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: Corrine Baker
Course: EDSP473: Assessment and Transition Planning for Diverse Learners (D01)
Date: 04/10/2024
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EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Student Name_____Clara_____________________________________________________ Date__04__/08____/_2024___
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 14-year-old student who is not quite where she needs to be and is not performing at the grade level that she is in.
She is new to our school; we have no background information on Clara from her old school. Clara has no brother or sisters,
it’s just her and her parents. Clara parents work and speak Spanish. Clara was taught English at her old school. She speaks the
English and Spanish at the same rate. He parents Spanish is better than their English, but they are willing to help. Clara test
score is copied below.
Clara was given the (WRAT) test and her scores were reading= .03 Percentile and Arithmetic = .04 Percentile.
She was also given the Vineland assessment and she scored Communication Domain = 40, Daily Living Skills = 50,
Socialization = 68, Motor Skills = 52 and Adaptive Behavior Composite = 48 she was given this assessment to measure her
adaptive behavior and support the diagnosis of intellectual and developmental disabilities, autism, and developmental delays.
Clara was given the Stanford-Binet Test so that we could gage her skills in reading and math. Clara test score are as
follows.
Stanford-Binet Intelligence Test
Full Scale IQ = 40
Brigance Inventory of Basic Skills
Reading
Recognized 15 words on pre-primer level
EDSP 473
Page 2 of 2
Knew 12 initial letter sounds
Math
Rote count to 25
Recognize numbers to 30
Writing numbers to 30
Knowing addition facts to 8
Knowing values of three coins and dollar
Tell time to half-hour
Written Language
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EDSP 473
Can write all letters
Functional Language
Recognize several high-frequency functional words (exit, women’s, restroom, in,
out, stairs, keep out, police, go, walk, danger)
Recognize several directional words (name, address, state, zip, phone, date,
email, cell
Because of these test scores. My suggestion would be Clara should be considered for the (LRE) environment. Clara
needs to receive extra assistance from SPED for 45 min d days a week. We fill that it would also goo to allow more
time for her to complete her Work. because she does have issues staying on task and transitioning.
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EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued
Student Name_Clara_______________________________________________________ Date __04__/_08 ___/_2024___
Page ___of___
Student ID Number__________________________________
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued.
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EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name__________Clara_____________________________________________ Date__04__/_08___/_24___ Page
___of___
Student ID Number________________________________ Area of
Need_________Reading_______________________________
# ___1__ MEASURABLE ANNUAL GOAL: By the yearly review Clara will be able to correctly read thirty words
with 80% accuracy
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 #__1_Given a 3rd grade word list Clara will correctly read 12 words with 60% correctness attained by the 1st
term.
Objective #__2_Given a 5th grade word list Clara will correctly read 22 words with 70% Correctness attained by the
2ndterm.
Objective #_3__given a seventh-grade word list, Clara will correctly read 30 words with 80% Correctness attained by
the 3rd term.
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
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.
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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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EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name______Clara_________________________________________________ Date__04__/08____/2024____ Page
___of___
Student ID Number________________________________ Area of
Need___________Math_____________________________
# ____2_ MEASURABLE ANNUAL GOAL:
When given a hundred chart, Clara will be able to correctly identify and write numbers to 100 with 90% Correctness
by the Yearly analysis.
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 #__1_ When given a number chart, Clara will be able to correctly recognize and mark down numbers to
100 with 70%Correctness attained by the 1st Term.
Objective #__2_ When given a number chart, Clara will be able to correctly recognize and mark down numbers to
100 with 80% Correctness attained by the 2nd term.
Objective\#_3__ When given a number chart, Clara will be able to correctly recognize and mark down numbers to
100 with 90% Correctness attained by the 3rd term.
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
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.
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EDSP 473
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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EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name______Clara_________________________________________________ Date__04/08/2024__ Page ___of___
Student ID Number________________________________ Area of Need____________Social
skills____________________________
# __3___ MEASURABLE ANNUAL GOAL: Clara will actively manage her feelings and frustration daily with 3 out
of 3 times by her Yearly analysis
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_ Clara will actively manage her feelings and frustration 1/3 time attained by 1st term
Objective/Benchmark #__2_ Clara will actively manage her feelings and frustration 2/3 times attained by the 2nd
quarter.
Objective/Benchmark #_3 Clara will actively manage her feelings and frustration 3/3 times attained by the 3rd
term.
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: _____With
teacher___________________________________
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.
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EDSP 473
* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
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EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Student Name____Clara_____________________________________________________ Date___4_/__8__/__2024__ 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 Daily School GE classroom 04/08/24-04/09/24
Extra time As needed School GE classroom 04/08/24-04/09/24
Managing stress with teacher Daily School GE classroom 04/08/24-04/09/24
* 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) ______________________________________________________________
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EDSP 473
Any personnel that works directly with Clara will be notified of any issues at hand. They will also be notified of the
hardships ands the language barrier. Any modifications that is needed will also be noted for the other staff members.
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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 __04/08/2024__
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.
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EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
(continued)
Student Name________Clara________________________________________________ Date __04__/_08___/__24__ Page
___of___
Student ID Number__________________________________
PARTICIPATION IN STATEWIDE ASSESSMENTS
Test
Assessment Type*
(SOL, VSEP,VAAP) Accommodations** If yes, list accommodation(s)
Reading X ____SOL___________________________________
Not Assessed at this Grade Level
X Yes No
Extra time
Math X ____SOL___________________________________
Not Assessed at this Grade Level
X Yes No
Extra time
Science X ______SOL_________________________________
Not Assessed at this Grade Level
X Yes No
Extra time
History/SS X ________SOL_______________________________
Not Assessed at this Grade Level
X 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
___NA_______________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
__
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name_______Clara_________________________________________________ Date___4_/__08__/___24_ 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
Speech 2 times a week School 04/08/2024-04/05/2025
Math Services 5 times a week School 04/08/2024-04/05/2025
Reading services 5 times a week School 04/08/2024-04/05/2025
** 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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EDSP 473
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name_____Clara____________________________________________ Date__04__/_08___/__2024__ 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):
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:
We have found while going through the evaluation process Clara has a slight learning disability. Because of these
findings the IEP team has encouraged Clara to be placed in (LRE), which will take place in a general ed classroom.
Being placed in LRE she will receive the support that is needed for 60 minutes, 4 days a week.
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EDSP 473
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE AND PARENT CONSENT
Student Name_______Clara___________________________________________________ Date__04__/_08___/__24__
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.
I found writing this IEP very helpful for my future development. I understand the need of gathering any all
information before making a decision that is best for the student. Being that I just recently got a chance to see and be
part of an IEP meeting everything makes so much more sense to me. The way that everything connects for the good of
the student.
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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:
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EDSP 473
SECTION 2
Additional Forms
To Be Used
As Needed
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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
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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.
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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:
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 24 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
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 26 of 27
Summary of previous treatment if not addressed elsewhere:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________________________________
Intervention, treatment, and modalities if not addressed elsewhere:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________________________________
a
EDSP 473
Required for Billable Services
ICD9 Code _________________________ Medicaid Discharge Plan/Disposition
_______________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 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.
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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 #___
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 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 ___
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 33 of 27
