IEP_FORM.doc

7/21/2019 IEP_FORM.doc

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THE INDIVIDUALIZED EDUCATION PROGRAM FOR:

Name: First Middle Last

STUDENT DEMOGRAPHIC INFORMATION (Optional):

Current Address: Phone:

Birth date: / / Age: Student ID #/MOSIS#:

Present Grade Leel: !esident Distri"t ome S"hool:

I$ the "hild is Not re"eiing his/her s%e"ial edu"ation and related seri"es in his/her home s"hool or resident distri"t& indi"ate 'elo(

(here the seri"es are 'eing %roided)

Distri"t/Agen"* Name:

S"hool Name:

Address:

Phone:

Primar* Language or Communi"ation Mode+s,: -nglish S%anish sign language other +s%e"i$*,..............

-du"ational De"ision Maer is: Parent Legal Guardian -du"ational Surrogate Foster Parent Child 0aged 1234

other................

Name:

Address:

Phone: -mail: Fa5:

I-P Case Manager: Case Manager %hone num'er:

I-P 6*%e Initial Annual Date o$ most re"ent ealuation/reealuation / /

Date o$ Preious I-P !eie(: / / Pro7e"ted date $or ne5t triennial ealuation / /

IEP CONTENT (Re!i"e#):

Date o$ I-P Meeting: / / Initiation Date o$ I-P: / /

Pro7e"ted Date o$ Annual I-P !eie(: / / Parent+s,/Legal Guardian+s, %roided "o%* o$ this I-P: / /

PARTICIPANTS IN IEP MEETING AND ROLE(S)6he names and roles o$ indiiduals pa"ti$ipatin% in #e&elopin% the I-P meeting must 'e do"umented)

Na'e o Pe"on an# RoleSignatures are not re8uired) I$ a signature is used it onl* indi"ates attendan"e& not agreement)

Met*o# o Atten#an$e

Parent/Guardian

Parent/Guardian

Student

L-A !e%resentatie in %erson e5"used

in (riting +i$ a%%li"a'le,

S%e"ial -du"ation 6ea"her in %erson e5"used in (riting +i$ a%%li"a'le,

!egular Classroom 6ea"her in %erson e5"used in (riting +i$ a%%li"a'le,

Indiidual Inter%reting Instru"tional

Im%li"ations o$ -aluation !esults

in %erson e5"used

in (riting +i$ a%%li"a'le,

Part C !e%resentatie +i$ a%%li"a'le,

!e%resentatie o$ an agen"* (hi"h ma* %roide

%ostse"ondar* transition seri"es +i$ a%%li"a'le,

Other:

Rev. October 7, 2011 Page 1 of 9



Student Name: .................................................................. Date o$ I-P:..................

+, P"eent Le&el o A$a#e'i$ A$*ie&e'ent an# F!n$tional Pe"o"'an$e

Present Leel must in"lude:

• o( the "hild9s disa'ilit* a$$e"ts his/her inolement and %rogress in the general edu"ation "urri"ulum or $or %res"hool

"hildren& %arti"i%ation in age;a%%ro%riate a"tiities) +For students (ith transition %lans& "onsider ho( the "hild9s disa'ilit*

(ill a$$e"t the "hild9s a'ilit* to rea"h his/her %ost;se"ondar* goals +(hat the "hild (ill do a$ter high s"hool,),

• 6he strengths o$ the "hild +For students (ith transition %lans& "onsider ho( the strengths o$ the "hild relate to the "hild9s

%ost;se"ondar* goals),

• Con"erns o$ the %arent/guardian $or enhan"ing the edu"ation o$ the "hild +For students (ith transition %lans& "onsider the

%arent/guardian9s e5%e"tations $or the "hild a$ter the "hild leaes high s"hool),

• Changes in "urrent $un"tioning o$ the "hild sin"e the initial or %rior I-P +For students (ith transition %lans& "onsider ho(

"hanges in the "hild9s "urrent $un"tioning (ill im%a"t the "hild9s a'ilit* to rea"h his/her %ost;se"ondar* goal),

• A summar* o$ the most re"ent ealuation/re;ealuation results

• A summar* o$ the results o$ the "hild9s %er$orman"e on:

Formal or in$ormal age a%%ro%riate transition assessments:

•

For students %arti"i%ating in alternatie assessments& a des"ri%tion o$ 'en"hmars or short;term o'7e"ties N/A O'7e"ties/'en"hmars are on goal %age+s,

O'7e"ties/'en"hmars des"ri'ed 'elo(:





-, Spe$ial Coni#e"ation: Fe#e"al an# State Re!i"e'ent Note: For the $irst si5 items 'elo(& i$ the I-P team determines that the "hild needs a %arti"ular dei"e or seri"e +in"luding aninterention& a""ommodation& or other %rogram modi$i"ation, in$ormation do"umenting the team9s de"ision regarding the dei"e or

seri"e must 'e in"luded in the a%%ro%riate se"tion o$ the I-P) 6hese must 'e "onsidered annuall*)

I t*e t!#ent .lin# o" &i!all/ i'pai"e#0

No

<es) I$ *es& "om%lete Form A: Blind and =isuall* Im%aired)

I t*e t!#ent #ea o" *ea"in% i'pai"e#0 No <es) 6he I-P 6eam has "onsidered the "hild9s language and "ommuni"ation needs& o%%ortunities $or dire"t "ommuni"ation (ith

%eers and %ro$essionals in the "hild9s language and "ommuni"ation mode& a"ademi" leel& and $ull range o$ needs in"luding

o%%ortunities $or dire"t instru"tion in the "hild9s language and "ommuni"ation mode in the deelo%ment o$ the I-P)

Doe t*e t!#ent e1*i.it .e*a&io" t*at i'pe#e *i2*e" lea"nin% o" t*at o ot*e"0

No

<es) I$ *es& strategies in"luding %ositie 'ehaior interentions and su%%orts must 'e "onsidered '* the I-P team& and i$ determinedne"essar*& addressed in this I-P) I$ a 'ehaior interention %lan is deelo%ed it must 'e a %art o$ the I-P)

Doe t*e t!#ent *a&e li'ite# En%li* p"oi$ien$/0

No

<es) 6he student9s language needs are addressed in this I-P) Students (ho are -nglish Language Learners +-LL, in grades >;1? tae

the state9s annual -nglish Language Pro$i"ien"* assessment& @IDA;ACC-SS)

Doe t*e t!#ent *a&e $o''!ni$ation nee#0 No <es) 6he student9s "ommuni"ation needs are addressed in this I-P)

Doe t*e t!#ent "e!i"e Aiti&e Te$*nolo%/ #e&i$e() an#2o" e"&i$e0

No

<es) 6he student9s assistie te"hnolog* needs are addressed in this I-P)

E1ten#e# S$*ool 3ea":

No) 6he student is not eligi'le $or -S< seri"es)

<es) 6he student is eligi'le $or -S< seri"es) Co'plete Fo"' 4

6he need $or -S< seri"es (ill 'e addressed at a later date) @ill 'e addressed '* / +month/*ear,)

Atta$* IEP A'en#'ent pa%e an# Fo"' 4

T"ane" o Ri%*t: Noti$i"ation must 'e gien 'eginning not later than one *ear 'e$ore the student is 12 in$orming the student o$ therights under ID-A that (ill trans$er to the student u%on rea"hing the age o$ ma7orit*)

N/A $or this student/I-P

Noti$i"ation (as gien: / / +month/da*/*ear,)

State Ae'ent

IDEA "e!i"e t!#ent 5it* #ia.ilitie to pa"ti$ipate in tate ae'ent, @IDA;ACC-SS is the annual -nglish Language

Pro$i"ien"* assessment $or -LL students in grades >;1?) Grade;Leel Assessment is administered in grades ;2) MAP;A isadministered in grades ;2 and 1;11) For eligi'ilit* "riteria $or MAP;A see:

htt%://((()dese)mo)go/diim%roe/assess/MAP.A/eligi'ilit*."riteria.1.)%d$

En# o Co!"e E1a' a"e a#'inite"e# to e$on#a"/ t!#ent 5*o *a&e $o'plete# $o!"e le&el e1pe$tation o" 5*o a"e

