Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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Virginia Department of Education’s Sample IEP Form
For Use with Students up to Age Thirteen, as Appropriate
COMPLETE ALL COMPONENTS HIGHLIGHTED IN YELLOW
Teacher Candidate Name: Meredith Williamson
Course: EDUC 521
Date: May 8, 2020
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Student Name Elli Smith Date_5 / 8 / 20 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.
Elli Smith is a cheerful 8-year-old girl currently entering the 2nd grade. Elli was found eligible for service for
Specific Learning Disability. Elli loves school, her friends, enjoys art and anything craft related. She works hard and always
seems ready for a challenge. Elli also has asthma and needs access to her inhaler, as well as regular check-ins with the school
nurse.
According to the psychological evaluation, Elli demonstrates an overall ability in the average range. She
demonstrates substantially less developed long-term retrieval associative memory and auditory processing, specifically
phonemic awareness. These relative weaknesses coupled with difficulties in the aspect of auditory processing, such as
phonemic awareness, which is the understanding of the smallest units of sound (phonemes), might make the acquisition of
reading difficult. Also, the spelling of unfamiliar words might also prove to be a challenging task. Elli’s social functioning, as
assessed through rating scales, teacher interviews, and direct observation appears to be a challenging at times, but not a major
concern. According to achievement assessment, Elli demonstrates average oral language skills, mathematics and written
expression in the low average range with significant deficient range. Teacher reports indicate that Elli demonstrates an
independent reading level of pre-primer 1. Her auditory comprehension is very good, but her word attack is very poor. She
has received PALS remediation and Title I supports for reading for a period of 6 months and has made very minimal progress
despite supplemental instruction interventions targeting her identified areas of deficit.
Elli demonstrates substantially less developed long-term retrieval, associative memory, and auditory processing,
specifically phonemic awareness. These relative weaknesses coupled with difficulties in aspects of auditory processing, such
as phonemic awareness, which is the understanding of the smallest units of sound (phonemes), makes the acquisition of
reading difficult as well as the spelling of unfamiliar words.
Elli’s areas of need resulting from her disability related deficits include:
Decoding
Reading
Spelling
Written language
Prolonged or moderate/heavy physical activity (Asthma) Medical aspect, not related to the SLD category.
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Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued
Student Name Elli Smith Date 5 / 8 / 20 Page
of
Student ID Number
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued.
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
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name Elli Smith
of Date 5 / 8 /_20 Page
Student ID Number Area of Need Spelling
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 Class work
x Homework
Observation
Criterion-referenced test:
Norm-referenced test:
Other:
Special Projects
x Tests and Quizzes
Written Reports
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
ES - The student demonstrates Emerging Skill but may not
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.
# 1 MEASURABLE ANNUAL GOAL: By the next annual review, when given unfamiliar sight words at the 2nd
grade level, Elli will correctly spell 80% or higher on an assessment of spelling in 3 out of 4 trials.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name Elli Smith Date 5 / 8 / 20 Page of
Student ID Number Area of Need Reading
The IEP team considered the need for short-term objectives/benchmarks.
□ Short-term objectives/benchmarks are included for this goal. (Required for students participating in the VAAP)
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 Class work
x Homework
Observation
Criterion-referenced test:
Norm-referenced test:
Other:
Special Projects
x_ Tests and Quizzes
Written Reports
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
ES - The student demonstrates Emerging Skill but may not
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.
# 2 MEASURABLE ANNUAL GOAL: By the next annual review, when given phonemes within one-syllable
words on a 2nd grade level, Elli will correctly identify 80% or higher on an assessment of phoneme
identification in 13 out of 15 trials.
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* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name Elli Smith Date_5 / 8 / 20 Page of
Student ID Number Area of Need Retention
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 Class work
Homework
x Observation
Criterion-referenced test:
Norm-referenced test:
Other:
x Special Projects
x Tests and Quizzes
_x 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.
# 3 MEASURABLE ANNUAL GOAL: By the next annual review, when given a nonfiction text on a 2nd grade
level, Elli will correctly use prior content and knowledge to apply to current text 80% or higher on assessment
of comprehension in 4 out of 5 trials.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Page of
Student ID Number
Accommodations/modifications provided as part of the instructional and testing/assessment process will allow the student
equal opportunity to access the curriculum and demonstrate achievement. Accommodations/modifications also provide access
to nonacademic and extracurricular activities and educationally related settings. Accommodations/modifications based solely
on the potential to enhance performance beyond providing equal access are inappropriate.
Accommodations may be in, but not limited to, the areas of time, scheduling, setting, presentation and response including
assistive technology and/or accessible materials. The impact of any modifications listed should be discussed.
ACCOMMODATIONS/MODIFICATIONS (list, as appropriate)
Accommodation(s)/Modification(s)
Frequency
Location
(name of school
*)
Instructional
Setting
Duration
m/d/y to m/d/y
Reading tests to be taken orally
As needed
School
Classroom
08/12/2020-
05/10/21
* 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.
Student Name Elli Smith Date / /
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
Supports for School Personnel: (Describe supports such as equipment, consultation, or training for school staff to meet the unique
needs for the student)
There is no need for specific training to be done for teachers, but it is important that teachers or a paraprofessional reads
the test for Elli. The teacher or paraprofessional should only read-aloud, not aid in the test in any other way.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
Student Name Elli Smith Date _5 / 8 / 20 Page
of
Student ID Number
This student’s participation in state and divisionwide assessments must be discussed annually. During the duration
of this IEP:
Will the student be at a grade level or enrolled in a course for which the student must
participate in a state and/or divisionwide assessment? If yes, continue to next question.
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
X 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 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.
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
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
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 SOL
□
Not Assessed at this Grade Level
□Yes X No
Math
X SOL
□
Not Assessed at this Grade Level
□Yes X No
Science
□
X Not Assessed at this Grade Level
□Yes □No
History/SS
□
X Not Assessed at this Grade Level
□Yes □No
Writing
X SOL
□
Not Assessed at this Grade Level
□Yes X 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):
Student Name Elli Smith Date _5 / 8_/ 20_
EXPLANATION FOR NON-PARTICIPATION IN REGULAR STATE OR DIVISION-WIDE ASSESSMENTS
If an IEP team determines that a student must take an alternate assessment instead of a regular state assessment, explain in the
space below why the student cannot participate in this regular assessment; why the particular assessment selected is
appropriate for the student, including that the student meets the criteria for the alternate assessment; and how the student’s
nonparticipation in the regular assessment will impact the child’s promotion; or other matters. Refer to the VDOE’s Students
with Disabilities: Guidelines for Assessment Participation for guidance.
□
Alternate/Alternative Assessments Participation Criteria is attached or maintained in the student’s educational record
n/a
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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
Tutoring
3 hours a week
classroom
9/15/20 – 5/1/21
Speech therapy
30 minutes a day
Speech classroom
9/15/20 – 5/1/21
Nurse
Daily
Nurses office
9/15/20 – 5/1/21
** 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.
Student Name Elli Smith Date_5 / 8 / 20
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SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name Elli Smith Date 5 / 8 /_20 Page of
Student ID Number
Extended School Year Services (ESY): (see attached summary sheet as a means to document discussion)
The IEP team determined that the student needs ESY services.
The IEP team determined that the student does not need ESY services. Describe.
The IEP team will determine and/or address ESY services at a later date. Addressed by date:
Explain:
PLACEMENT
No single model for the delivery of services to any population or category of children with disabilities is acceptable for
meeting the requirement for a continuum of alternative placements. All placement decisions shall be based on the individual
needs of each student. The team may consider placement options in conjunction with discussing any needed supplementary
aids and services, accommodations/modifications, assistive technology and/or accessible materials, and supports for school
personnel. In considering the placement continuum options, check those the team discussed. Then, describe the placement
selected in the PLACEMENT DECISION section below. Determination of the Least Restrictive Environment (LRE) and
placement may be one or a combination of options along the continuum.
Based upon identified services and the consideration of least restrictive environment (LRE) and placement continuum
options, describe in the space below the placement. Additionally, summarize the discussions and decision around LRE and
placement. This must include an explanation of why the student will not be participating with students without disabilities in
the general education class(es), programs, and activities. Attach additional pages as needed.
X general education class(es)
❑
special class(es)
❑
special education day school
❑
state special education program / school
❑
Public residential facility
❑
Private residential facility
❑
Homebound
❑
Hospital
❑
Other
PLACEMENT CONTINUUM OPTIONS CONSIDERED: (check all that have been considered):
Explanation of Placement Decision:
Overall, Elli is a great student. She excels in math, social studies, science, art, and movement ED. The main areas of
need for Elli are reading, writing, pronouncing, and retention. Elli will benefit greatly from remaining in general
education classes with the help of a tutor or paraprofessional every day, three times a week while focusing on her areas
of need.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE AND PARENT CONSENT
Student Name Elli Smith Date 5 /_8 /_20 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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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:
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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SECTION 2
Additional Forms
To Be Used
As Needed
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ELEMENTARY INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PROCESS CHECKLIST
❑
Meeting notices sent to parent and agency representatives, as appropriate
❑
Acquire written consent from parent for an agency representative to attend the IEP meeting
❑
Welcome and introductions of team members
❑
Review purpose of meeting
❑
Review meeting agenda
❑
Review rights and procedural safeguards pertaining to special education and the IEP meeting
❑
Review of special factors to be considered by the IEP team
❑
Develop Present Level of Academic Achievement and Functional Performance
❑
Develop measurable annual goals
(Discuss progress report on previous annual goals, as needed.)
