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
Leah Eckard
EDSP 473: Assessment and Transition Planning for Diverse Learners
June 5, 2023
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Student Name_Clara Date_6 /_5 /_2023 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 fourteen-year-old who displays academic delays and performs below grade level. She is new in the
community and recently enrolled in school. She did not bring any of her former academic records from her previous
schools with her, so there is no documentation to provide evidence of her educational strengths, weaknesses, etc. Clara
lives with her mother and father, and she has no siblings. Her mother works in a pre-school as a teacher’s assistant
and her father works as a short- distance truck driver. Clara and her parents all speak Spanish because it’s their
native language. Clara learned how to read, write, and speak English at her last school. Her English abilities are at the
same level as her Spanish abilities. Her parents are not as fluent in English as Clara is, but they are cooperative.
Wide Range Achievement Test (WRAT)
Reading = .03 Percentile
Arithmetic = .04 Percentile
Vineland Adaptive Behavior Scale
Communication Domain = 40
Daily Living Skills = 50
Socialization = 68
Motor Skills = 52
Adaptive Behavior Composite = 48
Clara was administered the Stanford-Binet Intelligence Test where she obtained a Full-Scale IQ score of 40. Her score
places her in the moderately impaired or delayed IQ range.
Clara was administered the Brigance Inventory of Basic Skills to assess her abilities in reading and math. For reading,
she recognized 15 pre-primer level words and knew 12 initial letter sounds. For math, she was able to rote count to 25,
recognize numbers to 30, and write numbers to 30. Clara also knew addition facts to 8, the values of three coins and a
dollar, and she could tell time to the half hour. For written language, she could write all the letters of the alphabet. For
functional language, Clara could recognize several high-frequency functional words and several directional words.
However, Clara struggles to express her feelings in appropriate ways and tends to lash out when she becomes
frustrated.
Clara gets along well with her peers, and she enjoys playing with them in social settings. However, she struggles with
transitioning from one task to another and following directions. She also struggles with expressing her feelings in
appropriate ways as she tends to lash out on others, especially authority figures. Clara wants to get a job in the future.
She enjoys working with food, but only for a little while. She would like to get married and move away from her
family.
After completing the initial evaluation and assessments, all indicators suggest that Clara has a moderate learning
TT
Te
Sareea
eee
EDSP 473
disability. Because of this, it would be best for Clara to be placed in the least restrictive environment (LRE). For her,
that would be general education classroom with her classmates. There she will be receiving extra assistance from the
special education teacher for 45 mins 5 days a week. Since Clara struggles with following directions, staying on tasks,
and transitioning from one task to another, she will be given extra allotted time to complete assignments. In the
classroom, she will sit front and center to help her stay focused.
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued
Student Name_Clara Date _6 /_5 /_2023 Page
of
Student ID Number
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued.
EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name Clara
_3 of Date 6 /_5 /_2023 Page
Student ID Number Area of Need
Reading
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
_X Checklist
Class work
Homework
_X Observation
Criterion-referenced test:
Norm-referenced test:
Other:
Special Projects
Tests and Quizzes
Written Reports
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.
ES - The student demonstrates Emerging Skill but may not
achieve this 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.
NI -The student has Not been provided Instruction on
this goal.
# 1 MEASURABLE ANNUAL GOAL:
When given a Fry’s Sight Word List, Clara will correctly read thirty words with 80% accuracy in 5 out of 6 trials by
the next annual review.
SHORT TERM OBJECTIVES:
Objective/Benchmark #_1 Given a third grade Fry Sight Word List, Clara will correctly read 10 words with 80%
accuracy in 5 out of 6 trials by the end of the first quarter.
Objective/Benchmark #_2 Given a fifth grade Fry Sight Word List, Clara will correctly read 20 words with 80%
accuracy in 5 out of 6 trials by the end of the second quarter.
Objective/Benchmark #_3 Given a seventh grade Fry Sight Word List, Clara will correctly read 30 words with 80%
accuracy in 5 out of 6 trials by the end of the third quarter.
