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
EDSP 521
June 8, 2025
INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
__ 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.
Academic Performance
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 61Oral Reading Rate 78
Listening Comprehension Receptive Vocabulary 81 Below Average
Oral Discourse Comprehension 103
Average Sentence Composition Sentence Combining 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
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 1 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
Functional Strengths
Elli is a joyful student. She loves school and gets along well with her peers. She strives to do her best work and can complete
preferred classwork assignments independently. She is always up for a challenge despite her disability. She enjoys library
and likes art and crafts.
Academic Strengths
READING-- Elli demonstrates comprehension of text by recalling key events and answering questions about the story that
has been read to her. Her listening comprehension is great.
MATH—Elli is meeting grade level standards for her grade level concepts, including adding and subtracting, word problems,
and solving.
INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
__ Page ___of___
Student ID Number__________________________________
SCIENCE AND SOCIAL STUDIES—Elli does well in both classes.
Academic Needs
READING-- Elli is not yet demonstrating grade-level decoding skills and reading fluency skills. She has received PALS and Title I
reading interventions and has made minimal progress. Elli’s reading difficulties impact her ability to access grade-level
curriculum and demonstrate comprehension knowledge independently in reading.
WRITING—Elli is a great speller because she memorizes the words, but she can’t read the words she spells. Her deficiency in
phonemic awareness results in difficulties spelling unfamiliar words.
Other Needs
In PE, she will need access to her inhaler and regular check-ins with the school nurse because she has Asthma.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 2 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
__ Page ___of___
Student ID Number__________________ Area of Need: Reading ________________________________________
# __1___ MEASURABLE ANNUAL GOAL: Reading
Given a 2nd grade level reading passage, Elli will use semantic clues, suffixes, and prefixes to identify the meaning of
unfamiliar words during small or whole group instruction with 80% accuracy or more in 4 out of 5 observed opportunities by
the next annual review.
The Virginia SOL number related to this goal: 2.6, 2.7
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)
____ Classroom Participation
____ Checklist
__x__ Classwork
____ Homework
__x__ Observation
____ Criterion-referenced
test:_________________________
____ Norm-referenced test:
___________________________
__x__ Other: ____Data collection _____________
____ Special Projects
____ Tests and Quizzes
____ Written Reports
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
ES - The student demonstrates Emerging Skill but may not
IP -The student has demonstrated Insufficient
Progress to meet this annual goal and may not
achieve this goal within the duration of this IEP.
achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction
on this goal.
M -The student has Mastered this annual goal.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 3 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 4 of 24
EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
__ Page ___of___
Student ID Number________________________________ Area of Need: Decoding real words or nonsense words ______
# __2___ MEASURABLE ANNUAL GOAL: Decoding
Given a 2nd grade level word list or pseudowords during small group instruction or assessment, Elli Smith will sound out and
decode unfamiliar grade-level words using phonetic strategies with 80% accuracy or more in 4 out of 5 observed
opportunities by the next annual review.
The Virginia SOL number related to this goal: 2.5
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)
____ Classroom Participation
____ Checklist
__x__ Classwork
____ Homework
__x__ Observation
____ Criterion-referenced
test:_________________________
____ Norm-referenced test:
___________________________
___x_ Other: date collection
____ Special Projects
__x__ Tests and Quizzes
____ Written Reports
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
ES - The student demonstrates Emerging Skill but may not
IP -The student has demonstrated Insufficient
Progress to meet this annual goal and may not
achieve this goal within the duration of this IEP.
achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction
on this goal.
M -The student has Mastered this annual goal.
* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 5 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
__ Page ___of___
Student ID Number________________________ Area of Need: Reading comprehension
# ___3__ MEASURABLE ANNUAL GOAL: Reading comprehension
Given a 2nd grade level reading passage, Elli Smith will read and answer comprehension questions of fictional and
nonfictional texts in small or whole group instruction using visual support with 90% accuracy in 9 out of 10 observed
opportunities by the next annual review.
