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IEP DEC 4 (1 of 10)

Check Purpose: ( FORMCHECKBOX ) Initial

( FORMCHECKBOX ) Annual Review

( FORMCHECKBOX ) Reevaluation

( FORMCHECKBOX ) Addendum

( FORMCHECKBOX ) Transition Part C to B

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Duration of Special Education and Related Services: From: To:

Student: DOB:

School: FORMTEXT Grade:

Primary Area of Eligibility* Secondary Area(s) of Eligibility: (if applicable)

(*Reported on Child Count)

Student Profile

Student’s overall strengths:

Summarize assessment information (e.g. from early intervention providers, child outcome measures, curriculum based measures, state and district assessments results, etc.), and review of progress on current IEP/IFSP goals:

Parent’s concerns, if any, for enhancing the student’s education:

Parent’s/Student’s vision for student’s future:

Consideration of Transitions

If a transition (e.g. new school, family circumstances, etc.) is anticipated during the life of this IEP/IFSP what information is known about the student that will assist in facilitating a smooth process? FORMCHECKBOX N/A

The student is age 14 or older or will be during the duration of the IEP. FORMCHECKBOX Yes FORMCHECKBOX No

IEP DEC 4 (2 of 10)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Duration of Special Education and Related Services: From: To:

Student: DOB:

School: FORMTEXT Grade:

Consideration of Special Factors (Note: If you check yes, you must address in the IEP.)

Does the student have behavior(s) that impede his/her learning or that of others? FORMCHECKBOX Yes FORMCHECKBOX No

Does the student have Limited English Proficiency? FORMCHECKBOX Yes FORMCHECKBOX No

If the student is blind or partially sighted, will the instruction in or use of Braille be needed? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A

Does the student have any special communication needs? FORMCHECKBOX Yes FORMCHECKBOX No

Is the student deaf or hard of hearing? FORMCHECKBOX Yes FORMCHECKBOX No

FORMCHECKBOX The child’s language and communication needs;

FORMCHECKBOX Opportunities for direct communications with peers and professional personnel in the child’s language and communication mode;

FORMCHECKBOX Academic level;

FORMCHECKBOX Full range of needs, including opportunities for direct instruction in the child’s language; and

FORMCHECKBOX Communication mode.

(Communication Plan Worksheet available at www.ncpublicschools.org/ec/policy/forms .)

Does the student require specially designed physical education? FORMCHECKBOX Yes FORMCHECKBOX No

IEP DEC 4 (3 of 10)

Complete Pages 3-4 for Each Annual Goal

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Duration of Special Education and Related Services: From: To:

Student: DOB:

School: FORMTEXT Grade:

Present Level(s) of Academic and Functional Performance

Include specific descriptions of what the student can and cannot do in relationship to this area. Include current academic and functional performance, behaviors, social/emotional development, other relevant information, and how the student’s disability affects his/her involvement and progress in the general curriculum.

Annual Goal

FORMCHECKBOX Academic Goal FORMCHECKBOX Functional Goal

Does the student require assistive technology devices and/or services? FORMCHECKBOX Yes FORMCHECKBOX No

If yes, describe needs:

(Address after determination of related services.) Is this goal integrated with related service(s)? FORMCHECKBOX Yes* FORMCHECKBOX No

*If yes, list the related service area(s) of integration:

IEP DEC 4 (4 of 10)

Complete Pages 3-4 for Each Annual Goal

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Duration of Special Education and Related Services: From: To:

Student: DOB:

School: FORMTEXT Grade:

Competency Goal

Required for areas (if any) where student participates in state assessments using modified achievement standards.

Select Subject Area: FORMCHECKBOX Language Arts FORMCHECKBOX Mathematics FORMCHECKBOX Science

List Competency Goal from the NC Standard Course of Study:

(Standard must match the student’s assigned grade.)

Note: Selected Grade Standard Competency Goals listed are those identified for specially designed instruction. In addition to those listed, the student has access to grade level content standards through general education requirements.

Benchmarks or Short Term Objectives (if applicable)

(Required for students participating in state alternate assessments aligned to alternate achievement standards)

Describe how progress toward the annual goal will be measured

IEP DEC 4 (5 of 10)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Duration of Special Education and Related Services: From: To:

Student: DOB:

School: FORMTEXT Grade:

Least Restrictive Environment

I. General Education Program Participation

In the space provided, list the general education classes, nonacademic services, and activities (ex: lunch, recess, assemblies, media center, field trips, etc.) in which the student will participate and the supplemental aids, supports, modifications, and/or accommodations required (if applicable) to access the general curriculum and make progress toward meeting annual goals. Discussion and documentation must include any test accommodations required for state and/or district-wide assessment. If supplemental aids/services, modifications/accommodations and/or assistive technology will be provided in special education classes include in the table below.

GENERAL EDUCATION NONACADEMIC SERVICES & ACTIVITIES SPECIAL EDUCATION (If Applicable)	SUPPLEMENTAL AIDS/SERVICES MODIFICATIONS/ACCOMMODATIONS ASSISTIVE TECHNOLOGY (If Applicable)	IMPLEMENTATION SPECIFICATIONS (Example: Who? What? When? Where?)

If the student is in preschool, describe how the student is involved in the general education program. FORMCHECKBOX N/A

Specify the technical assistance, if any, that will be provided to the general education teacher(s) and/or other school personnel for implementation of the IEP. FORMCHECKBOX None

IEP DEC 4 (6 of 10)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student Name: Duration From: To:

II. North Carolina Testing Program

Select the appropriate state assessment(s) that will allow the student to demonstrate his/her knowledge. Accommodations listed on the IEP must be used routinely in classroom instruction and on similar classroom assessments. Select testing accommodations that correlate to instructional accommodations used routinely throughout the academic year. For specifics regarding accommodation use and availability for specific tests, refer to the Testing Students with Disabilities publication, available at http://www.ncpublicschools.org/accountability/policies/tswd.

IEP Teams are instructed to select, for each assessment, only those accommodations that do not invalidate the score.

FORMCHECKBOX Student will participate in the Standard Test Administration with No Accommodations

FORMCHECKBOX Student will participate in the NCEXTEND1 with No Accommodations

FORMCHECKBOX Student will participate in the NCEXTEND1 with Accommodations

If checked, complete IEP DEC4 (6a of 10)

NC Testing Program

Approved Accommodations

Grades 3–8

Grades 5 & 8

Course Assessments

CTE

Tests of English Language

Proficiency

Grades K–12

FORMCHECKBOX W-APTTM

FORMCHECKBOX ACCESS for ELLs®

ELA

Mathematics

Science 1

English II 1

Algebra I/

Integrated I 1

Biology 1

Post-Assessment 1

Reading

Writing

Listening

Speaking

MUST BE COMPLETED

Student will participate in:

General Assessment

FORMCHECKBOX

NCEXTEND2 2

FORMCHECKBOX

Braille Edition

FORMCHECKBOX

Large Print Edition (not for online assessments)

FORMCHECKBOX

One Test Item Per Page Edition (not for online assessments)

FORMCHECKBOX

Assistive Technology Devices: Specify

FORMCHECKBOX

Braille Writer/Slate and Stylus (Braille Paper)

FORMCHECKBOX

Crammer Abacus

FORMCHECKBOX

Dictation to a Scribe

FORMCHECKBOX

Interpreter/Transliterator Signs/Cues Test

FORMCHECKBOX

Magnification Devices

FORMCHECKBOX

Word-to-Word Bilingual (English/Native Language) Dictionary/Electronic Translator (LEP only) 3

FORMCHECKBOX

Student Marks Answers in Test Book (not for online assessments)

FORMCHECKBOX

Student Reads Test Aloud to Self

FORMCHECKBOX

Test Administrator Reads Test Aloud

(In English)

FORMCHECKBOX Read Everything

FORMCHECKBOX

FORMCHECKBOX Read by Student Request

FORMCHECKBOX

FORMCHECKBOX Other

FORMCHECKBOX

Computer Reads Test Aloud – Student Controlled

(not for paper and pencil assessments)

FORMCHECKBOX

Multiple Testing

Sessions

FORMCHECKBOX More Frequent Breaks (Every Min.)

FORMCHECKBOX

FORMCHECKBOX Over Multiple Days (Number of Days )

FORMCHECKBOX

FORMCHECKBOX Other

FORMCHECKBOX

Scheduled Extended Time

FORMCHECKBOX Approximately minutes

FORMCHECKBOX

FORMCHECKBOX Other

FORMCHECKBOX

Testing in a

Separate Room

FORMCHECKBOX Small Group

FORMCHECKBOX

FORMCHECKBOX One-on-One

FORMCHECKBOX

Other (specify): 4

FORMCHECKBOX

1 Dependent upon the platform used to provide the student the general assessment (online vs. paper and pencil), some accommodations may be non-applicable or unavailable.

2 All NCEXTEND2 tests are designed to be administered online; therefore, some of the state-approved testing accommodations do not apply to these tests. If a paper and pencil version of the NCEXTEND2 test is needed as an accommodation, an Accommodation Notification Form (available from the school test coordinator) must be submitted to the LEA test coordinator.

3 Available only for students identified as limited English proficient (LEP) who scored below Level 5.0 Bridging on the reading subtest of the W-APT™ or ACCESS for ELLs®.

4 In order to be used on the state assessment this accommodation must be approved by the NCDPI. To request approval, an Accommodation Notification Form (available from the school test coordinator) must be submitted to the LEA test coordinator.

IEP DEC 4 (6b of 10)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Duration of Special Education and Related Services: From: To:

Student: DOB:

School: FORMTEXT Grade:

II. A. EXPLORE/PLAN/ACT/WorkKeys

	Accommodations:	Implementation Specifications:
8TH Grade - Explore1
10th Grade – PLAN¹
11th Grade – ACT²
12th Grade – WorkKeys1

¹ EXPLORE, PLAN, and WorkKeys accommodations must meet accommodations guidelines specified in the Supervisor’s Manuals that correspond to each test.

² Accommodations for the ACT must be requested and reviewed by ACT via submission of an ACT-Approved Accommodations Application. ACT-approved accommodations result in scores that are college-reportable, while state-allowed accommodations result in scores that are not college-reportable but may be used for state accountability purposes.

IEP DEC 4 (7 of 10)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Duration of Special Education and Related Services: From: To:

Student: DOB:

School: FORMTEXT Grade:

III. District-Wide Assessment Program

In the space provided, list the district-wide assessments, if any, and any accommodations or alternate assessments to be used by the student.

DISTRICT-WIDE ASSESSMENT(S)

ACCOMMODATION(S) OR ALTERNATE ASSESSMENT(S)

IMPLEMENTATION SPECIFICATIONS

IV. Alternate Assessment Justification

If the student is participating in any alternate assessment(s), explain why the regular testing program, with or without accommodations, is not appropriate and why the selected assessment is appropriate: FORMCHECKBOX N/A

V. Specially Designed Instruction, Related Services, and Nonacademic Services and Activities

A. Anticipated Frequency, Duration, and Location of Specially Designed Instruction

Special Education: Sessions Per: Session Length: Location:

Reporting

Week Month Period Year

1st Semester

2nd Semester

1st Semester

2nd Semester

1st Semester

2nd Semester

IEP DEC 4 (8 of 10)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Duration of Special Education and Related Services: From: To:

Student: DOB:

School: FORMTEXT Grade:

B. Anticipated Frequency and Location of Related Services

FORMCHECKBOX The IEP Team determined related services are not required to assist the student to benefit from special education.

FORMCHECKBOX The IEP Team determined the following related services are required to assist the student to benefit from special education.

Related Service(s): Sessions Per: Reporting Session Length: Location: Week Month Year Period

FORMCHECKBOX Support Description

FORMCHECKBOX Transportation is required as related service. Describe special transportation services:

C. Nonacademic Services & Activities (Refer to Section I: General Education Program Participation)

List the nonacademic services and activities in which the student will not participate with nondisabled peers. This time must be factored into the determination of continuum of alternative educational placement below.

Nonacademic Services & Activities: Sessions Per: Session Length:

Week Month Year Reporting Period

VI. Continuum of Alternative Educational Placements

Check all alternative placements considered by the team and circle the decision reached.

Educational placement is determined by calculating the amount of time the student is with nondisabled peers. Regular Early Childhood Program (RECP) is at least 50% of children enrolled in a class are nondisabled and do not have an IEP. A Special Education Program (Separate) class includes less than 50 percent nondisabled children.

School Age: Preschool:

FORMCHECKBOX Regular - 80% or more of the day with nondisabled peers FORMCHECKBOX RECP at least 10 hours a week, services in RECP program

FORMCHECKBOX Resource - 40% - 79% of the day with nondisabled peers FORMCHECKBOX RECP at least 10 hours a week, services in other location

FORMCHECKBOX Separate - 39% or less of the day with nondisabled peers FORMCHECKBOX RECP less than 10 hours a week, services in RECP program

FORMCHECKBOX Separate School FORMCHECKBOX RECP less than 10 hours a week, services in other location

FORMCHECKBOX Residential FORMCHECKBOX Separate, Special Education Class

FORMCHECKBOX Home/Hospital FORMCHECKBOX Separate School

FORMCHECKBOX Separate, Residential Facility

FORMCHECKBOX Home, or

FORMCHECKBOX Service Provider Location

IEP DEC 4 (9 of 10)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Duration of Special Education and Related Services: From: To:

Student: DOB:

School: FORMTEXT Grade:

VII. Least Restrictive Environment Justification Statement

If the student will be removed from nondisabled peers for any part of the day (general education classroom, nonacademic services and activities), explain why the services cannot be delivered with nondisabled peers with the use of supplemental aids and services.

FORMCHECKBOX N/A Student will not be removed from nondisabled peers.

VIII. Progress toward annual goals will be reported with the issuance of report cards unless otherwise specified below:

IX. Extended School Year Status (ESY worksheet available at www.ncpublicschools.org/ec/policy/forms.)

FORMCHECKBOX Is not eligible for extended school year

FORMCHECKBOX Is eligible for extended school year

FORMCHECKBOX Eligibility is under consideration and will be determined by

X. Record of IEP Team Participation (Note with an * any team member who used alternative means to participate.)

A. IEP Team. The following were present and participated in the development and writing of the IEP.

Name Position Date

LEA Representative

General Education Teacher

Special Education Teacher

Parent

Student

Copy given/sent to parent(s): by on .

IEP DEC 4 (page 10 of 10)

INDIVIDUALIZED EDUCATION PROGRAM (IEP) ADDENDUM

Duration of Special Education and Related Services: From: To:

Student: DOB:

School: FORMTEXT Grade:

X. Record of IEP Team Participation continued

(Note with an * any team member who used alternative means to participate.)

B. Reevaluation. The IEP was reviewed at reevaluation and was found to be appropriate. An annual review of this IEP will be conducted on or before .

Name Position Date

LEA Representative

General Education Teacher

Special Education Teacher

Parent

Student

XI. Amending the IEP

The IEP was amended due to a disciplinary change in placement. FORMCHECKBOX yes FORMCHECKBOX no

A. IEP Addendum Team.

The following were present and participated in the development and writing of the addendum to the IEP.

Name Position Date

LEA Representative

General Education Teacher

Special Education Teacher

Parent

Student

B. Amending the IEP without holding a meeting after the annual IEP Team meeting for the school year.

FORMCHECKBOX The parent and LEA agreed that the IEP could be amended by on without holding a meeting.

FORMCHECKBOX Copies of the amendment were provided to individuals responsible for implementing changes to the IEP by on

Indicate page(s) and section(s) where any amendment(s) were made:

FORMCHECKBOX A revised copy of the IEP with amendments incorporated was provided to parent(s) on by .

Revised 09/2012