EDSP 521
Virginia Department of Education’s Sample IEP Form
For Use with Students up to Age Thirteen, as Appropriate
Adrienne Isaacs
EDUC 521 Foundations of Exceptionality
April 10, 2023
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 1 of 27
EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ Page ___of___
Student ID Number_____________________________________________________
Demographic Information and Background:
Elli Smith is an 8-year-old female currently entering the second grade. According to psychological evaluation, Elli
demonstrates an overall ability in the average range.
Elli was found eligible for special education services based on a diagnosis of specific learning disability. She has
received PALS remediation and Title I supports for reading for six months and has made minimal progress despite
supplemental instruction interventions targeting her identified deficit areas.
Test Scores:
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
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE, continued
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ Page ___of___
Student ID Number__________________________________
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE, continued.
Teacher Feedback:
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 has
made very little growth.
Language: instructional level (below grade level); She has memorized certain sentence 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: Elli 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.: Elli follows directions and does all activities; she gets along with everyone during class and
enjoys PE. She needs access to her inhaler during PE and recess and regular check-ins with the school nurse.
She appears to love Art and Library and works well with other students.
Areas of Need:
Based on the above teacher feedback and achievement test scores, Elli demonstrates the following areas of need:
Receptive Vocabulary
Decoding
Reading
Spelling
Written language
Elli demonstrates below average scores in receptive vocabulary, sentence building, basic reading, oral reading
accuracy and oral reading fluency.
It should also be noted that Elli also has an area of need unrelated to her specific learning disability—asthma.
However, this need is being addressed by providing access to her inhaler, and increased supervision through
frequent check-ins with the school nurse.
Assistive Technology and/or Accessible Materials:
Elli could benefit from the use of assistive technology including audio versions of texts which would increase her
comprehension of the material. Elli could benefit from the use of speech-to-text technology such as Dragon
Naturally Speaking, and text-to-speech technology, such as a C-Pen.
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE, continued
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ Page ___of___
Student ID Number__________________________________
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE, continued.
Effects of Disability on Academic Performance:
Elli’s specific learning disability (SLD) affects writing by decreasing her ability to formulate sentences and
communicate in writing on grade-level. Elli’s reading is affected because she is unable to decode accurately. She
had poor word attack skills and has not been able to make progress in this area despite the intervention of Title
and PALS remediation. Elli overall academic performance is affected because her SLD makes reading acquisition
difficult, therefore she is unable to sufficiently comprehend written materials provided in class.
Mathematics, science, and history/social sciences are not currently affected by Elli’s SLD.
Effects of Disability on Functional Performance:
Elli’s SLD does not appear to affect her functional performance. Based on teacher feedback, Elli’s social
competence, communication, behavior, and personal management are within normal range. She gets along well
with others and seems to love being around her peers at school. Elli also is reported to have positive interactions
with her teachers. She is also reported to demonstrate eagerness and cheerfulness in school.
Interests, Preferences and Strengths:
Based on the above teacher feedback and achievement test scores, Elli demonstrates average oral language skills
as evidenced by listening comprehension, oral discourse comprehension, and oral language scores. Teachers also
report that Elli does well when comprehension is tested orally. Therefore, oral language skills appear to be an area
of strength.
Artistic expression is also an area of strength and interest for Elli. art. She loves art, and anything related to crafts.
Connecting reading related activities to art activities may help to build upon Elli’s strengths and interests.
Based on achievement scores and teacher feedback, mathematics skills also appear to be an area of strength for
Elli. She had average mathematics scores on the WIAT- III and teachers report that she has been using the math
strategies taught in class well.
