INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Student Name_Elli Smith_____________________________________________ Date_03_/_03_/_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.
_______________________________________________________________________________________________
Student’s Strengths, Preferences, and Interests
Elli Smith is currently entering the 2nd grade and was found eligible for Specific Learning Disability. She has asthma and
needs access to her inhaler, and regular check-ins with the school nurse, but she doesn’t let that stop her love of school, her
friends, and anything craft related. She is very cheerful, works hard, and is always ready for a challenge.
As indicated by the mental assessment, Elli exhibits a general capacity in the normal range. She demonstrates substantially
less developed in long-term retrieval associative memory and auditory processing, explicitly phonemic awareness. These
relative shortcomings combined with challenges in the part of auditory processing, such as phonemic awareness, which is the
comprehension of the littlest units of sound (phonemes), may make the obtaining of reading troublesome. Likewise, the
spelling of new words may also end up being a difficult undertaking. Elli's social working, as evaluated through rating scales,
instructor meets, and direct perception seems to be a difficult now and again, but not a significant concern. As indicated by
achievement assessment, Elli shows normal oral language aptitudes, mathematics and written expression in the below normal
range with significant deficient range. Teacher reports show that Elli exhibits an independent reading level of pre-primer 1.
Her auditory comprehension is generally excellent, yet her word attack is poor. She has gotten PALS remediation and Title I
supports for reading for a period of 6 months and has gained negligible ground despite supplemental guidance interventions
focusing on her recognized areas of need.
Student’s Areas of Need (Deficits that Require Supports)
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.
Effect of Disability on Student
The disability that Elli has made reading difficult and the spelling of unfamiliar words difficult, but it has not impacted her
spirit or love for school.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued
Student Name__ Elli Smith ______________________________________________ Date_03_/_03_/_20_ Page ___of___
Student ID Number__________________________________
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued.
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 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
Teacher Educational Information
In regard to her reading, Elli’s comprehension is good as long as she is tested orally. She is very good at describing story
elements and information when the story is read to her. Her retention of words, however, is weak and she has difficulty
putting sounds together, but knows the sounds when they are isolated. She is currently receiving Title 1 and PALS
Remediation but has not improved.
In regard to her language, she has memorized certain sentence structures and adapts it to the current topic. She is an excellent
speller, but cannot read the words she is spelling, but memorizing the spelling features.
In regard to her math, she has not had an issue with progressing in math. She understands basic addition and subtraction and
has caught on well to the strategies she is being taught.
In regard to her Social Studies and Science, she does very well in both.
In regard to her Movement Ed, she follows directions and does the activities. She enjoys PE a lot and loves everyone in her
class. The only assistance needed in PE and recess is the use of her inhaler and regular check-ins with the school nurse.
Overall, Elli loves art and works well with other students.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 2 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name__ Elli Smith ______________________________________________ Date_03_/_03_/_20_ Page ___of___
Student ID Number________________________________ Area of Need__ Reading___________________________
# __1__ MEASURABLE ANNUAL GOAL:
By the next annual review, when given a 200-word grade-level 2 reading passage, Elli will orally read 150 or more
words correctly in 7 minutes with 90% accuracy in 4/4 consecutive trials.
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
____ Class work
_X_ Homework
____ Observation
_X_ 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
disabilities.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name__ Elli Smith ______________________________________________ Date_03_/_03_/_20_ Page ___of___
Student ID Number________________________________ Area of Need___Spelling_______________________________
# __2__ MEASURABLE ANNUAL GOAL:
By the next annual review, when given a grade-level 2 spelling test, Elli will be able to not only spell the words
correctly, but will be able to pronounce the words correctly with 80% accuracy in 4/4 consecutive trials.
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
____ Class work
_X_ 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
disabilities.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 4 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name__ Elli Smith ______________________________________________ Date_03_/_03_/_20_ Page ___of___
Student ID Number________________________________ Area of Need__Retention of Words/Written Language___
# __3__ MEASURABLE ANNUAL GOAL:
By the next annual review, when given a grade-level 2 writing assignment of creating a short story, Elli will be able to
use an expanded vocabulary and be able to discuss the meaning of words with 80% accuracy in 2/2 trials.
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
_X_ Checklist
_X_ Class work
____ Homework
_X_ Observation
____ Special Projects
____ Tests and Quizzes
_X_ Written Reports
____ Criterion-referenced test:_________________________
____ Norm-referenced test: ___________________________
____ Other: ________________________________________
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
IP -The student has demonstrated Insufficient Progress
to meet this annual goal and may not achieve this goal
within the duration of this IEP.