EDSP 473
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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 7 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
EDSP 473
Student Name Clara
_4 of Date_6 / 5 /_2023 Page
Student ID Number Area of Need
Math
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
X Class work
Homework
Observation
Criterion-referenced test:
Norm-referenced test:
Other:
Special Projects
X Tests and Quizzes
Written Reports
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.
ES - The student demonstrates Emerging Skill but may not
achieve this 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.
NI -The student has Not been provided Instruction on
this goal.
# 2 MEASURABLE ANNUAL GOAL:
When given a hundreds chart, Clara will correctly recognize and write numbers to 100 with 90% accuracy in 3 out of
4 trials by the next annual review.
SHORT TERM OBJECTIVES:
Objective/Benchmark #_1 When given a hundreds chart, Clara will correctly recognize and write numbers to 50
with 80% accuracy in 3 out of 4 trials by the end of the first quarter.
Objective/Benchmark #_2 When given a hundreds chart, Clara will correctly recognize and write numbers to 70
with 85% accuracy in 3 out of 4 trials by the end of the second quarter.
Objective/Benchmark #_3 When given a hundreds chart, Clara will correctly recognize and write numbers to 90
with 90% accuracy in 3 out of 4 trials by the end of the third quarter.
EDSP 473
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.
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 9 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name Clara Date 6 /_5 /_2023 Page
_5 of
Student ID Number Area of Need
Social Skills
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
Class work
Homework
_X Observation
Criterion-referenced test:
Norm-referenced test:
_X Other:
Special Projects
Tests and Quizzes
Written Reports
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
# _3 MEASURABLE ANNUAL GOAL:
Given the mindfulness corner, Clara will politely excuse herself to gather her feelings when feeling frustrated in the
classroom in 4 out of 5 trials before the next annual review.
SHORT TERM OBJECTIVES:
Objective/Benchmark #_1 Given the mindfulness corner, Clara will politely excuse herself to gather her feelings
when feeling frustrated in the classroom in 1 out of 5 trials by the end of the first quarter.
Objective/Benchmark #_2 Given the mindfulness corner, Clara will politely excuse herself to gather her feelings
when feeling frustrated in the classroom in 2 out of 5 trials by the end of the second quarter.
Objective/Benchmark #_3 Given the mindfulness corner, Clara will politely excuse herself to gather her feelings
when feeling frustrated in the classroom in 3 out of 5 trials by the end of the third quarter.
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 10 of 27
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
ES - The student demonstrates Emerging Skill but may not
IP -The student has demonstrated Insufficient Progress
to meet this annual goal and may not achieve this goal
within the duration of this IEP.
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.
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 11 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Student Name Clara Date_6 /_5 /_2023 Page
_6 of
Student ID Number
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
Daily
Lucky School
General
6/5/2023 -
Education
6/4/2024
Classroom
Breaks
Daily
Lucky School
General
6/5/2023 -
Education
6/4/2024
Classroom
Transition Signals and Prompts
Daily
Lucky School
General
6/5/2023 -
Education
6/4/2024
Classroom
Extra time on assignments
During
Lucky School
General
6/5/2023 -
assignments
Education
6/4/2024
Classroom
Mindfulness Corner
Daily
Lucky School
General
6/5/2023 -
Education
6/4/2024
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
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 12 of 27
Classroom
Seating Arrangement
Daily
Lucky School
General
6/5/2023 -
Education
6/4/2024
Classroom
Checks for Understanding
Daily
Lucky School
General
6/5/2023 –
Education
6/4/2024
Classroom
* 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)
School personnel will be notified of Clara’s native language and how she is doing with English. They will also be aware of
her outbursts when she becomes frustrated as it is typically aimed at those in authority positions. Personnel should be
prepared for this because if/when it occurs, they should lead Clara to the mindfulness corner and allow her to take a break
for reflection. School personnel should also use transition signals and prompts since she struggles with that as well.
Personnel should have Clara sit front and center in the classroom. They should also be aware that she is given extra time
on assignments, and they should always perform checks for understanding.
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 13 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
Student Name Clara Date 6 /_5 /_2023 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 division wide 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.