%"a#!atin% o" e1itin% e$on#a"/ $*ool #!e to a%e li'it 5it*o!t $o'pletin% $o!"e le&el e1pe$tation, Does this student9s grade

%la"ement or "ourse o$ stud* during the time this I-P is in e$$e"t re8uire "onsideration o$ %arti"i%ation in state assessments

No

<es) I$ *es& Co'plete Fo"' D)

Dit"i$t65i#e Ae'entAre there distri"t;(ide assessments administered $or this student9s age/grade leel

No

<es) I$ *es& Co'plete Fo"' E)

Pot6e$on#a"/ T"anition Se"&i$e: (M!t .e in$l!#e# not late" t*an t*e i"t IEP to .e in ee$t 5*en t*e $*il# t!"n +78 an#

!p#ate# ann!all/ t*e"eate",)

Is a Post;se"ondar* 6ransition Plan re8uired

No +Child (ill not turn si5teen (hile this I-P is in e$$e"t),

<es +Child is/(ill 'e si5teen (hile this I-P is in e$$e"t), I /e8 Co'plete Fo"' C 9 Pot6e$on#a"/ T"anition Plan


http://www.dese.mo.gov/divimprove/assess/MAP_A/eligibility_criteria_10_07.pdf






, IEP Goal Annual Measura'le Goals

Annual Goal #: ......

For students (ith Post;se"ondar* 6ransition Plans& %lease indi"ate (hi"h goal domain+s, this annual goal (ill su%%ort:

Post;se"ondar* -du"ation/6raining -m%lo*ment Inde%endent Liing

Progress to(ard the goal (ill 'e measured '*: ($*e$; all t*at appl/)

@or sam%les Curri"ulum 'ased tests Port$olios Che"lists

S"oring guides O'seration "hart !eading re"ord Other:

Comments:







Comments:







Comments:





<, Repo"tin% P"o%"e=*en P"o%"e 5ill .e "epo"te# to t*e pa"ent()2%!a"#ian()

Euarterl* Bi;Euarterl* Semester Annuall* Other:

>, Se"&i$e S!''a"/

A'o!nt F"e!en$/ Lo$ation 4e%inDate?

EnDat

Spe$ial E#!$ation Se"&i$e

...............................................

...............................................

............................................

........

........

........

@@@@@@@@@

@@@@@@@@@

@@@@@@@@@

.....................

.....................

.....................

.....

.....

.....

....

....

....

Relate# Se"&i$e

...............................................

............................................... ............................................

N/A

........

........ ........

@@@@@@@@@

@@@@@@@@@

@@@@@@@@@

.....................

..................... .....................

..... .....

.....

.... ....

....

S!pple'enta"/ Ai#2Se"&i$e

...............................................

...............................................

............................................

N/A

........

........

........

@@@@@@@@@

@@@@@@@@@

@@@@@@@@@

.....................

.....................

.....................

.....

.....

.....

....

....

....

P"o%"a' Mo#ii$ation an# A$$o''o#ation

Do$!'ente# on alte"nate Fo"' F

N/A

S!ppo"t o" S$*ool Pe"onnel

Do$!'ente# on alte"nate Fo"' F

N/A

*N/A if will be sae as i!itiatio! a!" a!!#al review "ate i!"icate" o! $age 1. %f a "ate is liste", it #st i!cl#"e t&e o!t&, "a', a!" 'ear.

7, T"anpo"tation a a Relate# Se"&i$e

6he student #oe not re8uire trans%ortation as a related seri"e)

6he student re8uires trans%ortation as a ne"essar* related seri"e)

6he student needs a""ommodations or modi$i"ations $or trans%ortation) No <es

I$ *es& "he" an* trans%ortation a""ommodations/modi$i"ations that are needed)

@heel"hair li$t

Child sa$et* restraint s*stem) S%e"i$*:..................................................... Door to door %i";u% and dro%;o$$

Cur' to "ur' %i";u% and dro%;o$$

Aide

Other) S%e"i$*: .......................................................................

Rev. October 7, 2011 Page ( of 9




, Re%!la" E#!$ation Pa"ti$ipation

-5tent o$ Parti"i%ation in !egular -du"ation

Fo" P"e$*ool: @ill all o$ this "hild9s s%e"ial edu"ation and related seri"es 'e %roided (ith non;disa'led %eers in a regular edu"ation setting+designed %rimaril* $or "hildren (ithout disa'ilities,

<es)

No) I$ no:a) 6o (hat e5tent (ill the "hild not re"eie s%e"ial edu"ation and related seri"es in a regular edu"ation setting +minutes or o$ s%e"ial

edu"ation and related seri"e minutes on the I-P,....................................................................

') Des"ri'e the reasons (h* the I-P team determined that %roision o$ seri"es in the regular edu"ation setting (as not a%%ro%riate)

Fo" B6+-: 6he regular edu"ation enironment in"ludes all a"ademi" instru"tion as (ell as meals& re"ess& assem'lies& $ield tri%s& et") @ill this studen %arti"i%ate 1 o$ the time (ith non;disa'led %eers in the regular edu"ation enironment

<es)

No) I$ no& des"ri'e 'elo( to (hat e5tent the student (ill not %arti"i%ate an# (h* $ull %arti"i%ation is not a%%ro%riate) .+"hild9s name, ............ (ill %arti"i%ate in regular edu"ation ...... o$ the time) Full %arti"i%ation in regular edu"ation is not a%%ro%riate

'e"ause:

Parti"i%ation in Ph*si"al -du"ation

6he student (ill %arti"i%ate in:!egular %h*si"al edu"ation

!egular %h*si"al edu"ation (ith a""ommodations as addressed in this I-P

Ada%ted %h*si"al edu"ation +in"ludes s%e"ial P-& ada%ted P-& moement edu"ation and motor deelo%ment, No %h*si"al edu"ation a"tiities are re8uired $or one o$ the $ollo(ing reasons:

Credit alread* earned Credit (aied Child is %res"hool age Other:

Parti"i%ation in Program O%tions& Nona"ademi"& and -5tra"urri"ular A"tiities

6he distri"t assures that this student (ill hae an e8ual o%%ortunit* to %arti"i%ate in %rogram o%tions& nona"ademi" and/or e5tra"urri"ular a"tiitiesand seri"es o$$ered '* the distri"t)

Rev. October 7, 2011 Page ) of 9




, Pla$e'ent Coni#e"ation an# De$iion

6his se"tion is a SMMA!< o$ all o$ the $ollo(ing: Present Leel o$ A"ademi" A"hieement and Fun"tional Per$orman"e& goals&

o'7e"ties/'en"hmars +i$ a%%li"a'le,& "hara"teristi"s o$ seri"es& ada%tations& and s%e"ial edu"ation and related seri"es in$ormation)

Ann!al Coni#e"ation o Pla$e'ent

Fo" ECSE: At least annuall* the I-P team must "onsider (hether all the s%e"ial edu"ation and related seri"es (ill 'e %roided (ith non;disa'led

%eers in a regular edu"ation setting +designed %rimaril* $or "hildren (ithout disa'ilities,)

Fo" B6+-: At least annuall*& the I-P team must "onsider i$ the I-P goals "an 'e met (ith seri"es %roided 1 o$ the time in the regular edu"ation

enironment)

Che" all %la"ement o%tions that (ere $oni#e"e# $or the %roision o$ s%e"ial edu"ation and related seri"es +$or >;1?& Inside regular "lass at least

2 o$ time must 'e "he"ed) For %res"hool an -C setting must 'e "he"ed,)

Che" the one %la"ement o%tion that (as sele"ted)

Pla$e'ent Contin!!' (B6+-)

Considere

d

Sele"ted

Inside regular "lass at least 2 o$ timeInside regular "lass H to o$ time

Inside regular "lass less than H o$ time

Pu'li" se%arate s"hool +da*, $a"ilit*Priate se%arate s"hool +da*, $a"ilit*

Pu'li" residential $a"ilit*

Priate residential $a"ilit*ome'ound/hos%ital

Pla$e'ent Option (ECSE)

Considere

d

Sele"ted

-arl* "hildhood setting-arl* "hildhood s%e"ial edu"ation

ome

Part;time earl* "hildhood/Part;time earl*"hildhood s%e"ial edu"ation

!esidential $a"ilit*

Se%arate s"hoolItinerant seri"e outside the home

Fo" B6+- t!#ent: Is this student9s %la"ement as "lose as %ossi'le to the "hild9s home and/or in the s"hool he/she (ould attend i$ nondisa'led

<es)

No) I$ NO& e5%lain (h* another s"hool/setting is re8uired)

I-P team de"ision

Parent trans$er re8uest

Other:




Student Name: .................................................................. Date o$ I-P:..................Alte"nate Fo"' FIndi"ate 'elo( the a""ommodations and modi$i"ations $or the student to 'e used in general and/or s%e"ial edu"ation and su%%orts to 'e %roided to s"ho

%ersonnel)

Lo$ation F"e!en$/ D!"ation?

A l l A r e a s

L a n g u a g e A r t s

M a t h e m a t i " s

S " i e n " e

S o " i a l S t u d i e s

# e a l t h

F i n e A r t s

P - / A t h l e t i " s

! e a d i n g

! e l a t e d S e r i " e s

O t h e r :

Modi$i"ations/A""ommodations

D a i l *

@ e e l *

M o n t h l *

O t h e r :

Beg) Date -nd Date

+, G"a#in% Modi$* (eight o$ "ourse e5aminations

Modi$* (eight o$ "ourse "om%onents

se (eel* grade "he"s

Other:

-, Te1t

Audio

Digital

Braille

ighlighted

Proide home set o$ te5t'oos/materials

Stud* Guides

Large Print

Ada%ted or sim%li$ied te5t/material

Other:

, Le$t!"e

6a%ed

Note taing assistan"e

Pre$erential Seating

6ea"her %roides notes

Stud* Guides

Other:

<, Tet2E1a'

Oral

Short Ans(er

-5tended time $or "om%letion

6a%ed

Multi%le sessions -5ams o$ redu"ed length

O%en 'oo e5ams

!ead test to student

Modi$* 6est Format

!e"ord student res%onses

Alternatie setting

Other:

>, En&i"on'ent

Pre$erential seating

Alter %h*si"al room arrangement +des"ri'e,

Ad7ustments $or s%ee"h intelligi'ilit*/$luen"*

Stud* "arrel $or inde%endent (or

Other:7, Ai%n'ent

!ead or ta%e re"ord dire"tions to student

Allo( "o%*ing $rom %a%er/'oo

Lo(er di$$i"ult* leel;shorten assignments

Dire"tions gien in a ariet* o$ (a*s

!edu"e %a%er/%en"il tass

Gie oral "ues/%rom%ts

Allo( student to re"ord or t*%e assignments

Ada%t (orsheets and %a"ets

Aoid %enaliJing $or %enmanshi%

Aoid %enaliJing $or s%elling errors

-5tended 6ime $or "om%letion

Rev. October 7, 2011 Page of 9




Lo$ation F"e!en$/ D!"ation?

A l l A r e a s

L a n g u a g e A r t s

M a t h e m a t i " s

S " i e n " e

S o " i a l S t u d i e s

# e a l t h

F i n e A r t s

P - / A t h l e t i " s

! e a d i n g

! e l a t e d S e r i " e s

O t h e r :

Modi$i"ations/ A""ommodations

D a i l *

@ e e l *

M o n t h l *

O t h e r :

Beg) Date -nd Da

Proide stud* aides

Maintain assignment note'oo Proide stru"tured time $or organiJation o$ materials

Assistan"e in re"ording assignments

Other:

, Reino"$e'ent

se %ositie/"on"rete rein$or"ers

!e%eated reie( and drill

Fre8uent reminders o$ rules

Che" o$ten $or understanding/reie(

Fre8uent e*e "onta"t/%ro5imit* "ontrol

Other:

, Pa$in%

-5tended time $or oral res%onses

-5tended time $or (ritten res%onses

Allo( $re8uent 'reas/ar* a"tiities

Other:

, Ot*e" (Spe$i/)

S!ppo"t o" S$*ool Pe"onnel

S%e"ialiJed Material +S%e"i$*,

6raining +S%e"i$*,

Consultant Seri"es +S%e"i$*,

Other:

Other:

Other:


Documents

IEP_FORM.doc