Needs to be completed Important Information for this assignment IEP Information EDSP 524
IEP: DEVELOPMENT TEMPLATE
INDIVIDUALIZED EDUCATION PROGRAM
COVER PAGE
Student Name Bryan Jones Page ___ of ___
Student ID Number_____________123456789_________________________________________________ Grade: 6
DOB: Age 11 Disability(ies) _____________Specific Learning Disability (SLD)_________________
Parent(s) Name: Tom and Anne Jones_______________________Email: [email protected]_______________________
Home Address: __123 Mains Street________________________________Primary (123) 456-7890
____________________________________________________ Secondary (____)____________________
Date of IEP meeting…………………...…………………….……………………….....……..………….._____/_____/_____
Date parent notified of IEP meeting………………………………..……………………...………………_____/_____/_____
This IEP will be reviewed no later than ………..…………………….……………..……….……………_____/_____/_____
Most recent eligibility date…………………………….…………………………………….……………._____/_____/_____
Next re-evaluation, including eligibility, must occur before ………..……..…………..…..…………….._____/_____/_____
Copy of IEP given to parent (Name) _____________________________________________ On (Date)_____/_____/_____
IEP Teacher/Manager_________________________________________ Phone Number (____)______________________
The Individualized Education Plan (IEP) that accompanies this document is meant to support the positive process and team
approach. The IEP is a working document that outlines the student’s vision for the future, strengths, and needs. The IEP is
not written in isolation. The intent of an IEP is to bring together a team of people who understand and support the student in
order to come to consensus on a plan and an appropriate and effective education for the student. No two teams are alike and
each team will arrive at different answers, ideas, and supports and services to address the student’s unique needs. The student
and his/her family members are vital participants, as well as teachers, assistants, specialists, outside service providers, and the
principal. When all team members are present, the valuable information shared supports the development of a rich student
profile and education plan.
PARTICIPANTS INVOLVED:
The list below indicates that the individual participated in the development of this IEP and the placement decision; it
does not authorize consent. Parent consent is indicated on the “Prior Notice” page.
NAME OF PARTICIPANT (EDSP 524 student) POSITION
__________john doe_____________________________________ Parent________________________________
___________john doe______________________________________ Special Education Teacher/ Case Manager_
________Kathleen Bradley______________________________ General Education Teacher______________
_________John Doe____________________________________ Administrator_________________________
_____________________________________________________ ____________________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
INDIVIDUALIZED EDUCATION PROGRAM
FACTORS FOR IEP TEAM CONSIDERATION
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number: 123456789_
During the IEP meeting, the following factors must be considered by the IEP team. Best practice suggests that the IEP team
document that the factors were considered and any decision made relative to each. The factors are addressed in other sections
of the IEP if not documented on this page (for example: see Present Level of Academic Achievement and Functional
Performance).
1. Results of the initial or most recent evaluation of the student;
See PLAAFP
2. The strengths of the student;
See PLAAFP
3. The academic, developmental, and functional needs of the student;
See PLAAFP
4. The concerns of the parent(s) for enhancing the education of their child;
See PLAAFP
5. The communication needs of the student;
See PLAAFP
6. The student’s needs for benchmarks or short-term objectives;
See PLAAFP
7. Whether the student requires assistive technology devices and services. When considering whether assistive technology is
required, the IEP team may refer to the Virginia Assistive Technology Resource Guide to facilitate the discussions about goals
and objectives, areas of difficulty, and whether AT devices or services are needed, and whether accessible instructional
materials in alternate formats are needed.
See PLAAFP
8. In the case of a student whose behavior impedes his or her learning or that of others, consider the use of positive
behavioral interventions, strategies, and supports to address that behavior;
See PLAAFP
9. In the case of a student with limited English proficiency, consider the language needs of the student as those needs relate
to the student’s IEP;
The student does not have limited English proficiency.
10. In the case of a student who is blind or is visually impaired, provide for instruction in Braille and the use of Braille
unless the IEP team determines after an evaluation of the student’s reading and writing skills, needs, and appropriate reading
and writing media, including an evaluation of the student’s future needs for instruction in Braille or the use of Braille, that
instruction in Braille or the use of Braille is not appropriate for the student. When considering that Braille is not appropriate
for the child the IEP team may use the Functional Vision and Learning Media Assessment for Students who are Pre-Academic
or Academic and Visually Impaired in Grades K-12 (FVLMA) or similar instrument; and
The student is not blind or visually impaired.