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ Page ___of___
Student ID Number________________________________ Area of Need____Receptive Vocabulary___________________
# 1 MEASURABLE ANNUAL GOAL:
By next annual review, when verbally given one new vocabulary within a sentence for context, Elli will correctly identify a
picture depicting the vocabulary word by pointing and orally explaining her choice with an oral story of 8 or more words, in 4
out of 5 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 these annual goals be measured? (Check all that apply)
☐Classroom Participation
☐Checklist
☐Classwork
☐Homework
☐Observation
☐Special Projects
☐Tests and Quizzes
☐Written Reports
☐Criterion-referenced test:_____________________
☐Norm-referenced test: _______________________
☒Other:_weekly receptive vocabulary probes______
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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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ Page ___of___
Student ID Number________________________________ Area of Need____Reading______________________________
# 2 MEASURABLE ANNUAL GOAL:
By the next annual review, given a one-minute timed word fluency reading probe, Elli will attain a score of 30 wcpm (words
correct per minute) or more on 4 consecutive progress monitoring probes. Probes will be conducted weekly.
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 these annual goals be measured? (Check all that apply)
☐Classroom Participation
☐Checklist
☐Classwork
☐Homework
☐Observation
☐Special Projects
☐Tests and Quizzes
☐Written Reports
☐Criterion-referenced test:_____________________
☐Norm-referenced test: _______________________
☒Other:_weekly reading progress monitoring probes_
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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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ Page ___of___
Student ID Number________________________________ Area of Need____Writing_________________________
# 3 MEASURABLE ANNUAL GOAL:
By the next annual review, given a picture prompt, Elli will compose and self-edit a sentence with correct spelling on her
instructional level (first grade), correct capitalization and punctuation, and correct subject-verb agreement with 80 %
accuracy over 4 out of 5 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 these annual goals be measured? (Check all that apply)
☐Classroom Participation
☐Checklist
☐Classwork
☐Homework
☐Observation
☐Special Projects
☐Tests and Quizzes
☐Written Reports
☐Criterion-referenced test:_____________________
☐Norm-referenced test: _______________________
☒Other:_weekly writing progress monitoring probes_
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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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ Page ___of___
Student ID Number___________________________________
This student will be provided access to general education classes, special education classes, other school services and
activities, including nonacademic activities, extracurricular activities, and education-related settings:
___ with no accommodations/modifications
_X_ with the following accommodations/modifications
Accommodations/modifications provided as part of the instructional and testing/assessment process will allow the student
equal opportunity to access the curriculum and demonstrate achievement. Accommodations/modifications also provide access
to nonacademic and extracurricular activities and educationally related settings. Accommodations/modifications based solely
on the potential to enhance performance beyond providing equal access are inappropriate.
Accommodations may be in, but not limited to, the areas of time, scheduling, setting, presentation and response including
assistive technology and/or accessible materials. The impact of any modifications listed should be discussed.
ACCOMMODATIONS/MODIFICATIONS (list, as appropriate)
Accommodation(s)/Modification(s) Frequency Location
(name of school
*)
Instructional
Setting
Duration
m/d/y to m/d/y
Audiobooks daily Elli’s Elementary
School
Reg Ed Classroom 4/10/23 to 6/30/23
(the remainder of
the school year)
C-Pen (text-to-speech pen reader) daily Elli’s Elementary
School
Reg Ed Classroom 4/10/23 to 6/30/23
(the remainder of
the school year)
Highlighted Class Notes daily Elli’s Elementary
School
Reg Ed Classroom 4/10/23 to 6/30/23
(the remainder of
the school year)
Graphic Organizers daily Elli’s Elementary
School
Reg Ed Classroom 4/10/23 to 6/30/23
(the remainder of
the school year)
* 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) ___The school will need to acquire audiobooks and a headset for Elli to use to listen to
materials provided in text format for the other students. Elli will also need the books to read along with the
audios. The teachers could use training in how to create graphic organizers and highlighted class notes that will
assist Elli in better accessing the essential information in her lessons. The school will also need to purchase a C-
Pen and headset that Elli can use to scan and read books that do not have audiobooks available . ______________
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ Page ___of___
Student ID Number__________________________________
This student’s participation in state and division-wide assessments must be discussed annually. During the
duration of this IEP:
Will the student be at a grade level or enrolled in a course for which the student must
participate in a state and/or division-wide assessment? If yes, continue to next question.
