INDIVIDUALIZED EDUCATION PRyOGRAM (IEP)

INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

Student’s Name:
IEP Team Meeting Date (mm/dd/yy):
IEP Implementation Date (Projected Date when Services and Programs Will Begin):
Anticipated Duration of Services and Programs:
Date of Birth:
Age:
Grade:
Anticipated Year of Graduation:
Local Education Agency (LEA):
County of Residence:
Name and Address of Parent/Guardian/Surrogate:	Phone (Home):
		Phone (Work):
Other Information:

The LEA and parent have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:

Date of Revision(s)	Participants/Roles	IEP Section(s) Amended

IEP TEAM/SIGNATURES

The Individualized Education Program team makes the decisions about the student’s program and placement. The student’s parent(s), the student’s special education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not agreement.

Role	Printed Name	Signature
Parent/Guardian/Surrogate
Parent/Guardian/Surrogate
Student*
Regular Education Teacher**
Special Education Teacher
Local Ed Agency Rep
Career/Tech Ed Rep***
Community Agency Rep
Teacher of the Gifted****

* The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.

** If the student is, or may be, participating in the regular education environment

*** As determined by the LEA as needed for transition services and other community services

**** A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.

One individual listed above must be able to interpret the instructional implications of any evaluation results.

Written input received from the following members:

Transfer of Rights at Age of Majority

For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.

PROCEDURAL SAFEGUARDS NOTICE

I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights, including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.

Signature of Parent/Guardian/Surrogate:

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical Assistance programs)

I understand that the school may charge the School-Based Access Program (“SBAP”)—or any program that replaces or supplements the SBAP—the cost of certain special education and related services described in my child’s IEP.  To make these charges to the SBAP, the school will release to the administrator of that program the name, age, and address of my child, verification of Medicaid eligibility for my child, a copy of my child’s IEP, a description of the services provided and the times and dates during which such services were provided to my child, and the identity of the provider of such services.  I understand that such information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have provided written consent to disclose such information.

I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to write, at any time.  My refusal to consent or my withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my family, any service or program to which my child is entitled under the Individuals with Disabilities Education Act (“IDEA”) or that is necessary to enable my child to receive a free appropriate public education as described in my child’s IEP. 

I understand that the school cannot—

Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a condition of receiving a free appropriate public education for my child;

Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including co-payments and deductibles, unless it agrees to pay such expenses on my or my family’s behalf;

Cause a decrease in available lifetime coverage or any other insured benefit;

Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that are required for my child outside the time that he or she is in school;

Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.

I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS “YES” MUST BE ADDRESSED IN THE IEP.

Is the student blind or visually impaired?

	Yes		The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an evaluation of the student’s reading and writing skills, needs, and appropriate reading and writing media (including an evaluation of the student’s future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of Braille is not appropriate for the student.
	No

Is the student deaf or hard of hearing?

	Yes		The IEP must include a communication plan to address the following: language and communication needs; opportunities for direct communications with peers and professional personnel in the student’s language and communication mode; academic level; full range of needs, including opportunities for direct instruction in the student’s language and communication mode; and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The Communication Plan must be completed and is available at www.pattan.net
	No

Does the student have communication needs?

	Yes		Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)
	No

Does the student need assistive technology devices and/or services?

	Yes		Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)
	No

Does the student have limited English proficiency?

	Yes		The IEP team must address the student’s language needs and how those needs relate to the IEP.
	No

Does the student exhibit behaviors that impede his/her learning or that of others?

	Yes		The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A Positive Behavior Support Plan and a Functional Behavioral Assessment form are available at www.pattan.net
	No

Other (specify):

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:

· Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based assessments, transition assessments, progress toward current goals)

· Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress toward current goals)

· Present levels related to current postsecondary transition goals if the student’s age is 14 or younger if determined appropriate by the IEP team (e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)

· Parental concerns for enhancing the education of the student

· How the student’s disability affects involvement and progress in the general education curriculum

· Strengths

· Academic, developmental, and functional needs related to student’s disability

III. TRANSITION SERVICES – This is required for students age 14 or younger if determined appropriate by the IEP team. If the student does not attend the IEP meeting, the school must take other steps to ensure that the student’s preferences and interests are considered. Transition services are a coordinated set of activities for a student with a disability that is designed to be within a results oriented process, that is focused on improving the academic and functional achievement of the student with a disability to facilitate the student’s movement from school to post school activities, including postsecondary education, vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent living, or community participation that is based on the individual student’s needs taking into account the student’s strengths, preferences, and interests.

POST SCHOOL GOALS – Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal. Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.

For students in Career and Technology Centers, CIP Code:

Postsecondary Education and Training Goal:	Measurable Annual Goal Yes/No (Document in Section V)
Courses of Study:
Service/Activity	Location	Frequency	Projected Beginning Date	Anticipated Duration	Person(s)/Agency Responsible
Employment Goal:	Measurable Annual Goal Yes/No (Document in Section V)
Courses of Study:
Service/Activity	Location	Frequency	Projected Beginning Date	Anticipated Duration	Person(s)/Agency Responsible

Independent Living Goal, if appropriate:	Measurable Annual Goal Yes/No (Document in Section V)
Courses of Study:
Service/Activity	Location	Frequency	Projected Beginning Date	Anticipated Duration	Person(s)/Agency Responsible

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS Instructions for IEP Teams: Please select the appropriate assessment option. Information on available testing accommodations may be found in the Accommodations Guidelines available on www.education.state.pa.us . State Assessments Not Assessed No statewide assessment is administered at this student’s grade level. No English proficiency assessment administered because the student is not an English Language Learner. PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5 and 8; and ELA*) Tested Subject Without Accommodations With Accommodations Accommodations to be Provided Math Science Reading Writing ELA* *ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8. Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11th grade) Tested Subject Without Accommodations With Accommodations Accommodations to be Provided Algebra 1 Literature Biology Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam module.) Tested Subject Without Accommodations With Accommodations Accommodations to be Provided Algebra 1 Literature Biology Validated Local Assessment (Available when selected as option by LEA) Tested Subject Without Accommodations With Accommodations Accommodations to be Provided Algebra 1 Literature Biology PASA (Administered in grades 3-8, 11 for Reading and Math; Grades 4, 8, 11 for Science) Student will participate in the PASA. Explain why the student cannot participate in the PSSA or the Keystone Exam for Reading/Literature, Math/Algebra 1, Science/Biology, and Composition (The Composition exam will be available for the 2016-17 school year): Explain why the PASA is appropriate: Choose how the student’s performance on the PASA will be documented. Videotape (preferred method) Written narrative notes (requires prior approval in accordance with PDE guidance) ACCESS for ELLs (Administered in grades K-12) Domains Without Accommodations With Accommodations Unable to Participate Accommodations to be Provided or Rationale for Inability to Participate in Selected Domains Listening Reading Writing Speaking Alternate ACCESS for ELLs (Administered in grades 1-12) Student will participate in the Alternate ACCESS for ELLs. Explain why the student cannot participate in the ACCESS for ELLs: Explain why the Alternate ACCESS for ELLs is appropriate: Domains Without Accommodations With Accommodations Unable to Participate Accommodations to be Provided or Rationale for Inability to Participate in Selected Domains Listening Reading Writing Speaking Local Assessments Local assessment is not administered at this student’s grade level; OR Student will participate in local assessments without accommodations; OR Student will participate in local assessments with the following accommodations; OR The student will take a local alternate assessment. Explain why the student cannot participate in the local regular assessment: Explain why the local alternate assessment is appropriate:

V. GOALS AND OBJECTIVES – Include, as appropriate, academic and functional goals. Use as many copies of this page as needed to plan appropriately. Specially designed instruction may be listed with each goal/objective or listed in Section VI.

Short term learning outcomes are required for students who are gifted. The short term learning outcomes related to the student’s gifted program may be listed under Goals or Short Term Objectives.

MEASURABLE ANNUAL GOAL Include: Condition, Name, Behavior, and Criteria (Refer to Annotated IEP for description of these components)	Describe HOW the student’s progress toward meeting this goal will be measured	Describe WHEN periodic reports on progress will be provided to parents	Report of Progress

SHORT TERM OBJECTIVES – Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).

Short term objectives / Benchmarks

VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS – Include, as appropriate, for nonacademic and extracurricular services and activities.

A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)

· SDI may be listed with each goal or as part of the table below.

· Include supplementary aids and services as appropriate.

· For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or modifications to the general education curriculum, as appropriate for a student with a disability.

Modifications and SDI	Location	Frequency	Projected Beginning Date	Anticipated Duration

B. RELATED SERVICES – List the services that the student needs in order to benefit from his/her special education program.

Service	Location	Frequency	Projected Beginning Date	Anticipated Duration

C. SUPPORTS FOR SCHOOL PERSONNEL – List the staff to receive the supports and the supports needed to implement the student’s IEP.

School Personnel to Receive Support	Support	Location	Frequency	Projected Beginning Date	Anticipated Duration

D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS IDENTIFIED AS A STUDENT WITH A DISABILITY – Support services are required to assist a gifted student to benefit from gifted education (e.g., psychological services, parent counseling and education, counseling services, transportation to and from gifted programs to classrooms in buildings operated by the school district).

Support Service
Support Service
Support Service

E. EXTENDED SCHOOL YEAR (ESY) – The IEP team has considered and discussed ESY services, and determined that:

		Student IS eligible for ESY based on the following information or data reviewed by the IEP team:
		OR
		As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:

The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the student’s ESY Program are:

If the IEP team has determined ESY is appropriate, complete the following:

ESY Service to be Provided	Location	Frequency	Projected Beginning Date	Anticipated Duration

VII. EDUCATIONAL PLACEMENT

A. QUESTIONS FOR IEP TEAM – The following questions must be reviewed and discussed by the IEP team prior to providing the explanations regarding participation with students without disabilities.

It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public or private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal of students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education in general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily. · What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general education class. · What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special education class? · What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the class, even with supplementary aids and services? · To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:

B. Type of Support

1. Amount of special education supports

	Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day
	Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than 80% of the school day
	Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day

2. Type of special education supports

	Autistic Support
	Blind-Visually Impaired Support
	Deaf and Hard of Hearing Support
	Emotional Support
	Learning Support
	Life Skills Support
	Multiple Disabilities Support
	Physical Support
	Speech and Language Support

C. Location of student’s program

Name of School District where the IEP will be implemented:
Name of School Building where the IEP will be implemented:

Is this school the student’s neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?

	Yes
	No. If the answer is “no,” select the reason why not.
			Special education supports and services required in the student’s IEP cannot be provided in the neighborhood school
			Other. Please explain:

VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one Educational Environment)

To calculate the percentage of time inside the regular classroom, divide the number of hours the student spends inside the regular classroom by the total number of hours in the school day (including lunch, recess, study periods). The result is then multiplied by 100.

SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers – Indicate the Percentage of time INSIDE the regular classroom for this student:

Time spent outside the regular classroom receiving services unrelated to the student’s disability (e.g., time receiving ESL services) should be considered time inside the regular classroom. Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time spent inside the regular classroom.

Calculation for this Student:

Column 1	Column 2	Calculation	Indicate Percentage	Percentage Category
Total hours the student spends in the regular classroom per day	Total hours in a typical school day (including lunch, recess & study periods)	(Hours inside regular classroom ÷ hours in school day) x 100 = % (Column 1 ÷ Column 2) x 100 = %	Section A: The percentage of time student spends inside the regular classroom:	Using the calculation result – select the appropriate percentage category
			_____% of the day	FORMCHECKBOX INSIDE the Regular Classroom 80% or More of the Day FORMCHECKBOX INSIDE the Regular Classroom 79-40% of the Day FORMCHECKBOX INSIDE the Regular Classroom Less Than 40% of the Day

SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day – select and indicate the Name of School or Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP team must do the calculation in Section A)

FORMCHECKBOX Approved Private School (Non Residential) _________________________

FORMCHECKBOX Approved Private School (Residential) _________________________

FORMCHECKBOX Other Private Facility (Non Residential) _________________________

FORMCHECKBOX Other Private Facility (Residential) ________________________

FORMCHECKBOX Other Public Facility (Residential) ________________________

FORMCHECKBOX Other Public Facility (Non Residential) _________________________

FORMCHECKBOX Hospital/Homebound _________________________

FORMCHECKBOX Correctional Facility _________________________

FORMCHECKBOX Out of State Facility _________________________

FORMCHECKBOX Instruction Conducted in the Home _________________________

EXAMPLES for Section A: How to Calculate PennData–Educational Environment Percentages

	Column 1	Column 2	Calculation	Indicate Percentage
	Total hours the student spends in the regular classroom per day	Total hours in a typical school day (including lunch, recess & study periods)	(Hours inside regular classroom ÷ hours in school day) x 100 = % (Column 1 ÷ Column 2) x 100 = %	Section A: The percentage of time student spends inside the regular classroom:
Example 1	5.5	6.5	(5.5 ( 6.5) x 100 = 85%	85% of the day (Inside 80% or More of Day)
Example 2	3	5	(3 (5) x 100 = 60%	60% of the day (Inside 79-40% of Day)
Example 3	1	5	(1( 5) x 100 = 20%	20% of the day (Inside less than 40% of Day)

For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on the website. If you do not have access to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.