11. In the case of a student who is deaf or hard of hearing, consider the student’s language and communication needs,
opportunities for direct communications with peers and professional personnel in the student’s language and communication
mode, academic level, and full range of needs, including opportunities for direct instruction in the student’s language and
communication mode. The IEP team may use the Virginia Communication Plan when considering the student's language and
communication needs and supports that may be needed. The student is not deaf or hard of hearing.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number: 123456789_
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.
_______________________________________________________________________________________________
Bryan is 12-year-old African American male in the 6th grade. Bryan has been diagnosed with Dyslexia,
Dyscalculia, and ADHD (inattentive subtype) and was found eligible for special education services for a Specific
Learning Disability (SLD).
Bryan loves art, music, and excels in PE. His favorite sport is soccer. Bryan is an only child and lives at home
with both parents. His parents are very supportive and involved in his education. Bryan struggles with
inattentiveness and distractibility when working independently but actively participates in whole class and small
group discussions. Brian is generally compliant and respectful toward his teachers and peers.
An Assistive Technology Evaluation was performed which indicates Bryan’s proficient use of the technology and
need for it to access the general education curriculum. Below is a summary of Bryan’s most recent cognitive test
scores. Using the Wechsler Intelligence Scale for Children - Fourth edition (WISC-IV), Bryan scored a Full-Scale
IQ of 96.
Standard Score Percentile
Rank
95% Confidence
Interval
Verbal Comprehension Index 112 79 105-118
Perceptual Reasoning 94 34 87-102
Working Memory Index 77 6 71-86
Processing Speed Index 97 42 88-106
Full Scale IQ 96 39 91-101
General Ability Index 104 61 99-109
Reading is an area of weakness for Bryan. Subtests of the Brigance Reading Inventory indicate he struggles to
decode unfamiliar words. Although he can successfully substitute consonant sounds and long and short vowel
sounds in simple words, he has difficulty with multisyllabic words and vowel combinations. He does not identify
root words, prefixes, and some suffixes. According to the STAR Reading Assessment which assesses reading
comprehension, administered on May 20, 2019, Bryan is able to read passages and answer comprehension
questions related to the passage at the 4.2 grade level. Results of the assessments and teacher observation indicate
that his reading instructional level is at the 4th grade which will affect his involvement and progress in the 6th-
grade general curriculum. Comprehension difficulties were also identified using both narrative and expository
reading passages from the Qualitative Reading Inventory. Miscues in recognizing word parts and letter cues were
observed in third and fourth-grade passages for both familiar and unfamiliar topics. Fifth and sixth-grade passages
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
are challenging, at the frustration level, for Bryan, with word by word oral reading, 12 self-corrections, and 5 out
of 8 correct comprehension questions. Bryan’s ability to listen and comprehend the concepts and information in
expository texts (Science and History) is better than his ability to read the texts independently. He experiences
difficulty determining story elements including main idea and details and recalling and retelling information after
reading. He relies on his background knowledge of the topics to answer comprehension questions and is often
unable to look back and locate information in the text he has just read. When he is struggling to decode the text,
he does not appear to monitor his comprehension.
In written language, Bryan is able to spell words for the spelling test, but due to memory issues, the same words
are often misspelled in his written work. When asked to write answers to text questions and other written
narratives, he writes brief responses in simple sentences with limited choice of vocabulary. Samples of his written
work show consistent mistakes in spelling, punctuation, and paragraph structure. His handwriting is very
laborious and he often has trouble reading back what he has written which contributes to his challenges in
completing assignments in content areas and homework. Bryan has benefited from the use of a word processor,
spell checking tools, word prediction programs, and opportunities to respond orally, either by supplementing or
replacing written responses, and these accommodations tend to reflect a more in-depth understanding of the topic.
Bryan was administered the STAR Math Assessment which assesses skills expected at grade level. He scored a
grade equivalent score of 4.1. Results indicated a weakness in completing multi-step problems through the test
items that addressed solving a multi-step problem involving decimals and whole numbers and using estimation to
solve a multi-step practical problem. Due to his weakness in reading, Bryan will not achieve grade-level
proficiency without a read-aloud accommodation for word problems and a checklist of pictorial steps to reference
when solving multi-step equations to address his weakness in organization. The successful use of these
accommodations was evidenced by his passing performance on the SOL Math Assessment administered in early
May.
Bryan’s teacher observes the following: “Bryan struggles with multi-step problems, he also does not recognize
how to attack word problems. Bryan counts with his fingers and uses his finger to solve simple calculations.