Yes No
Based on the Present Level of Academic Achievement and Functional Performance, is this
student being considered for participation in the Virginia Standards of Learning
(SOL)Assessments (select appropriate content area)
Reading Math Science History/Social Science Grade 8 Writing
Yes No
Based on the Present Level of Academic Achievement and Functional Performance, is this
student being considered for participation in the Special Permission Request Virginia
Substitute Evaluation Program (VSEP)? If yes, complete the “VSEP Participation
Criteria” for each content area considered. (Grades 3-8 only)
Reading Math Science History/Social Science Grade 8 Writing
Yes No
Does the student meet the VSEP participation criteria? If yes, determine for specific content
area. Reading Math Science History/Social Science Grade 8 Writing
Special permission for eligible students with disabilities in grades 3-8. refer to VDOE’s
Students with Disabilities: Guidelines for Assessment Participation for guidance.
Yes No
Based on the Present Level of Academic Achievement and Functional Performance, is this
student being considered for participation in the Virginia Alternate Assessment Program
(VAAP), which is based on Aligned Standards of Learning? If yes, complete the “VAAP
Participation Criteria”.
Yes No
Does the student meet VAAP participation criteria? Yes No
If “yes” to any of the above, check the assessment(s) chosen and attach (or maintain in student’s educational record) the
assessment page(s), which will document how the student will participate in Virginia’s accountability system and any needed
accommodations and/or modifications.
___ SOL Assessments Reading Math Science History/Social Science Grade 8 Writing
___ Virginia Substitute Evaluation Program (VSEP) Reading Math Science History/Social Science Grade 8 Writing
___ Virginia Alternate Assessment Program (VAAP)
Division-wide Assessment (list):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
*Refer to Students with Disabilities: Guidelines for Assessment Participation for additional guidance on the assessment programs.
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM
(continued)
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ Page ___of___
Student ID Number__________________________________
PARTICIPATION IN STATEWIDE ASSESSMENTS
Test
Assessment Type*
(SOL, VSEP,VAAP) Accommodations** If yes, list accommodation(s)
Reading ____SOL_______________________________
Not Assessed at this Grade Level
Yes No
Reader for passages and
questions, Additional Time
Math ___SOL______________________________
Not Assessed at this Grade Level
Yes No
Reader (for word problems
only)
Science ___SOL______________________________
Not Assessed at this Grade Level
Yes No
Reader for passages and
questions, Additional Time
History/SS ___SOL______________________________
Not Assessed at this Grade Level
Yes No
Reader for passages and
questions, Additional Time
Writing ___SOL______________________________
Not Assessed at this Grade Level
Yes No
N/A
* Students with disabilities are expected to participate in all content area assessments that are available to students without
disabilities. The IEP Team determines how the student will participate in the accountability system.
** Accommodation(s) must be based upon those the student generally uses during classroom instruction and assessment,
including assistive technology and/or accessible materials. For the accommodations that may be considered, refer to VDOE’s
Students with Disabilities: Guidelines for Assessment Participation for guidance.
Division-wide Assessment (list):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
___________________________________________________________________________________________________
EXPLANATION FOR NON-PARTICIPATION IN REGULAR STATE OR DIVISION-WIDE ASSESSMENTS
If an IEP team determines that a student must take an alternate assessment instead of a regular state assessment, explain in the
space below why the student cannot participate in this regular assessment; why the particular assessment selected is
appropriate for the student, including that the student meets the criteria for the alternate assessment; and how the student’s
nonparticipation in the regular assessment will impact the child’s promotion; or other matters. Refer to the VDOE’s Students
with Disabilities: Guidelines for Assessment Participation for guidance.
Alternate/Alternative Assessments Participation Criteria is attached or maintained in the student’s educational record
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ 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
Orton Gillingham Tutoring Twice weekly Resource classroom 4/10/23 to 6/30/23 (the
remainder of the school year)
** IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the
location of the services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the
parents do not indicate that they will object to any particular school or state that the team should identify a single school.
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EDSP 521
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ 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:
General education classes and special classes were considered. It was decided that with appropriate services, Elli
can continue in a general education setting. Orton-Gillingham tutoring will be the only service for which Elli will
be pulled from the regular classroom. This is to provide an uninterrupted environment for Elli to focus on the
tutor. The style of the tutoring necessitates a one-to-one environment. Otherwise, Elli may remain in the general
education classroom among other non-disabled peers. Elli’s social development remains best served in the general
education setting. Her math, science and social studies instruction are also at grade level and can be provided in
the general education setting.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE AND PARENT CONSENT
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EDSP 521
Student Name______Elli Smith___________________________________ Date_4_/10__/_23_ Page ___of___
Student ID Number___________________________________
PRIOR NOTICE
The school division proposes to implement this IEP. This proposed IEP will allow the student to receive a free appropriate
public education in the least restrictive environment. This decision is based upon a review of current records, current
assessments and the student’s performance as documented in the Present Level of Academic Achievement and Functional
Performance. Other options considered, if any, and the reason(s) for rejection are attached, or can be found in the Placement
Decision section of this IEP. Additionally, other factors, if any that are relevant to this proposal are attached. Parent and adult
student rights are explained in the Procedural Safeguards. If you, the parent(s) and adult student, need another copy of the
Procedural Safeguards or need assistance in understanding this information please contact
________________________________ at (___) ____________ or e-mail ________________________________ or
________________________________ at (___) ____________ or e-mail ________________________________ .
____ Parent(s) initials here indicate that the parent(s) has read the above prior notice and attachments, if any, before giving
permission to implement this IEP.
PARENT/ADULT STUDENT CONSENT: Indicate your response by checking the appropriate space and sign below.
___ I give permission to implement this IEP.
___ I do not give permission to implement this IEP.
____________________________________________________ ____/____/____
Parent Signature Date
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EDSP 521
TRANSITION INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR WRITTEN NOTICE
Student Name__________________________________________________________ Date____/____/____ Page ___of___
Student ID Number___________________________________
Describe the action that the school division proposes or refuses to take: (Required upon graduation with a standard or advanced diploma)
Explanation of why the school division is proposing or refusing to take action:
Description of each evaluation procedure, assessment, record or report the school division used in deciding to propose or
refuse the action:
Description of any other choices that the Individualized Education Program (IEP) team considered and the reasons why those
choices were rejected:
Description of other reasons or other factors relevant as to why the school division proposed or refused the action:
Resources for the parent to contact for help in understanding the Individuals with Disabilities Education Act (IDEA) and the
related federal and Virginia Regulations:
If this notice is not the initial referral for evaluation, document when the parent was provided a copy of the procedural
safeguards and how a copy maybe obtained, if the parent requests an additional copy:
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EDSP 521
SECTION 2
Additional Forms
To Be Used
As Needed
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EDSP 521
ELEMENTARY INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PROCESS CHECKLIST
Meeting notices sent to parent and agency representatives, as appropriate
Acquire written consent from parent for an agency representative to attend the IEP meeting
Welcome and introductions of team members
Review purpose of meeting
Review meeting agenda
Review rights and procedural safeguards pertaining to special education and the IEP meeting
Review of special factors to be considered by the IEP team
Develop Present Level of Academic Achievement and Functional Performance
Develop measurable annual goals
(Discuss progress report on previous annual goals, as needed.)
Determine progress report schedule
Document that the IEP team considered the need for short-term objectives or benchmarks for students other than
those who take alternate assessments aligned to alternate achievement standards
Develop short-term objectives or benchmarks for the annual goals, as needed
Determine any needed accommodations and/or modifications in instruction and assessment
Determine participation in state and divisionwide assessments
Determine services and placement
Determine if student needs ESY services
Review any requests proposed and/or refused
Provide prior written notice and obtain parental consent
Identify how staff will be informed of their responsibilities for implementation of the IEP
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EDSP 521
Special Education Meeting Notice
(School Division Letterhead)
Date:
To: ___________________________________
_ and ______________________________________
Parent(s)/Adult Student Student (if appropriate or if transition will be discussed)
You are invited to attend a meeting regarding ____________________________________________
Student’s Name
PURPOSE OF MEETING (check all that apply):
IEP Development or Annual Review
IEP Amendment
Team Review of Referral
Team Review of Existing Data
Transition: PartC to Part B
Eligibility Determination
Team Determination of Needed Data
Transition: Postsecondary Goals, Transition Services
Manifestation Determination
Other: ____________________________
The meeting has been scheduled for:
Date Time Location
Meetings are scheduled at a mutually agreed upon place and time by you and the school division. If you are
unable to attend this meeting you may request participation through other means. If you are unable to attend this
meeting, please contact:
Special Education Staff Contact / IEP Case Manager Title Phone
You and the school division may invite individuals to participate in the team meeting who have knowledge or
expertise about the student’s educational needs. The determination of the knowledge or special expertise shall be
made by the party who invited the individual. For IEP Meetings, if the division intends to invite a representative
of an agency that is likely to be responsible for providing or paying for transition services to the IEP meeting,
written consent of the parent or adult student is required.
Below is a list of the participants (by name or position) the division will be inviting to attend the meeting:
Please review and return the following page to assist the school staff in preparing for the meeting.
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EDSP 521
Special Education Meeting Notice Parent/Student Response Form
To the Parent(s) / Guardian(s) / Student:
Student: Date of Meeting:
Please check your choice and return this page to:
at
I the parent student will attend the meeting as scheduled.
I the parent student cannot attend the meeting as scheduled. Please reschedule this
meeting.
I can attend on at
(date) (time and place)
Please contact me at
to determine a mutually agreeable date, time, and place for this IEP meeting.
I the parent student do not wish to attend this meeting even though I understand the
importance of attending. You may hold this meeting in my absence.
I the parent student would like my preferences, interests, and concerns shared with the
team. I will provide my input to you by:
Mail Telephone Other means: prior to the meeting.
An IEP worksheet is enclosed.
I will need the following accommodations for this IEP meeting:
I plan to bring _______ individuals that I believe have knowledge or expertise regarding my child.
______________________________________ ___________________________________
Parent Signature Date
Date received by the school:
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EDSP 521
SAMPLE
School Division Letterhead
CONSENT TO INVITE AGENCY PERSONNEL
Date: _____________
If the division intends to invite a representative of any agency that is likely to be responsible for providing or
paying for transition services to the IEP meeting, written consent from the parent or adult student is required
prior to the meeting date.
_____ I give my consent for an agency representative(s) named on the meeting notice to be invited to
the IEP meeting.
_____ I do not give my consent for an agency representative(s) named on the meeting notice to be
invited to the IEP meeting.
Parent/Adult Student Signature Date
________________________________________ ______________________
Parent/Adult Student Signature Date
**Please sign and return this page to your child’s IEP Case Manager.
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
COVER PAGE – MEDICAID ELIGIBLE STUDENTS
Student Name_________________________________________________________________________ Page ___ of ___
Student ID Number__________________________________ Medicaid/FAMIS # ____________________ Grade_______
DOB ____/____/____ Age* ________ Disability(ies) (if identified) ____________________________________________
Parent (s)Name_____________________________________________________Email ____________________________
Home Address_____________________________________________________ Primary (____)_____________________
_____________________________________________________ Secondary (____)___________________
Date of IEP meeting…………………...…………………….……………………….....……..………….._____/_____/_____
Date parent notified of IEP meeting………………………………..……………………...………………_____/_____/_____
This IEP will be reviewed no later than ………..…………………….……………..……….……………_____/_____/_____
Most recent eligibility date…………………………….…………………………………….……………._____/_____/_____
Next re-evaluation, including eligibility, must occur before ………..……..…………..…..…………….._____/_____/_____
Copy of IEP given to parent (Name) _____________________________________________ On (Date)_____/_____/_____
IEP Teacher/Manager_________________________________________ Phone Number (____)______________________
PARTICIPANTS INVOLVED:
The list below indicates that the individual participated in the development of this IEP and the placement decision; it does not
authorize consent. Parent consent is indicated on the “Prior Notice” page.
