your experience writing this IEP and plans for professional
growth in the future.
It is important for all individuals that are involved in the IEP process to present any and all data that is collected or
available on the student. This can include testing, assessments, evaluations, and previous material that may be
available from the student’s educational history. I have a good foundation of reading and writing an IEP but have only
Page 17 of 27
EDSP 473
been present at three IEP meetings this far. I look forward to furthering my knowledge of the IEP meeting process,
who is involved, different topics that are discussed and finding solutions should a problem arise.
I have a great deal of knowledge of the data collection system I currently use within my job. This software is known as
catalyst datafinch. This is a wonderful program that offers many options; however, I look forward to learning new
ways of collecting and interpreting data. I also look forward to learning how to interpret data collected within some of
the formal tests that are given. I have spent the better part of my six years working with students in an elementary
and middle school self-contained classroom. Within this classroom I did not have the opportunity to learn about
transitional goals. Recently I have made a change where I am working in the high school self-contained classroom
where we primarily work on social and life skills that the students will use post-school. I look forward to learning
about assessments and other details that go into the transitional process including transition goals.
I am interested in joining the Council for Children with Behavioral Disorders (CCBD) for many different reasons. As I
reviewed the information within the Council for Exceptional Children (CEC) the CCBD really stood out to me. I have
worked at a behavioral school for the last 6 years. I am currently in the high school ABA in a self-contained classroom.
I have worked with all ages, sex, cultural backgrounds, and disabilities that range from minor to severe. By joining the
CCBD I would be able to hear stories and speak to other individuals with the same profession. This could open up
new doors to procedures and practices that I may not have been aware of previously. This would allow me access to
other professionals dealing with the same or similar social and emotional problems and suggestions on how to deal
with them. It would also allow me the opportunity to share my information about different things that are or are not
working in the classroom. Ultimately this would help me assist my students in my classroom to the best of my ability.
Page 18 of 27
EDSP 473
TRANSITION INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR WRITTEN NOTICE
Student Name__________________________________________________________ Date____/____/____ Page ___of___
Student ID Number___________________________________
Describe the action that the school division proposes or refuses to take: (Required upon graduation with a standard or advanced diploma)
Explanation of why the school division is proposing or refusing to take action:
Description of each evaluation procedure, assessment, record or report the school division used in deciding to propose or
refuse the action:
Description of any other choices that the Individualized Education Program (IEP) team considered and the reasons why those
choices were rejected:
Description of other reasons or other factors relevant as to why the school division proposed or refused the action:
Resources for the parent to contact for help in understanding the Individuals with Disabilities Education Act (IDEA) and the
related federal and Virginia Regulations:
If this notice is not the initial referral for evaluation, document when the parent was provided a copy of the procedural
safeguards and how a copy maybe obtained, if the parent requests an additional copy:
Page 19 of 27
EDSP 473
SECTION 2
Additional Forms
To Be Used
As Needed
Page 20 of 27
EDSP 473
ELEMENTARY INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PROCESS CHECKLIST
Meeting notices sent to parent and agency representatives, as appropriate
Acquire written consent from parent for an agency representative to attend the IEP meeting
Welcome and introductions of team members
Review purpose of meeting
Review meeting agenda
Review rights and procedural safeguards pertaining to special education and the IEP meeting
Review of special factors to be considered by the IEP team
Develop Present Level of Academic Achievement and Functional Performance
Develop measurable annual goals
(Discuss progress report on previous annual goals, as needed.)
Determine progress report schedule
Document that the IEP team considered the need for short-term objectives or benchmarks for students other than
those who take alternate assessments aligned to alternate achievement standards
Develop short-term objectives or benchmarks for the annual goals, as needed
Determine any needed accommodations and/or modifications in instruction and assessment
Determine participation in state and divisionwide assessments
Determine services and placement
Determine if student needs ESY services
Review any requests proposed and/or refused
Provide prior written notice and obtain parental consent
Identify how staff will be informed of their responsibilities for implementation of the IEP
Page 21 of 27
EDSP 473
Special Education Meeting Notice
(School Division Letterhead)
Date:
To: ____________________________________ and ______________________________________
Parent(s)/Adult Student Student (if appropriate or if transition will be discussed)
You are invited to attend a meeting regarding ____________________________________________
Student’s Name
PURPOSE OF MEETING (check all that apply):
IEP Development or Annual Review
IEP Amendment
Team Review of Referral
Team Review of Existing Data
Transition: PartC to Part B
Eligibility Determination
Team Determination of Needed Data
Transition: Postsecondary Goals, Transition Services
Manifestation Determination
Other: ____________________________
The meeting has been scheduled for:
Date Time Location
Meetings are scheduled at a mutually agreed upon place and time by you and the school division. If you are
unable to attend this meeting you may request participation through other means. If you are unable to attend this
meeting, please contact:
Special Education Staff Contact / IEP Case Manager Title Phone
You and the school division may invite individuals to participate in the team meeting who have knowledge or
expertise about the student’s educational needs. The determination of the knowledge or special expertise shall be
made by the party who invited the individual. For IEP Meetings, if the division intends to invite a representative
of an agency that is likely to be responsible for providing or paying for transition services to the IEP meeting,
written consent of the parent or adult student is required.