The Virginia SOL number related to this goal: 2.8, 2.9
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)
____ Classroom Participation
____ Checklist
__x__ Classwork
____ Homework
___x_ Observation
____ Criterion-referenced
test:_________________________
____ Norm-referenced test:
___________________________
__x__ Other: date collection ________
____ Special Projects
__x__ Tests and Quizzes
____ Written Reports
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
ES - The student demonstrates Emerging Skill but may not
IP -The student has demonstrated Insufficient
Progress to meet this annual goal and may not
achieve this goal within the duration of this IEP.
achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction
on this goal.
M -The student has Mastered this annual goal.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 6 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
__ 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
Audio Test On all state,
district, and
summative
classroom
assessments when
reading is not
being assessed
Assigned School General and
special Education
classroom
06/09/2025-
06/08/2026
Small group testing When classroom
assessments are
given
Assigned School General and
special Education
classroom
06/09/2025-
06/08/2026
Read aloud (except on reading
assessments)
When non-reading
assessments are
given
Assigned School General and
special Education
classroom
06/09/2025-
06/08/2026
Extended time On classroom
reading and
writing
assignments
Assigned School General and
special Education
classroom
06/09/2025-
06/08/2026
Graphic organizer To support
completion of
Assigned School General and
special Education
06/09/2025-
06/08/2026
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 7 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
multistep writing
tasks
classroom
Visual support To support
completion of
multistep writing
tasks
Assigned School General and
special Education
classroom
06/09/2025-
06/08/2026
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
__ Page ___of___
Student ID Number___________________________________
* 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) __
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
______________________________________________________________________________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 8 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
__ 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 xYes No state
and/or division-wide assessment? If yes, continue to next question.
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) Yes xNo
Reading Math Science History/Social Science Grade 8 Writing
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 Yes xNo considered. (Grades 3-
8 only)
Reading Math Science History/Social Science Grade 8 Writing
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 Yes xNo Students with Disabilities:
Guidelines for Assessment Participation for guidance.
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 Yes xNo based on Aligned Standards of
Learning? If yes, complete the “VAAP Participation Criteria”.
Does the student meet VAAP participation criteria? Yes xNo
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.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 9 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM (continued)
__ 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
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 10 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
INDIVIDUALIZED EDUCATION PROGRAM (IEP) SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
__ 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
English/ Language Arts instructions Push-
in support on all reading tasks
30 min 5 time(s) a
week
General Education
setting
06/09/2025- 06/08/2026
Reading Instructions 40 min 5 time(s) a
week
Special Education
setting
06/09/2025- 06/08/2026
Written language instruction Push-
in support
30 min 5 time(s) a
week
General Education
setting
06/09/2025- 06/08/2026
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 11 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
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.
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
__ 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 demonstrates impairments in the areas of reading comprehension skills, orthographic processing, and learning efficiency
as a result of a Specific Learning Disability, which affects her word recognition, oral reading fluency, and reading
comprehension. Elli requires specially designed instruction and support in the areas of basic reading skills and reading
comprehension across curricular areas.
Elli will participate with her non-disabled peers during the majority of the school day. Elli will not participate with
nondisabled peers, while in the special education setting, for 40 minutes, 5 times weekly, during small group reading
instruction to support her decoding, encoding, reading fluency, and reading comprehension.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 12 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE AND PARENT CONSENT
__ Page ___of___ Student
ID Number___________________________________
PRIOR NOTICE
The school division proposes to implement this IEP. This proposed IEP will allow the student to receive a free appropriate
public education in the least restrictive environment. This decision is based upon a review of current records, current
assessments and the student’s performance as documented in the Present Level of Academic Achievement and Functional
Performance. Other options considered, if any, and the reason(s) for rejection are attached, or can be found in the
Placement Decision section of this IEP. Additionally, other factors, if any that are relevant to this proposal are attached.