NAME OF PARTICIPANT POSITION
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
_____________________________________________________ ____________________________________
Required for Billable Services
ICD9 Code _________________________ Medicaid Discharge Plan/Disposition _______________________________
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 20 of 27
Summary of previous treatment if not addressed elsewhere:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________________________________
Intervention, treatment, and modalities if not addressed elsewhere:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________________________________
EDSP 521
PARENTAL CONSENT FOR BILLING PUBLIC INSURANCE LANGUAGE
FOR THE IEP or IEP AMENDMENT
One-Time Consent
(This document is optional and is not a necessary component of the IEP annual review)
For Medicaid or FAMIS (Family Access to Medical Insurance Securities) Insured Only
If your child is now or later becomes eligible for Medicaid or FAMIS and he or she receives health-related
services written in an Individual Education Program (IEP), the federal government can help the public school
division pay for these health-related services, such as, but not limited to physical, occupational or speech therapy;
audiology, nursing, psychological or personal care services and health screening associated with Early Periodic
Screening Diagnosis and Treatment (EPSDT). Parent/Guardian consent is required before the public school
system can bill Medicaid or FAMIS.
Additional information about the one-time parental consent, the parental consent form and the procedural
safeguards can be found at http://www.doe.virginia.gov/support/health_medical/medicaid/index.shtml.
If prior consent has been given, no further action is required.
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT, continued
Student Name_______________________________________________________ Date____/____/____ Page ___of___
Student ID Number________________________________ Area of Need________________________________________
# _____ MEASURABLE ANNUAL GOAL:
The IEP team considered the need for short-term objectives/benchmarks.
Short-term objectives/benchmarks are included for this goal. (Required for students participating in the VAAP)
Short-term objectives/benchmarks are not included for this goal.
How will progress toward this annual goal be measured? (check all that apply)
____ Classroom Participation
____ Checklist
____ Class work
____ Homework
____ Observation
____ Special Projects
____ Tests and Quizzes
____ Written Reports
____ Criterion-referenced test:_________________________
____ Norm-referenced test: ___________________________
____ Other: ________________________________________
Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using
progress report comment form located in section two.
Anticipated Date of Progress Report*
Actual Date of Progress Report
Progress Code
SP -The student is making Sufficient Progress to achieve this
annual goal within the duration of this IEP.
IP -The student has demonstrated Insufficient Progress
to meet this annual goal and may not achieve this goal
within the duration of this IEP.
ES -The student demonstrates Emerging Skill but may not
achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction on
this goal.
M -The student has Mastered this annual goal.
* Progress reports will be provided at least as often as parents are informed of the progress of their children without
disabilities.
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SHORT TERM OBJECTIVES OR BENCHMARKS, as determined by IEP Team
(Required for students participating in the VAAP)
Student Name__________________________________________________________ Date____/____/____ Page ___of___
Student ID Number________________________________ Goal # _____ Area of Need: ___________________________
Short Term Objectives or Benchmarks, as needed
Objective/Benchmark #___
Objective/Benchmark #___
Objective/Benchmark #___
Objective/Benchmark #___
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PROGRESS REPORT COMMENTS, Continued
(This document is optional)
Student Name__________________________________________________________ Date____/____/____ Page ___of___
Student ID Number________________________________
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
Goal #___ Progress Report Code ___
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EDSP 521
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
EXTENDED SCHOOL YEAR SERVICES (ESY)
(Optional)
Student Name_________________________________________________________ Date____/____/____ Page ___of___
Student ID Number___________________________________
Summarize the IEP team’s discussions and decision about ESY:
If ESY services are to be provided identify which goals in the current IEP will be addressed by the ESY services:
Identify the Extended School Year services needed to meet these goals:
Service(s) Frequency **School/location
Instructional
Setting
(classroom)
Duration
m/d/y to m/d/y
** IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the location of the
services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the parents do not indicate that they
will object to any particular school or state that the team should identify a single school.
Virginia Department of Education -- Sample IEP Form—Revised August, 2015 Page 25 of 27
