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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
Erin Tobar
EDUC 521
June 6, 2022
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INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Student Name: Elli Smith_________________________________________________ Date____/____/____ 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 Strengths, Preferences, and Interests:
Elli Smith is a cheerful 8-year-old girl currently entering the 2nd grade. Elli was found eligible for services 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 inhale, 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 challenge 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 instructions interventions targeting her
identified areas of deficit.
Student’s Area of Need (Deficits that require support):
- 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:
Elli demonstrates substantially less developed long-term retrieval, associated 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.
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Academic Performance:
Wechsler Individual Achievement Test—Third Edition (WIAT—III)
Subtest with age-based scores:
Alphabet Writing Fluency 96
Basic Reading 75 Below Average
Early Reading Skills 92
Expressive Vocabulary 85 Average
Listening Comprehension 90
Mathematics 85 Average
Math Fluency 86 Average
Math Fluency—Addition 83
Math Problem Solving 80
Math Fluency—Subtraction 89
Numerical Operations 93
Oral Discourse Comprehension 103 Average
Oral Expression 95
Oral Language 91 Average
Oral Reading Accuracy 61
Oral Reading Fluency 63
Oral Reading Rate 78
Oral Word Fluency 107 Average
Pseudoword Decoding 77
Reading Comprehension 79
Receptive Vocabulary 81 Below Average
Sentence Composition 90
Sentence Building 84 Below Average
Sentence Combining 98 Average
Sentence Repetition 97 Average
Spelling 80
Total Achievements 82 Below Average
Total Reading 69 Low
Word Reading 72
Written Expression 85 Average
Teacher Educational Information:
Reading instructional level (1st); independent level (Readiness); Elli’s comprehension is good as long as it is tested
orally. She can recall story elements and information when the story is read to her. Her word attack skills are
extremely limited. She knows sounds when they are isolated but has difficulty putting the sounds together. Her
retention of words (sight words) is very weak, she is currently receiving Title 1 and PALS remediation, but she gas
made very little growth. Language instructional level (below grade level); She has memorized certain sentences
structures and adapts it to the current topic Elli is an excellent speller, but she cannot read the words she is spelling.
She memorizes the spelling features. Math: She is very good at adding and subtracting and has caught on well to the
strategies she has been taught. She does a great job deciding which operation should be used and then working out a
word problem. Social Studies and Science: Elli does very well in both classes. Movement Ed.: she follows directions
and does all activities; seems to get along with everyone during class and seems to enjoy PE. She does need access to
her inhaler during PE and recess. As well as regular check-ins with the school nurse. She appears to love Art and
Library and works well with others.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued
Student Name: Elli Smith________________________________________________ Date ____/____/____ Page ___of___
Student ID Number__________________________________
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name: Elli Smith________________________________________________ Date: 06/06/2022 Page ___of___
Student ID Number____________________________ Area of Need: SOL 2.8h—Reading Comprehension
# 1 MEASURABLE ANNUAL GOAL:
By the next annual review, Elli will be able to determine what happened at the beginning, middle, and end of a 2nd
grade level story. Elli will demonstrate mastery when she can do this with 6 consecutive stories with 80% accuracy.
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.
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
____ 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: 06/06/2022 Page ___of___
Student ID Number________________________________ Area of Need: SOL 2.5a—Reading, SOL 2.13h--Writing_____
# 2 MEASURABLE ANNUAL GOAL:
By the next annual review, when given a list of 6 spelling words, Elli will be able to read and write each word correctly
with 80% accuracy or more on an assessment in 5 of 6 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)
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
____ 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: 06/06/2022 Page ___of___
Student ID Number________________________________ Area of Need: SOL 2.7b & SOL 2.7d—Reading
# 3 MEASURABLE ANNUAL GOAL:
By the next annual review, when given 5 words read out loud, Elli will determine which two words end with the same
sounds correctly with 80% accuracy on 8 out of 10 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)
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
____ 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)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Student Name: Elli Smith________________________________________________ Date: 06/06/2022 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
Testing: Test and assignments read
out loud
As needed
Falcon Glenn
Elementary
School
Special and
general education
classroom
06/06/2022 to
06/06/2023
Setting: Providing space with
minimal distractions
As needed
Falcon Glenn
Elementary
School
Special and
general education
classroom
06/06/2022 to
06/06/2023
Response: Allow for verbal response
As needed
Falcon Glenn
Elementary
School
Special and
general education
classroom
06/06/2022 to
06/06/2023
Materials: Provide a copy of class
notes
Daily
Falcon Glenn
Elementary
School
Special and
general education
classroom
06/06/2022 to
06/06/2023
Timing: Allow student extended time
to complete assignments/assessments
As needed
Falcon Glenn
Elementary
School
Special and
general education
classroom
06/06/2022 to
06/06/2023
* IEP teams are required to identify the specific school site (public or private) when the parent expresses concern 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) :__Allow time for teachers and others working with Elli, to attend conferences or training sessions to
help them learn about Specific Learning Disabilities, effective teaching strategies, and/or curriculum/classroom
modification.
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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 06/06/2022 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.