Parent and adult student rights are explained in the Procedural Safeguards. If you, the parent(s) and adult student, need
another copy of the
Procedural Safeguards or need assistance in understanding this information please contact
________________________________ at (___) ____________ or e-mail ________________________________ or
________________________________ at (___) ____________ or e-mail ________________________________ .
____ Parent(s) initials here indicate that the parent(s) has read the above prior notice and attachments, if any, before giving
permission to implement this IEP.
PARENT/ADULT STUDENT CONSENT: Indicate your response by checking the appropriate space and sign below.
___ I give permission to implement this IEP.
___ I do not give permission to implement this IEP.
____________________________________________________ ____/____/____
Parent Signature Date
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:
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 13 of 24
Student Name: Elli Smith__________________________________ Date_6_/_8_/_2025
EDSP 521
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:
SECTION 2
Additional Forms
To Be Used
As Needed
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 14 of 24
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
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 ____________________________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 15 of 24
EDSP 521
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
Eligibility Determination
Team Determination of Needed Data
Transition: Postsecondary Goals, Transition Services
Manifestation Determination
Other: ____________________________
Transition: PartC to Part B
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.
Special Education Meeting Notice Parent/Student Response Form
To the Parent(s) / Guardian(s) / Student:
Student: Date of Meeting:
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 16 of 24
Please check your choice and return this page to:
EDSP 521
I the
I the
Please contact me at
to determine a mutually agreeable date, time, and place for this IEP meeting.
I thestudent do not wish to attend this meeting even though I understand the importance of
attending. You may hold this meeting in my absence.
I thestudent 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 received by the school:
Date
SAMPLE
School Division Letterhead
CONSENT TO INVITE AGENCY PERSONNEL
Date: _____________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 17 of 24
a
t
paren
t
studen
t
will attend the meeting as
scheduled.
paren
t
studen
t
cannot attend the meeting as scheduled. Please reschedule this
meeting.
I can attend
on
a
t
(dat
e
) (time and
place
)
pare
nt
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EDSP 521
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.
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…………………………….…………………………………….……………._____/_____/_____
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 18 of 24
EDSP 521
Next re-evaluation, including eligibility, must occur before ………..……..…………..…..…………….._____/_____/_____
Copy of IEP given to parent (Name) _____________________________________________ On (Date)_____/_____/_____
IEP Teacher/Manager_________________________________________ Phone Number (____)______________________
Summary of previous treatment if not addressed elsewhere:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________________________________
Intervention, treatment, and modalities if not addressed elsewhere:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________________________________
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
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
Required for Billable Services
ICD9 Code _________________________ Medicaid Discharge Plan/Disposition _______________________________
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
healthrelated 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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 19 of 24
EDSP 521
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.
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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 20 of 24
EDSP 521
How will progress toward this annual goal be measured? (check all that apply)
____ Classroom Participation ____ Observation
____ Checklist ____ Special Projects ____ Criterion-referenced
____ Class work ____ Tests and Quizzes test:_________________________ ____ Homework ____ Written
Reports ____ 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.
ES -The student demonstrates Emerging Skill but may not
IP -The student has demonstrated Insufficient
Progress to meet this annual goal and may not
achieve this goal within the duration of this IEP.
achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction
on this goal.
M -The student has Mastered this annual goal.
* Progress reports will be provided at least as often as parents are informed of the progress of their children without
disabilities.
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 #___
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 21 of 24
EDSP 521
Objective/Benchmark #___
Objective/Benchmark #___
Objective/Benchmark #___
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PROGRESS REPORT COMMENTS, Continued (This document is optional)
Student Name__________________________________________________________ Date____/____/____ Page ___of___
Student ID Number________________________________
Goal #___ Progress Report Code ___
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 22 of 24
EDSP 521
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
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:
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 23 of 24
EDSP 521
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 24 of 24