ES - The student demonstrates Emerging Skill but may not
achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction on
this goal.
M -The student has Mastered this annual goal.
* Progress reports will be provided at least as often as parents are informed of the progress of children without
disabilities.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 5 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Student Name__ Elli Smith ______________________________________________ Date_03_/_03_/_20_ Page ___of___
Student ID Number___________________________________
This student will be provided access to general education classes, special education classes, other school services and
activities including nonacademic activities and extracurricular activities, and education related settings:
___ with no accommodations/modifications
_X_ with the following accommodations/modifications
Accommodations/modifications provided as part of the instructional and testing/assessment process will allow the student
equal opportunity to access the curriculum and demonstrate achievement. Accommodations/modifications also provide access
to nonacademic and extracurricular activities and educationally related settings. Accommodations/modifications based solely
on the potential to enhance performance beyond providing equal access are inappropriate.
Accommodations may be in, but not limited to, the areas of time, scheduling, setting, presentation and response including
assistive technology and/or accessible materials. The impact of any modifications listed should be discussed.
ACCOMMODATIONS/MODIFICATIONS (list, as appropriate)
Accommodation(s)/Modification(s) Frequency Location
(name of school *)
Instructional
Setting
Duration
m/d/y to m/d/y
Reading tests to be taken orally As needed School Classroom 09/08/20 –
06/11/21
* 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.
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 imperative that the teacher just read the questions for
Elli when she is taking a reading test. The teacher may help with questions Elli may have, but should not provide further
assistance than she would give a student taking the test normally.
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Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 7 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
Student Name___Elli Smith______________________________________________ Date_03_/_03_/_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)
X Reading X 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 Page 8 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
(continued)
Student Name___Elli Smith_______________________________________________ Date_03_/_03_/_20_ 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):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
___________________________________________________________________________________________________
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___________________________________________________________________________________________________
____________________________________________________________________________________________________
_________________________________________________________________________________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 9 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name___Elli Smith______________________________________________ Date_03_/_03_/_20_ 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/week Classroom 09/21/20 – 05/28/21
School Nurse visits Daily Nurses office 09/08/20 – 06/11/21
** 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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 10 of 27
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name___Elli Smith______________________________________________ Date_03_/_03_/_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.
PLACEMENT CONTINUUM OPTIONS CONSIDERED: (check all that have been considered):
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 ____________________________
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 is a great student, overall. She gets along very well with her classmates, and is excelling in math, social studies, science,
art, and movement ED. The only real areas of need for Elli, involve her reading, writing, and pronouncing and retention of
words. Due to this, keeping Elli in general education classes, with the help of a tutor for an hour a day, 3 times a week,
focusing solely on those areas of need, will help her succeed the best in her education.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 11 of 27
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE AND PARENT CONSENT
Student Name_____Elli Smith____________________________________________ Date_03_/_03_/_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
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 12 of 27
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 Page 13 of 27
SECTION 2
Additional Forms
To Be Used
As Needed
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 14 of 27
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
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 15 of 27
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.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 16 of 27
Special Education Meeting Notice Parent/Student Response Form
To the Parent(s) / Guardian(s) / Student:
Student: Date of Meeting:
Please check your choice and return this page to:
at
I the parent student will attend the meeting as scheduled.
I the parent student cannot attend the meeting as scheduled. Please reschedule this
meeting.
I can attend on at
(date) (time and place)
Please contact me at
to determine a mutually agreeable date, time, and place for this IEP meeting.
I the parent student do not wish to attend this meeting even though I understand the
importance of attending. You may hold this meeting in my absence.
I the parent student would like my preferences, interests, and concerns shared with the
team. I will provide my input to you by:
Mail Telephone Other means: prior to the meeting.
An IEP worksheet is enclosed.
I will need the following accommodations for this IEP meeting:
I plan to bring _______ individuals that I believe have knowledge or expertise regarding my child.
______________________________________ ___________________________________
Parent Signature Date
Date received by the school:
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 17 of 27
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
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
Required for Billable Services
ICD9 Code _________________________ Medicaid Discharge Plan/Disposition _______________________________
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Summary of previous treatment if not addressed elsewhere:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Intervention, treatment, and modalities if not addressed elsewhere:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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 20 of 27
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
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 21 of 27
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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Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 24 of 27
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.
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