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 14 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
(continued)
Student Name Clara Date _6 /_5 /_2023 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
Extra time & breaks
Math
_SOL
□
Not Assessed at this Grade Level
Yes □No
Extra time & breaks
Science
_SOL
□
Not Assessed at this Grade Level
Yes □No
Extra time
History/SS
_SOL
□
Not Assessed at this Grade Level
Yes □No
Extra time
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
_N/A
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 15 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name Clara Date 6 / 5 /_2023 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 a week
Lucky School
6/5/2023 - 6/4/2024
Math Services
5 times a week
Lucky School
6/5/2023 – 6/4/2024
Speech Services
3 times a week
Lucky School
6/5/2023 – 6/4/2024
** 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.
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 16 of 27
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name Clara Date 6 / 5 /2023 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.
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.
❑
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
PLACEMENT CONTINUUM OPTIONS CONSIDERED: (check all that have been considered):
Explanation of Placement Decision:
The evaluation process has revealed that Clara has moderate learning disabilities. Because of this the IEP team
encourages that Clara be placed in the least restrictive environment (LRE), which would be the general education
classroom for every subject along with her classmates. There she will receive extra support from the special education
teacher for 45 minutes, 5 days a week.
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 17 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE AND PARENT CONSENT
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
Student Name Clara Date 6 /_5 /_2023
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.
To create an IEP, the essential IEP team must gather information about the qualified student. They will collect student
data which can include tests, assessments, evaluations, etc. From the collected data they will set the direction. Upon
choosing which direction it should be taken, the IEP team will develop the IEP. The IEP always connects to the
student’s program and services. After developing the IEP, the IEP becomes implemented. Essential personnel will
observe and track the student’s progress, so when the next annual review comes (if not before), they will review and
update the IEP more accordingly.
I have personally never read, wrote, or experienced a real IEP meeting. I have worked with special need students for a
little over five years now and I have learned a lot about them from being around them and their families as well as
from school. But I still have never participated in a real-life IEP meeting. Because of this, I have an open mind going
into the process. I honestly want to know every bit of professional knowledge there is and all the skill areas on how to
create a quality IEP. I’m sure as I experience it in real life certain interests and preferences will come to light, but as of
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 18 of 27
right now I would like to know everything. However, if I had to choose only one area that I’d like to further develop as
I advance in the profession right now, I would have to say the Transition IEP. I am getting my degree in K-12 Special
Education, so I’ll have plenty of options when searching for employment. However, I really hope the high school I
work at now will have an opening after I graduate because I would love to work there with the students I have already
been working with for years. Not to mention the connections with school personnel I have made and having their
schedule down pat. There is a special needs teacher there now who recently opened an ice cream shop for her students
to work at after they age out, which I think is wonderful.
After reviewing the Council for Exceptional Children’s (CEC) Special Interest Divisions link, the one division I would
consider joining is the Division on Career Development and Transition (DCDT). The DCDT is focused on transitioning
disabled and gifted students from school to life, which as I have already stated is something I am very interested in.
From the website, I found other divisions I am also interested in, and they are listed below.
-Division on Autism and Developmental Disabilities (DADD)
-Division of Visual and Performing Arts Education (DARTS)
-Division for Learning Disabilities (DLD)
-The Association for the Gifted (TAG)
-Teacher Education Division (TED)
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 19 of 27
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:
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 20 of 27
SECTION 2
Additional Forms
To Be Used
As Needed
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 21 of 27
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
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 22 of 27
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.
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 23 of 27
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:
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 24 of 27
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.
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 25 of 27
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 26 of 27
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
Summary of previous treatment if not addressed elsewhere:
Intervention, treatment, and modalities if not addressed elsewhere:
ar
er
rn
ce
moter
ep
ene
ee
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 27 of 27
Required for Billable Services
ICD9 Code Medicaid Discharge Plan/Disposition
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 28 of 27
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.
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 29 of 27
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.
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.
ES -The student demonstrates Emerging Skill but may not
IP -The student has demonstrated Insufficient Progress
to meet this annual goal and may not achieve this goal
within the duration of this IEP.
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.
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:
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 30 of 27
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 #
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 31 of 27
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
EDSP 473
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Page 32 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
EXTENDED SCHOOL YEAR SERVICES (ESY)
(Optional)
Student Name Date / / Page of
Student ID Number
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.
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:
