TOOL 1: Sample ILP Instrument

Date Updated

Date of most recent update to ILP instrument: / Sections #s updated:
Dates of prior ILP instrument updates:

1)Student Personal Information

Student name: / Projected high school graduation year:
School mentor name: / School name:
Student date of birth: / Grade level:
Address: / Email:
Phone 1: / Phone 2:

2)Parent/Guardian/Other Caring Adult Information

Name 1: / Relationship:
Address: / Email:
Phone 1: / Phone 2:
Name 2: / Relationship:
Address: / Email:
Phone 1: / Phone 2:
Name 3: / Relationship:
Address: / Email:
Phone 1: / Phone 2:

3)Other Student Plans

Check off the other types of student plans that are in place, and provide the date of the most recent version for each applicable plan.

Student Plan / Date of Most Recent Version
504 Education Plan
Individualized Education Plan (IEP)
Transition Planning Form (TPF)
Education Proficiency Plan (EPP)
CVTE Career Plan (Career Plan)
Individual Student Success Plan (ISSP)
Other:
Other:

4)Student Identified Strengths

Provide an overview of your self-identified strengths in the personal/social, academic, and workplace readiness domains.

Personal/Social:
Academic:
Workplace Readiness:

5)Student Identified Barriers to Success

Check all boxes that apply to you and identify any steps to be taken to reduce barriers.

Potential Barriers / Notes and Next Steps to Reduce Barriers
Low Income
Language
Disability
Unemployment
Housing/ Homelessness
Gang Involvement
Substance Abuse
Domestic Violence
Pregnancy or Parenting
Physical Health
Mental Health
Lack of Guardian Support
Other:
Other:
Other:

6)State Agency Involvement

List any involvement with state agencies. Examples include Department of Youth Services, Department of Transitional Assistance, Department of Children and Families, and Department of Mental Health.

Agency Name / Contact Person / Contact Information / Permission to Contact (Y/N)

7)Career Interests

List your career interests (this may include results from interest inventories), career opportunities associated with the career interest area, and the education or training necessary to obtain that career. Create a separate row for each potential career opportunity – so one career interest area may have several rows with different career opportunities.

Career Interest Area / Career Opportunity / Post-Secondary Education or Training Required
Example: Early Childhood / Elementary school teacher / 4 year degree program

8)Short Term Student Goals

Provide at least one short term (1-2 month) goal for each domain (academic, personal/social, and workplace readiness). For each short-term goal, include action steps to reach this goal, including the description of activities, supports that will be needed or provided, and the timeline. Retain prior short-term goals for student review and reflection.

Short Term Goal – Academic Domain
Goal Description:
Step 1 / Activity Description: / Supports: / Timeline:
Step 2 / Activity Description: / Supports: / Timeline:
Step 3 / Activity Description: / Supports: / Timeline:
Short Term Goal – Personal/Social Domain
Goal Description:
Step 1 / Activity Description: / Supports: / Timeline:
Step 2 / Activity Description: / Supports: / Timeline:
Step 3 / Activity Description: / Supports: / Timeline:
Short Term Goal – Workplace Readiness Domain
Goal Description:
Step 1 / Activity Description: / Supports: / Timeline:
Step 2 / Activity Description: / Supports: / Timeline:
Step 3 / Activity Description: / Supports: / Timeline:

9)Long Term Student Goals

Provide at least one long term (post-secondary) goal related to future education, career, and personal/life goals. For each long-term goal, include some immediate action steps to reach this goal, including the description of activities, supports that will be needed or provided, and the timeline. Retain prior long-term goals for student review and reflection.

Long Term Goal1
Goal Description:
Step 1 / Activity Description: / Supports: / Timeline:
Step 2 / Activity Description: / Supports: / Timeline:
Step 3 / Activity Description: / Supports: / Timeline:
Long Term Goal2
Goal Description:
Step 1 / Activity Description: / Supports: / Timeline:
Step 2 / Activity Description: / Supports: / Timeline:
Step 3 / Activity Description: / Supports: / Timeline:
Long Term Goal3
Goal Description:
Step 1 / Activity Description: / Supports: / Timeline:
Step 2 / Activity Description: / Supports: / Timeline:
Step 3 / Activity Description: / Supports: / Timeline:

10) Middle School Courses Information

Provide an overview of the middle school courses taken and the associated grades.

Subject Area / Grade 6 / Grade 7 / Grade 8
English
Math
Science
History/ Social Studies
Physical Education
Art
Technology
Other:
Other:

11) High School Courses Information

Provide an overview of the courses taken, including the course titles, course grade (GR), and course credits earned (CR). Note in the course title if the course is taken for dual credit, is an AP course, etc.

Subject Area / Title / GR / CR / Title / GR / CR / Title / GR / CR / Title / GR / CR / Title / GR / CR
English
Math
Science
Social Sciences
Foreign Lang
Health
Arts
Physical Ed
Elective
Elective
Other
Other

12) High School Roadmap

For each subject area, provide the total number of credits required for graduation, the total applicable credits earned to date, and the total credits remaining to be earned in the subject area. If applicable, provide a short description of the course(s) options to fulfill the required credits. This table can be used a simple roadmap to graduation for students, families, and staff.

Subject Area / Total Credits Needed for Graduation / Total Applicable Credits Earned / Total Credits Remaining / Description of Course Options to Fulfill Required Credits
English
Math
Science
Social Sciences
Foreign Lang
Health
Arts
Physical Ed
Electives
Other
Yes/No/Unsure / Notes
Are you expecting to complete MassCore – the Massachusetts recommended course of study – by your high school graduation date?

13) Tier 2 and Tier 3 Supports or Interventions

Document the Tier 2 and Tier 3 supports and interventions (academic and non-academic) that you are participating in (or in which you previously participated). Tier 2 interventions and supports are moderately intensive and are targeted toward small groups of students with similar needs who would benefit from similar interventions or supports. Tier 3 interventions and supports are the most intensive and are provided to individual students with the highest levels of need.

Check off the grade levels in which you participated in that intervention or support.

Support or Intervention Name / Grade 6 / Grade 7 / Grade 8 / Grade 9 / Grade 10 / Grade 11 / Grade 12

14) Assessment Results

Provide an overview of your results on state, local, and other assessment results.

Grade 6 / Grade 7 / Grade 8 / Grade 9 / Grade 10 / Grade 11 / Grade 12
State Assessment:ELA
State Assessment:Math
State Assessment: Science
State Assessment: ACCESS for ELLs
Local Assessment:
Local Assessment:
Other: PSAT
Other: SAT
Other:

15) Extracurricular Activities

Document the extracurricular activities in which you are engaged, including those provided in school, and well as those offered out of school.

Grades 6 / Grade 7 / Grade 8 / Grade 9 / Grade 10 / Grade 11 / Grade 12
In school
Out of school

16) Career Development Education Activities

Career Development Education encompasses three stages – Awareness, Exploration, and Immersion – thathelp students move from the cognitive to the experiential. Document your participation in activities and/or courses that provide career awareness, exploration, or immersion opportunities.

  • Awareness stage examples include: career interest inventories, exploring labor market information through websites and publications, listening to career speakers, and/or participation in career days or fairs.
  • Exploration stage examples include participation in workshops or classes with a career focus, “job shadowing,” informational interviews with local professionals, and/or producing a career-related research or capstone project.
  • Immersion stage examples include internships, entrepreneurial enterprises, or other work-based learning opportunities.

Grades 6 / Grade 7 / Grade 8 / Grade 9 / Grade 10 / Grade 11 / Grade 12
Career Awareness Activities
Career Exploration Activities
Career Immersion Activities

17) Reflections

Reflections from the student, parent/guardian, and school should happen at the beginning and at the end of the school year. The reflection at the beginning of the year focuses all parties on the work and the specific goals for the upcoming year. The year-end reflection is an honest assessment of successes and challenges encountered throughout the school year. The end-of-year reflection may identify action steps for the next year.

Stakeholder / Reflection
Student
Parent/Guardian Name:
School Mentor
Name:

TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary Education