Below is a list of the participants (by name or position) the division will be inviting to attend the meeting:
Please review and return the following page to assist the school staff in preparing for the meeting.
Page 22 of 27
EDSP 473
Special Education Meeting Notice Parent/Student Response Form
To the Parent(s) / Guardian(s) / Student:
Student: Date of Meeting:
Please check your choice and return this page
to:
at
I the parent student will attend the meeting as scheduled.
I the parent student cannot attend the meeting as scheduled. Please reschedule this
meeting.
I can attend on at
(date) (time and place)
Please contact me at
to determine a mutually agreeable date, time, and place for this IEP meeting.
I the parent student do not wish to attend this meeting even though I understand the
importance of attending. You may hold this meeting in my absence.
I the parent student would like my preferences, interests, and concerns shared with the
team. I will provide my input to you by:
Mail Telephone Other means: prior to the meeting.
An IEP worksheet is enclosed.
I will need the following accommodations for this IEP meeting:
I plan to bring _______ individuals that I believe have knowledge or expertise regarding my child.
______________________________________ ___________________________________
Parent Signature Date
Date received by the school:
Page 23 of 27
EDSP 473
SAMPLE
School Division Letterhead
CONSENT TO INVITE AGENCY PERSONNEL
Date: _____________
If the division intends to invite a representative of any agency that is likely to be responsible for providing or
paying for transition services to the IEP meeting, written consent from the parent or adult student is required
prior to the meeting date.
_____ I give my consent for an agency representative(s) named on the meeting notice to be invited to
the IEP meeting.
_____ I do not give my consent for an agency representative(s) named on the meeting notice to be
invited to the IEP meeting.
Parent/Adult Student Signature Date
________________________________________ ______________________
Parent/Adult Student Signature Date
**Please sign and return this page to your child’s IEP Case Manager.
Page 24 of 27
EDSP 473
Page 25 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
COVER PAGE – MEDICAID ELIGIBLE STUDENTS
Student Name_________________________________________________________________________ Page ___ of ___
Student ID Number__________________________________ Medicaid/FAMIS # ____________________ Grade_______
DOB ____/____/____ Age* ________ Disability(ies) (if identified) ____________________________________________
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 (____)______________________
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
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
Page 26 of 27
Summary of previous treatment if not addressed elsewhere:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________________________________
Intervention, treatment, and modalities if not addressed elsewhere:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________________________________
--—-
So
oe
A
—
one
nap
-
EDSP 473
Required for Billable Services
ICD9 Code _________________________ Medicaid Discharge Plan/Disposition
_______________________________
Page 27 of 27
EDSP 473
PARENTAL CONSENT FOR BILLING PUBLIC INSURANCE LANGUAGE
FOR THE IEP or IEP AMENDMENT
One-Time Consent
(This document is optional and is not a necessary component of the IEP annual review)
For Medicaid or FAMIS (Family Access to Medical Insurance Securities) Insured Only
If your child is now or later becomes eligible for Medicaid or FAMIS and he or she receives health-related
services written in an Individual Education Program (IEP), the federal government can help the public school
division pay for these health-related services, such as, but not limited to physical, occupational or speech therapy;
audiology, nursing, psychological or personal care services and health screening associated with Early Periodic
Screening Diagnosis and Treatment (EPSDT). Parent/Guardian consent is required before the public school
system can bill Medicaid or FAMIS.
Additional information about the one-time parental consent, the parental consent form and the procedural
safeguards can be found at http://www.doe.virginia.gov/support/health_medical/medicaid/index.shtml.
If prior consent has been given, no further action is required.
Page 28 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT, continued
Student Name_______________________________________________________ Date____/____/____ Page ___of___
Student ID Number________________________________ Area of Need________________________________________
# _____ MEASURABLE ANNUAL GOAL:
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)
____ Classroom
Participation
____ Checklist
____ Class work
____ Homework
____ Observation
____ 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 their children without
disabilities.
Page 29 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SHORT TERM OBJECTIVES OR BENCHMARKS, as determined by IEP Team
(Required for students participating in the VAAP)
Student Name__________________________________________________________ Date____/____/____ Page ___of___
Student ID Number________________________________ Goal # _____ Area of Need: ___________________________
Short Term Objectives or Benchmarks, as needed
Objective/Benchmark #___
Objective/Benchmark #___
Objective/Benchmark #___
Objective/Benchmark #___
Page 30 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PROGRESS REPORT COMMENTS, Continued
(This document is optional)
Student Name__________________________________________________________ Date____/____/____ Page ___of___
Student ID Number________________________________
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
Page 31 of 27
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
EXTENDED SCHOOL YEAR SERVICES (ESY)
(Optional)
Student Name_________________________________________________________ Date____/____/____ Page ___of___
Student ID Number___________________________________
Summarize the IEP team’s discussions and decision about ESY:
If ESY services are to be provided identify which goals in the current IEP will be addressed by the ESY services:
Identify the Extended School Year services needed to meet these goals:
Service(s) Frequency **School/location
Instructional
Setting
(classroom)
Duration
m/d/y to m/d/y
** 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.
Page 32 of 27