❑
Determine progress report schedule
❑
Document that the IEP team considered the need for short-term objectives or benchmarks for students other than
those who take alternate assessments aligned to alternate achievement standards
❑
Develop short-term objectives or benchmarks for the annual goals, as needed
❑
Determine any needed accommodations and/or modifications in instruction and assessment
❑
Determine participation in state and divisionwide assessments
❑
Determine services and placement
❑
Determine if student needs ESY services
❑
Review any requests proposed and/or refused
❑
Provide prior written notice and obtain parental consent
❑
Identify how staff will be informed of their responsibilities for implementation of the IEP
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Special Education Meeting Notice
(School Division Letterhead)
Date:
To: and
Parent(s)/Adult Student Student (if appropriate or if transition will be discussed)
You are invited to attend a meeting regarding
Student’s Name
PURPOSE OF MEETING (check all that apply):
IEP Development or Annual Review
IEP Amendment
Team Review of Referral
Team Review of Existing Data
Transition: PartC to Part B
Eligibility Determination
Team Determination of Needed Data
Transition: Postsecondary Goals, Transition Services
Manifestation Determination
Other:
The meeting has been scheduled for:
Date Time Location
Meetings are scheduled at a mutually agreed upon place and time by you and the school division. If you are
unable to attend this meeting you may request participation through other means. If you are unable to attend this
meeting, please contact:
Special Education Staff Contact / IEP Case Manager Title Phone
You and the school division may invite individuals to participate in the team meeting who have knowledge or
expertise about the student’s educational needs. The determination of the knowledge or special expertise shall be
made by the party who invited the individual. For IEP Meetings, if the division intends to invite a representative
of an agency that is likely to be responsible for providing or paying for transition services to the IEP meeting,
written consent of the parent or adult student is required.
Below is a list of the participants (by name or position) the division will be inviting to attend the meeting:
Please review and return the following page to assist the school staff in preparing for the meeting.
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Special Education Meeting Notice Parent/Student Response Form
To the Parent(s) / Guardian(s) / Student:
Student: Date of Meeting:
Please check your choice and return this page
to:
at
I the parent student will attend the meeting as scheduled.
I the parent student cannot attend the meeting as scheduled. Please reschedule this
meeting.
I can attend on at
(date) (time and place)
Please contact me at
to determine a mutually agreeable date, time, and place for this IEP meeting.
I the parent student do not wish to attend this meeting even though I understand the
importance of attending. You may hold this meeting in my absence.
I the parent student would like my preferences, interests, and concerns shared with the
team. I will provide my input to you by:
Mail Telephone Other means: prior to the meeting.
□
An IEP worksheet is enclosed.
□
I will need the following accommodations for this IEP meeting:
□
I plan to bring individuals that I believe have knowledge or expertise regarding my child.
Parent Signature Date
Date received by the school:
Virginia Department of Education -- Sample IEP Form—Revised August, 2015
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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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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
COVER PAGE – MEDICAID ELIGIBLE STUDENTS
Student Name Page of
Student ID Number Medicaid/FAMIS # Grade
DOB / / Age* Disability(ies) (if identified)
Parent (s)Name Email
Home Address Primary ( )
Secondary ( )
Date of IEP meeting…………………...…………………….……………………….....……..………….. / /
Date parent notified of IEP meeting………………………………..……………………...……………… / /
This IEP will be reviewed no later than ………..…………………….……………..……….…………… / /
Most recent eligibility date…………………………….…………………………………….……………. / /
Next re-evaluation, including eligibility, must occur before ………..……..…………..…..…………….. / /
Copy of IEP given to parent (Name) On (Date) / /
IEP Teacher/Manager Phone Number ( )
PARTICIPANTS INVOLVED:
The list below indicates that the individual participated in the development of this IEP and the placement decision; it does not
authorize consent. Parent consent is indicated on the “Prior Notice” page.
NAME OF PARTICIPANT POSITION
Summary of previous treatment if not addressed elsewhere:
Intervention, treatment, and modalities if not addressed elsewhere:
a
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Required for Billable Services
ICD9 Code Medicaid Discharge Plan/Disposition
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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.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT, continued
Student Name Date / / Page of
Student ID Number Area of Need
# MEASURABLE ANNUAL GOAL:
The IEP team considered the need for short-term objectives/benchmarks.
□
Short-term objectives/benchmarks are included for this goal. (Required for students participating in the VAAP)
□
Short-term objectives/benchmarks are not included for this goal.
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
ES -The student demonstrates Emerging Skill but may not
IP -The student has demonstrated Insufficient Progress
to meet this annual goal and may not achieve this goal
within the duration of this IEP.
achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction on
this goal.
M -The student has Mastered this annual goal.
* Progress reports will be provided at least as often as parents are informed of the progress of their children without
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:
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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 #
Objective/Benchmark #
Objective/Benchmark #
Objective/Benchmark #
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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
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
EXTENDED SCHOOL YEAR SERVICES (ESY)
(Optional)
Student Name Date / / Page of
Student ID Number
Identify the Extended School Year services needed to meet these goals:
Service(s)
Frequency
**School/location
Instructional
Setting
(classroom)
Duration
m/d/y to m/d/y
** IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the location of the
services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the parents do not indicate that they
will object to any particular school or state that the team should identify a single school.
Summarize the IEP team’s discussions and decision about ESY:
If ESY services are to be provided identify which goals in the current IEP will be addressed by the ESY services:
