Due on 5/24/2016 @ 3:00 PM EST!! Please Utilize Template Provided!!!!

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Demographic Information

Individualized Education Program (IEP)
Student Name: Student Data/Cover Sheet (Form A-1) IEP Meeting Date:
Student ID: DOB:
Demographic Information
Student Number: Student Name: Birthdate: Gender: Grade:
Student Address: Home Phone:
City, State, Zip:
Parent 1 Name: Parent 1 Relationship:
Parent 1 Address: Home Phone:
City, State, Zip: Work Phone:
Parent 1 Email:
Parent 2 Name: Parent 2 Relationship:
Parent 2 Address: Home Phone:
City, State, Zip: Work Phone:
Parent 2 Email:
Primary Language of the Home: Primary Language Survey Date: Language of Instruction:
Primary Language Survey Results:
Home District: Service Coordinator:
Attendence District:
Home School: Attending School:
Vision Screened On: Results: Hearing Screened On: Results:
Meeting Date: Anticipated Duration of IEP: Re-evaluation Date:
To Current Evaluation:
Special Education Primary Category #1:
Special Education Primary Category #2:
Special Education Primary Category #3:
For students with SLD only, the following area(s) of eligibility was/were previously determined:
Level of Service:
Type of Meeting:
Date Meeting Notice Sent to the Date Procedural Safeguards given to the Parent(s):
Parent(s):

Signature Section

Individualized Education Program (IEP)
Student Name: Cover Sheet Signature Section (Form A-2) IEP Meeting Date:
Student ID: DOB:
The following persons participated in this conference and/or the development of the IEP. Additionally, parents have been given a copy of their rights regarding the student's placement in special education and understand that they have the right to request a review of their child's IEP at any time.
Position/Relation to Student Participant Date (MM/DD/YY)
*If during the IEP year the student turns 16, if the student is not present at the IEP meeting, the service
coordinator must review the IEP with the student and obtain the student's signature and the date of the review.

PLAAFP

Individualized Education Program (IEP)
Student Name: Student Data Cover Sheet (Form A-1) IEP Meeting Date:
Student ID: DOB:
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Section 1: Current IEP Information
Goal Number Written: Goal Number Met:
Summarize special education services the student is receiving:
Section 2: Evaluation Information
Areas of Eligibility:
Special Education Primary Category #1:
Special Education Primary Category #2:
Special Education Primary Category #3:
For students with SLD only, the following area(s) of eligibility was previously determined:
Section 3: Present Level of Academic Achievement
Reading
Writing
Math

PLAAFP Pg 2

Student Name: Present Level of Academic Achievement and IEP Meeting Date:
Student ID: Functional Performance (Form B) DOB:
Parent's Input on Student's Current Academic Achievement:
Current Classroom-Based Data:
State and District Assessment:
Section 4: Functional Performance
Social Emotional and Behavior:
Physical Development:
Occuptaional Development:
Physical Therapy Notes:
Communication:
Speech/Language Notes:

PLAAFP Pg 3

Student Name: Present Level of Academic Achievement and IEP Meeting Date:
Student ID: Functional Performance (Form B) DOB:
Parent's Input on Student's Current Functional Achievement:
Summary of Work Habits:
Section 5: Summary of Educational Needs

Considerations

Individualized Education Program (IEP)
Student Name: Considerations Form (Form C) IEP Meeting Date:
Student ID: DOB:
ADDITIONAL DOCUMENTATION/CONSIDERATION OF SPECIAL FACTORS
Considered Not Needed Included
Individual Transition Plan
Statement of Transfer of Parental Rights at Age of Majority
For a student whose behavior impedes his/her learning, or that of
others, positive behavior interventions, strategies, and
supports have been considered.
Statement of Language Needs in the Case of a Child with Limited
English Proficiency
Statement of Provision of Instruction in Braille & User of Braille
for a Visually Impaired Child
Statement of the Language of Needs, Opportunities for Direct
Communication with Peers in the Child's Language and
Communication Mode
Statement of Required Assisstive Technology Devices and Services
Statement of Communication Needs for a Child with a Disability
Statement of Health Concerns

IEP Goals 1

Individualized Education Program (IEP)
Student Name: Student Goals and Performance Objectives IEP Meeting Date:
Student ID: Progress Report DOB:
Skill Area: Signature: ___________________ Date:___________
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Student's Progress Towards Mastery of Goal:
1st Update: 2nd Update:
Level of Mastery Comments
1st Update:
2nd Update:
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Student's Progress Towards Mastery of Goal:
1st Update: 2nd Update:
Level of Mastery Comments
1st Update:
2nd Update:

IEP Goals 2

Student Name: Student Goals and Performance Objectives IEP Meeting Date:
Student ID: Progress Report DOB:
Skill Area: Signature: ___________________ Date:___________
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Student's Progress Towards Mastery of Goal:
1st Update: 2nd Update:
Level of Mastery Comments
1st Update:
2nd Update:
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Student's Progress Towards Mastery of Goal:
1st Update: 2nd Update:
Level of Mastery Comments
1st Update:
2nd Update:

IEP Goals 3

Student Name: Student Goals and Performance Objectives IEP Meeting Date:
Student ID: Progress Report DOB:
Skill Area: Signature: ___________________ Date:___________
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Student's Progress Towards Mastery of Goal:
1st Update: 2nd Update:
Level of Mastery Comments
1st Update:
2nd Update:
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Student's Progress Towards Mastery of Goal:
1st Update: 2nd Update:
Level of Mastery Comments
1st Update:
2nd Update:

IEP Goals 4

Student Name: Student Goals and Performance Objectives IEP Meeting Date:
Student ID: Progress Report DOB:
Skill Area: Signature: ___________________ Date:___________
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Student's Progress Towards Mastery of Goal:
1st Update: 2nd Update:
Level of Mastery Comments
1st Update:
2nd Update:
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Student's Progress Towards Mastery of Goal:
1st Update: 2nd Update:
Level of Mastery Comments
1st Update:
2nd Update:

IEP Goals 5

Student Name: Student Goals and Performance Objectives IEP Meeting Date:
Student ID: Progress Report DOB:
Skill Area: Signature: ___________________ Date:___________
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Student's Progress Towards Mastery of Goal:
1st Update: 2nd Update:
Level of Mastery Comments
1st Update:
2nd Update:
Standard:
Annual Goal:
Baseline Level of Mastery:
Service Provider(s) for this goal:
Student's Progress Towards Mastery of Goal:
1st Update: 2nd Update:
Level of Mastery Comments
1st Update:
2nd Update:

Accommodations

Individualized Education Program (IEP)
Student Name: Accommodations (Form E) IEP Meeting Date:
Student ID: DOB:
ACCOMMODATIONS
Date given to General Ed. Teacher: Service Coordinator:
Accommodations
Accommodations Type Location
Legend for Type and Location Fields
Type:
Location:
Parental Communication
IEP Team Consideration for Extended School Year
Consideration for Eligibility:
Eligible for ESY:
Written explanation as to why ESY is or is not needed:

Assessments

Individualized Education Program (IEP)
Student Name: Assessment (Form F) IEP Meeting Date:
Student ID: DOB:
ASSESSMENT
Rationale:
Not Age Appropriate
Standard Accommodation(s):
District Assessments
Standard Accommodation(s):
CURRENT STATE STANDARDIZED TEST (i.e. AIMS) RESULTS
Testing Area Test Resullts Grade Semester Year
Reading
Writing
Math
Science

Services and Environment

Individualized Education Program (IEP)
Student Name: Assessment (Form F) IEP Meeting Date:
Student ID: DOB:
SPECIAL EDUCATION SERVICES TO BE PROVIDED
Special Education Program(s) Necessary to Meet Special Education Goals and Objectives during the school
calendar year.
**The child is in need of specially designed instruction in the following areas:
Special Education Services Instructional Setting/Location Start Date Frequency Provider Duration/ End Date
`
RELATED SERVICES
Educationally Relevant Related Services Are Listed Below
Special Education Services Instructional Setting/Location Start Date Frequency Provider Duration/ End Date
Clarification:
SUPPLEMENTAL AIDS/ASSISTIVE TECHNOLOGY AND SERVICES FOR STUDENTS
Educationally Relevent Supplementary Aides/Assistive Technology and Services Are Listed Below
SUPPORTS FOR SCHOOL PERSONNEL
Supports For School Personnel Are Listed Below
Clarification:
LEAST RESTRICTIVE ENVIRONMENT
Provide an explanation of the extent, if any, to which the student will NOT participate with non-disabled students in the
general curriculum, extracurricular and nonacademic actitivities, and program options. §300.347(a)(4).
Consider any potential harmful effects of this placement for the child or on the quality of services that he or she needs §300.552(a-b):
Reason for Different Service School:

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