Bryan refuses to use a multiplication chart but does not know his facts. Bryan does not show his work and does
not ask for help. His parents help with homework every day and I have gotten a lot of emails about his inability to
fully understand the concepts that are being covered in class. He gets frustrated easily and shuts down. Bryan
does not verbalize his answers and does not like being questioned about the process he uses.”
Bryan’s parents state the following: “We are concerned about how far behind Bryan is in reading, as well as math.
He spends 1-2 hours a night on homework and struggles to finish written and reading assignments independently.
He seems to have an aversion to math. He struggles to count on or use strategies to solve problems. However, it
seems like he understands these ideas conceptually but cannot do the actual math. We want Bryan to go to college
and be algebra ready by 9th grade. We know he is bright, and we know that there is a “block” right now.”
In an information interview with Bryan, he stated: “I do not like reading and writing. Math is really hard at school,
but I can do math at home. Like I can help my dad with construction projects, and I understand the ideas. I also
use math in my coding that I do for fun. But in the classroom, I just get lost, and when I’m trying to figure out
one answer the class has moved on to the next problem.” When asked why he doesn't use the multiplication chart
he stated “Then everyone knows that I don't know it. I’m tired of feeling stupid in math class.”
At this time, the IEP team feels that Bryan will achieve grade-level proficiency within the year, with
accommodations and modifications. Bryan loves science and is particularly interested in animals but due to his
age, no transitional goals are required at this time.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number123456789 Area of Need: Reading
# __1___ MEASURABLE ANNUAL GOAL: Given a 6th-grade narrative text, Bryan will accurately identify the main
characters, setting, and major events in the plot, with 80% accuracy on three out of four trials
VA SOL: English 6.3: The student will read and demonstrate comprehension of nonfiction texts.
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)
X 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
__X__ Class work
____ Homework
__X__ Observation
____ Special Projects
_X___ Tests and Quizzes
__X__ Written Reports
____ Criterion-referenced test:_________________________
____ Norm-referenced test: ___________________________
____ Other: ________________________________________
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
IP -The student has demonstrated Insufficient Progress
to meet this annual goal and may not achieve this goal
within the duration of this IEP.
ES - The student demonstrates Emerging Skill but may not
achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction on
this goal.
M -The student has Mastered this annual goal.
* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number 123456789 Area of Need: Reading
# __2___ MEASURABLE ANNUAL GOAL: When presented with a 6th-grade informational text, Bryan will identify the
main idea, locate relevant details, and summarize the content accurately, achieving 70% accuracy on three out of four
trials
VA SOL: English 6.7: The student will write coherently, with a clear focus, sufficient detail, and proper organization, using
appropriate conventions of language.
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)
X 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
__X__ Class work
____ Homework
_X___ Observation
____ Special Projects
_X___ Tests and Quizzes
_X___ 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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number123456789 Area of Need: Math
# __3___ MEASURABLE ANNUAL GOAL: Given multi-step word problems involving decimals and whole numbers,
Bryan will solve them accurately using estimation and a checklist of pictorial steps, achieving 70% accuracy on three
out of four trials
VA SOL: Mathematics 6.5: The student will solve single-step and multistep practical problems, using proportional reasoning.
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)
X 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
__X__ Class work
____ Homework
_X___ 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.
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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
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
Needs to be completed Important Information for this assignment IEP Information EDSP 524
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number: 123456789 Area of Need: Math
# __4___ MEASURABLE ANNUAL GOAL: Bryan will accurately solve multiplication and division problems involving
whole numbers and decimals without using his fingers, demonstrating mastery on at least 80% of problems on
assessments on three out of four trials.
VA SOL: Mathematics 6.4: The student will compute with decimals, including round numbers to a specified place value,
compare and order decimals, and solve single-step and multistep practical problems involving decimals.
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)
X 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
_X___ Class work
____ Homework
__X__ 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.
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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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Needs to be completed Important Information for this assignment IEP Information EDSP 524
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
Needs to be completed Important Information for this assignment IEP Information EDSP 524
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number: 123456789
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 Goal 1: Given a 6th-grade
narrative text, Bryan will accurately
identify the main characters, setting,
and major events in the plot, with
80% accuracy on three out of four
trials
Accommodation: Provide Bryan
with access to audio versions of the
narrative texts and utilize text-to-
speech software, allow him to
respond orally and use a word
processor.
Weekly Middle School small group
reading sessions
September 1,
2023, to May 15,
2024.
Reading Goal 2: When presented
with a 6th-grade informational text,
Bryan will identify the main idea,
locate relevant details, and
summarize the content accurately,
achieving 70% accuracy on three out
of four trials
Accommodation: Audio versions of
the texts, utilize text-to-speech
software, use graphic organizers.