Yes No
Based on the Present Level of Academic Achievement and Functional Performance, is this
student being considered for participation in the Virginia Standards of Learning
(SOL)Assessments (select appropriate content area)
Reading Math Science History/Social Science Grade 8 Writing
Yes No
Based on the Present Level of Academic Achievement and Functional Performance, is this
student being considered for participation in the Special Permission Request Virginia
Substitute Evaluation Program (VSEP)? If yes, complete the “VSEP Participation
Criteria” for each content area considered. (Grades 3-8 only)
Reading Math Science History/Social Science Grade 8 Writing
Yes No
Does the student meet the VSEP participation criteria? If yes, determine for specific content
area. Reading Math Science History/Social Science Grade 8 Writing
Special permission for eligible students with disabilities in grades 3-8. refer to VDOE’s
Students with Disabilities: Guidelines for Assessment Participation for guidance.
Yes No
Based on the Present Level of Academic Achievement and Functional Performance, is this
student being considered for participation in the Virginia Alternate Assessment Program
(VAAP), which is based on Aligned Standards of Learning? If yes, complete the “VAAP
Participation Criteria”.
Yes No
Does the student meet VAAP participation criteria?
Yes No
If “yes” to any of the above, check the assessment(s) chosen and attach (or maintain in student’s educational record) the
assessment page(s), which will document how the student will participate in Virginia’s accountability system and any needed
accommodations and/or modifications.
State Assessments:*
___ 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.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
(continued)
Student Name: Elli Smith__________________________________________________________________ Date 06/06/2022
Student ID Number__________________________________
PARTICIPATION IN STATEWIDE ASSESSMENTS
* Students with disabilities are expected to participate in all content area assessments that are available to students without
disabilities. The IEP Team determines how the student will participate in the accountability system.
** Accommodation(s) must be based upon those the student generally uses during classroom instruction and assessment,
including assistive technology and/or accessible materials. For the accommodations that may be considered, refer to VDOE’s
Students with Disabilities: Guidelines for Assessment Participation for guidance.
Divisionwide Assessment (list):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
___________________________________________________________________________________________________
EXPLANATION FOR NON-PARTICIPATION IN REGULAR STATE OR DIVISION-WIDE ASSESSMENTS
If an IEP team determines that a student must take an alternate assessment instead of a regular state assessment, explain in the
space below why the student cannot participate in this regular assessment; why the particular assessment selected is
appropriate for the student, including that the student meets the criteria for the alternate assessment; and how the student’s
nonparticipation in the regular assessment will impact the child’s promotion; or other matters. Refer to the VDOE’s Students
with Disabilities: Guidelines for Assessment Participation for guidance.
Alternate/Alternative Assessments Participation Criteria is attached or maintained in the student’s educational record
___Virginia’s Standards of Learning Assessments are given from Grade 3 to Grade 12.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_________________________________________________________________________________________________
Test
Assessment Type*
(SOL, VSEP,VAAP)
Accommodations**
If yes, list accommodation(s)
Reading
_______________________________________
Not Assessed at this Grade Level
Yes No
Math
_______________________________________
Not Assessed at this Grade Level
Yes No
Science
_______________________________________
Not Assessed at this Grade Level
Yes No
History/SS
_______________________________________
Not Assessed at this Grade Level
Yes No
Writing
_______________________________________
Not Assessed at this Grade Level
Yes No
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name: Elli Smith_____________________________________________________ Date06/06/2022 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
Speech-Language Pathology
2x a week
Falcon Glenn
Elementary School—
Special Education
06/06/2022 to 06/06/2023
School Health Services
Daily
Falcon Glenn
Elementary School—
Nurse’s Office
06/06/2022 to 06/06/2023
Parent & Teacher Counseling/Training
Services
Quarterly (4x an
annual school
year)
Falcon Glenn
Elementary School—
General Classroom
06/06/2022 to 06/06/2023
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** 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
Student Name: Elli Smith_______________________________________________ Date 06/06/2022 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):
❑ 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, a 2nd grader with a Specific Learning Disability will receive majority of instruction from the general education
teacher. She will receive specialized reading, writing, and spelling instruction in the aided education room from the
special education teacher for 1 hour and 30 minutes each day.
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE AND PARENT CONSENT
Student Name: Elli Smith____________________________________________________ Date 06/06/2022 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:
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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:
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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
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
Required for Billable Services
ICD9 Code _________________________ Medicaid Discharge Plan/Disposition _______________________________
Summary of previous treatment if not addressed elsewhere:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Intervention, treatment, and modalities if not addressed elsewhere:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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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.
How will progress toward this annual goal be measured? (check all that apply)
____ Classroom Participation
____ Checklist
____ Class work
____ Homework
____ Observation
____ Special Projects
____ Tests and Quizzes
____ Written Reports
____ Criterion-referenced test:_________________________
____ Norm-referenced test: ___________________________
____ Other: ________________________________________
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
IP -The student has demonstrated Insufficient Progress
to meet this annual goal and may not achieve this goal
within the duration of this IEP.
ES -The student demonstrates Emerging Skill but may not
achieve this goal within the duration of this IEP.
NI -The student has Not been provided Instruction on
this goal.
M -The student has Mastered this annual goal.
* Progress reports will be provided at least as often as parents are informed of the progress of their children without
disabilities.
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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___________________________________
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.
