EDSP 521
Virginia Department of Education’s Sample IEP Form
For Use with Students up to Age Thirteen, as Appropriate
COMPLETE ALL COMPONENTS HIGHLIGHTED IN YELLOW
Davi Gannon
EDSP521
April 10, 2024
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 1 of 27
EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Student Name__Elli Smith________________________________________________ Date_4_/_10_/_2025_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.
_______________________________________________________________________________________________
Most Recent Evaluations:
Wechsler Individual Achievement Test – Third Edition (WIAT–III)
Subtests with age-based scores:
Listening Comprehension 90, Early Reading Skills 92, Reading Comprehension 79
Math Problem Solving 80, Alphabet Writing Fluency 96, Sentence Composition 90
Word Reading 72, Pseudoword Decoding 77, Numerical Operations 93
Oral Expression 95, Oral Reading Fluency 63, Spelling 80, Math Fluency – Addition 83, Math Fluency – Subtraction 89,
Oral Reading Accuracy 61
Oral Reading Rate 78,
Listening Comprehension
Receptive Vocabulary 81 Below Average
Oral Discourse Comprehension 103 Average
Sentence Composition
Sentence Combing 98 Average, Sentence Building 84 Below Average
Oral Expression
Expressive Vocabulary 85 Average, Oral Word Fluency 107 Average
Sentence Repetition 97 Average, Oral Language 91 Average
Total Reading 69 Low, Basic Reading 75 Below Average
Written Expression 85 Average
Mathematics 85 Average, Math Fluency 86 Average
Total Achievement 82 Below Average
Strengths:
Elli is an 8-year-old 2nd grade student who has been found eligible to receive special education services as s student with a
Specific Learning Disability. Elli is a cheerful and crafty young lady. She loves art class and going to the library. Elli is social
with her peers, a hard worker, and always ready for a challenge. Elli has demonstrated strength in spelling, adding, and
subtracting. She can also adapt previously learned, and memorized, sentence structures to the current topic being discussed.
Elli has also demonstrated great strength in decoding and solving word problems.
Areas of Need:
Elli’s greatest areas of need are that of long-term retrieval, associative memory, auditory processing, and phonemic
awareness. These areas of need, specifically phonemic awareness, makes reading and spelling of unfamiliar words a great
challenge for Elli.
Effect of Disability:
Elli’s diagnosis of Specific Learning Disability targets her reading and decoding skills. She can recall information that has
been read to her; however, if asked to read words herself, she struggles to put individual sounds together to form the words.
Her disability also is causing Elli to not advance her skill level beyond the pre-primer 1 range.
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EDSP 521
Academic Performance:
Elli demonstrates strong performances in math, science, and social studies. She also does well during her elective courses
(movement education and art). Elli struggles when it comes to reading and decoding words. She has stronger comprehension
skills when things are read aloud to her. She can also identify isolated sounds, but has difficulty putting the sounds together to
create a word. This causes her overall retention of words to be extremely week. She has been receiving Title 1 and PALS
Remediation to assist with these deficits; however, she has made little progress and continues to remain on a pre-primer 1
level.
Functional Performance:
Elli socializes appropriately with her peers. She is cheerful and easy to get along with. She does suffer with asthma, which
causes her to need constant access to her inhaler as well as regular check-ins with the school nurse.
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE, continued
Student Name__ Elli Smith _______________________________________________ Date_4_/_10_/_2025_Page ___of___
Student ID Number__________________________________
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE, continued.
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name___ Elli Smith ______________________________________________ Date_4_/_10_/_2025_Page ___of___
Student ID Number________________________________ Area of Need___Reading______________________________
# ___1__ MEASURABLE ANNUAL GOAL:
Given reading passages on a second-grade level, Elli Smith will use one vocabulary strategy (context clues) to learn the
meaning of unfamiliar words with 75% accuracy on 3 out of 4 observable opportunities by 4/9/25.
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.
SHORT-TERM OBJECTIVES:
Objective/Benchmark #___
Objective/Benchmark #___
Objective/Benchmark #___
How will progress toward this annual goal be measured? (check all that apply)
__X__ Classroom
Participation
____ Checklist
__X__ Classwork
____ 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.
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
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name___ Elli Smith ______________________________________________ Date_4_/_10_/_2025_ Page ___of___
Student ID Number________________________________ Area of Need___Written Expression______________________
# __2___ MEASURABLE ANNUAL GOAL:
Given sight words up to a 2nd grade level, Elli Smith will read each word and identify how many phonemes the word
contains with 75% accuracy on 3 out of 4 observable opportunities by 4/9/25.
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.
SHORT-TERM OBJECTIVES:
Objective/Benchmark #___
Objective/Benchmark #___
Objective/Benchmark #___
How will progress toward this annual goal be measured? (check all that apply)
__X__ Classroom
Participation
__X__ Checklist
__X__ Classwork
____ 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.
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
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name_____ Elli Smith ____________________________________________ Date_4_/_10_/_2025_Page ___of___
Student ID Number________________________________ Area of Need________________________________________
# __3___ MEASURABLE ANNUAL GOAL:
Given reading passages on a 2nd grade level, Elli Smith will increase her recognition and reading fluency with 75%
accuracy on 3 out of 4 observable opportunities by 4/9/25.
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.
SHORT-TERM OBJECTIVES:
Objective/Benchmark #___
Objective/Benchmark #___
Objective/Benchmark #___
How will progress toward this annual goal be measured? (check all that apply)
__X_ Classroom
Participation
__X__ Checklist
__X__ Classwork
____ 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.
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
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Student Name____ Elli Smith ____________________________________________ Date_4_/_10_/_2025_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, 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
Read Aloud As needed Liberty
Elementary
General Education
and Special
Education
Classroom
4/10/24 to 4/9/25
Access to a dictionary As needed Liberty
Elementary
General Education
and Special
Education
Classroom
4/10/24 to 4/9/25
Access to word processor As needed Liberty
Elementary
General Education
and Special
Education
Classroom
4/10/24 to 4/9/25
Break assignments into manageable
chunks
As needed on
phonics
assignments
Liberty
Elementary
General Education
and Special
Education
Classroom
4/10/24 to 4/9/25
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EDSP 521
* IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the
location of the services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the
parents do not indicate that they will object to any particular school or state that the team should identify a single school.
Supports for School Personnel: (Describe supports such as equipment, consultation, or training for school staff to meet the unique
needs for the student) __All personnel will be trained in how to properly work with Elli and implement this IEP to its
entirety.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
Student Name___ Elli Smith ______________________________________________ Date_4_/_10_/_2025_Page ___of___
Student ID Number__________________________________
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 next question.
Yes X 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)
Division-wide Assessment (list):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
*Refer to Students with Disabilities: Guidelines for Assessment Participation for additional guidance on the assessment programs.
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
(continued)
Student Name___ Elli Smith ______________________________________________ Date_4_/_10_/_2025_Page ___of___
Student ID Number__________________________________
PARTICIPATION IN STATEWIDE ASSESSMENTS
Test
Assessment Type*
(SOL, VSEP,VAAP) Accommodations** If yes, list accommodation(s)
Reading _______________________________________
X Not Assessed at this Grade Level
Yes No
Math _______________________________________
X Not Assessed at this Grade Level
Yes No
Science _______________________________________
X Not Assessed at this Grade Level
Yes No
History/SS _______________________________________
X Not Assessed at this Grade Level
Yes No
Writing _______________________________________
X 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.
Division-wide 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
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name__ Elli Smith _______________________________________________ Date_4_/_10_/_2025_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 instruction 60 minutes 1x a
day
Special Education
Classroom
4/10/24 to 4/9/25
Phonics instruction 60 minutes 1x a
day
Special Education
Classroom
4/10/24 to 4/9/25
** 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 521
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name__ Elli Smith _____________________________________________ Date_4_/_10_/_2025_Page ___of___
Student ID Number ___________________________________
Extended School Year Services (ESY): (see attached summary sheet as a means to document discussion)
The IEP team determined that the student needs ESY services.
The IEP team determined that the student does not need ESY services. Describe.
The IEP team will determine and/or address ESY services at a later date. Addressed by date:______________
Explain:
PLACEMENT
No single model for the delivery of services to any population or category of children with disabilities is acceptable for
meeting the requirement for a continuum of alternative placements. All placement decisions shall be based on the individual
needs of each student. The team may consider placement options in conjunction with discussing any needed supplementary
aids and services, accommodations/modifications, assistive technology and/or accessible materials, and supports for school
personnel. In considering the placement continuum options, check those the team discussed. Then, describe the placement
selected in the PLACEMENT DECISION section below. Determination of the Least Restrictive Environment (LRE) and
placement may be one or a combination of options along the continuum.
PLACEMENT CONTINUUM OPTIONS CONSIDERED: (check all that have been considered):
X general education class(es)
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:
Elli will benefit from participating in general education classes to maintain appropriate socialization with her same-aged
peers. Elli also requires access to special education classes to target her deficits in reading and phonemic awareness.
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE AND PARENT CONSENT
Student Name___ Elli Smith _____________________________________________ Date_4_/_10_/_2025_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
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EDSP 521
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 521
SECTION 2
Additional Forms
To Be Used
As Needed
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EDSP 521
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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EDSP 521
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 521
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:
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EDSP 521
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.
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EDSP 521
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 25 of 27
Summary of previous treatment if not addressed elsewhere:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________________________________
Intervention, treatment, and modalities if not addressed elsewhere:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________________________________
a
EDSP 521
Required for Billable Services
ICD9 Code _________________________ Medicaid Discharge Plan/Disposition
_______________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 26 of 27
EDSP 521
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 27 of 27
EDSP 521
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 521
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 29 of 27
EDSP 521
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 30 of 27
EDSP 521
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 32 of 27