Weekly Middle School individualized
reading sessions
September 1,
2023, to May 15,
2024.
Math Goal 1: Given multi-step word
problems involving decimals and
whole numbers, Bryan will solve
them accurately using estimation and
a checklist of pictorial steps,
achieving 70% accuracy on three out
of four trials
Weekly Middle School math problem-
solving sessions
September 1,
2023, to May 15,
2024.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
Accommodation: Provide read-
aloud accommodation, offer a
checklist of pictorial steps, and allow
use of a multiplication chart.
Math Goal 2: Bryan will accurately
solve multiplication and division
problems involving whole numbers
and decimals without using his
fingers, demonstrating mastery on at
least 80% of problems on
assessments on three out of four
trials.
Accommodation: Allow use of
multiplication charts and calculators
as needed.
Weekly Middle School math practice
sessions
September 1,
2023, to May 15,
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.
Supports for School Personnel: (Describe supports such as equipment, consultation, or training for school staff to meet the unique
needs of the student):
1. Assistive Technology Training:
Provide training to teachers on how to effectively integrate and support Bryan's use of assistive technology tools, such as
text-to-speech software, word processors, and spelling and grammar checking tools. This training should help teachers
understand how these tools can improve Bryan's reading and writing skills.
2. Differentiated Instruction Workshops:
Organize workshops for teachers on differentiated instruction strategies tailored to students with specific learning
disabilities. This training should equip teachers with strategies to modify content, assignments, and assessments to match
Bryan's learning style and needs.
3. Multi-Sensory Reading Approach:
Provide training to reading teachers on multi-sensory reading approaches, such as the Orton-Gillingham method, which
can be effective for students with dyslexia. This training can help teachers develop techniques that combine auditory,
visual, and kinesthetic elements to enhance Bryan's reading skills.
4. Math Problem-Solving Strategies:
Offer professional development sessions for math teachers focused on effective problem-solving strategies for students
with math difficulties. This training should help teachers provide additional guidance and resources to support Bryan's
understanding and application of math concepts.
5. Behavior Management Strategies:
Provide training to teachers on effective behavior management techniques that can help address Bryan's inattentiveness
and distractibility. Strategies could include positive behavior interventions, frequent check-ins, and providing clear
expectations.
6. Inclusive Classroom Practices:
Train all teachers involved in Bryan's education on inclusive classroom practices that foster a supportive and inclusive
learning environment. This training can help teachers create a classroom culture where all students feel valued and
supported.
7. Collaboration with Special Education Team:
Promote regular collaboration between Bryan's general education teachers and the special education team. This
collaboration can ensure that teachers are aware of Bryan's specific needs, accommodations, and progress, allowing for
more tailored instruction and support.
8. Parent Communication Workshops:
Offer workshops for teachers on effective communication strategies with parents, especially when working with students
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
who have specific learning disabilities. This training can help teachers maintain a strong partnership with Bryan's parents
and keep them informed about his progress and any challenges.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number: 123456789
This student’s participation in state and division-wide 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 the next question.
X 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 X 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 X 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 X 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 X No
Does the student meet VAAP participation criteria? Yes X 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.
__X 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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
(continued)
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number: 123456789
PARTICIPATION IN STATEWIDE ASSESSMENTS
Test
Assessment Type*
(SOL, VSEP, VAAP) Accommodations** If yes, list accommodation(s)
Reading _______________________________________
Not Assessed at this Grade Level
Yes No
Math _______________________________________
Not Assessed at this Grade Level
Yes No
Science _______________________________________
Not Assessed at this Grade Level
Yes No
History/SS _______________________________________
Not Assessed at this Grade Level
Yes No
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
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number: 123456789
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
Co-taught math and reading daily ABC Middle School/
General Education
Classroom
9/1/19 – 6/15/20
** 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
Needs to be completed Important Information for this assignment IEP Information EDSP 524
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number: 123456789
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.
X 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)
X 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:
Bryan is able to fully participate and succeed in the general education classroom with accommodations and modifications. He
will participate in all classes and activities with his peers.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
Needs to be completed Important Information for this assignment IEP Information EDSP 524
PRIOR NOTICE AND PARENT CONSENT
Student Name: ___ Bryan Jones __________ Date ____/____/____ Page _____ of _____
Student ID Number: 123456789
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.
_X__ I give permission to implement this IEP.
___ I do not give permission to implement this IEP.
____Kathleen Bradley________________________________________________ __8__/_28___/_23___
Parent Signature Date
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
