34-54: Individualized Education Program (IEP)

STUDENTNAME: DATEOFMEETING:
INDIVIDUALIZEDEDUCATIONPROGRAM(CONFERENCESUMMARYREPORT)
DATEOFMOSTRECENTEVALUATION / DATEOFNEXTREEVALUATION:
PURPOSEOF CONFERENCE(Checkallthat apply)
ReviewofExistingData / Reevaluation / IEPReview/Revision / FBA/BIP / Graduation
InitialEvaluation/Eligibility / InitialIEP / Secondary Transition / ManifestationDetermination / Other
STUDENTIDENTIFICATIONINFORMATION
STUDENT’SADDRESS(Street,City,State,ZipCode) / STUDENT’SDATEOFBIRTH / SISIDNUMBER
MALE
FEMALE / ETHNICITY / LANGUAGE/MODEOFCOMMUNICATIONUSEDBYSTUDENT / CURRENTGRADELEVEL / ANTICIPATEDDATEOFHIGHSCHOOLGRADUATION
PLACEMENT(Tobecompletedafterplacementdetermination)
Yes NoPlacementisinResidentSchool / DISABILITY(S) / MEDICAIDNUMBER
RESIDENTDISTRICT / RESIDENTSCHOOL
PLACEMENT
SERVINGDISTRICT / SERVINGSCHOOL
PARENTINFORMATION
(1)PARENT’SNAME EDUCATIONALSURROGATEPARENT / (2)PARENT’SNAME EDUCATIONALSURROGATEPARENT
(1)PARENTSADDRESS(Street,City,State,ZipCode) / (2)PARENTSADDRESS(Street,City,State,ZipCode)
(1)PARENT’STELEPHONENUMBER(IncludeAreaCode) / (2)PARENT’STELEPHONENUMBER(IncludeAreaCode)
(1)LANGUAGE/MODEOFCOMMUNICATIONUSEDBYPARENT’S)
Yes No Interpreter / (2)LANGUAGE/MODEOFCOMMUNICATIONUSEDBYPARENT’S)
Yes No Interpreter
PROCEDURALSAFEGUARDS
ExplanationofProceduralSafeguardswereprovidedto/reviewedwiththeparent(s)on .
TransferofRights-Seventeen-yearoldstudentinformedofhis/herrightsthatwilltransfertothestudentuponreachingage18. Yes No
Parent(s)weregivenacopyofthe: EvaluationreportandeligibilitydeterminationIEP
District’sbehavioralinterventionpoliciesDistrict’sbehavioralinterventionprocedures(initialIEPonly)
PARTICIPANTSINFORMATION
Signatureindicatesattendance.Checkappropriateboxestoindicatewhichmeetingswereattended.Anyoneservinginadualroleshouldindicatesoonthefollowing lines.If a required participantparticipates through writteninputor isexcused from allorpart of the IEPmeeting, the required excusalandwrittenreport, asnecessary,isattached.
ELIGIBILITYREVIEW / IEP / ELIGIBILITYREVIEW / IEP

Parent /
SchoolSocialWorker

Parent /
Speech-LanguagePathologist

Student /
BilingualSpecialist

LEARepresentative /
Interpreter

GeneralEducationTeacher /
School Nurse

SpecialEducationTeacher /
Other(specify)

SchoolPsychologist /
Other(specify)
Iftheparent(s)didnotattendtheIEPmeeting,documenttheattemptstocontacttheparent(s)priortotheIEPmeeting.
STUDENTNAME: DATEOFMEETING:
DOCUMENTATIONOFEVALUATIONRESULTS
Completeforinitialevaluations,reevaluations,orareviewofanindependentoroutsideevaluation.
Consideringallavailableevaluationdata,recordtheteam’sanalysesofthestudent’sfunctioninglevels.Onlythoseareaswhichwereidentifiedasrelevanttothecurrentevaluationmustbecompleted.Allotherareasshouldbenotedas“NotApplicable”.Evaluationdatamayinclude:parentalinput,teacherrecommendations,physicalcondition,socialorculturalbackground,adaptivebehavior,recordreviews,interviews,observations,testingetc.Describetheobservedstrengthsand/ordeficitsinthestudent’sfunctioninginthefollowingdomains.
AcademicAchievement(Currentorpastacademicachievementdatapertinenttocurrenteducationalperformance.)
FunctionalPerformance(Currentorpastfunctionalperformancedatapertinenttocurrentfunctionalperformance.)
CognitiveFunctioning(DataandotherInformationregardingintellectualability;howthestudenttakesininformation,understandsinformation,andexpressesinformation.)
CommunicativeStatus(Informationregardingcommunicativeabilities(language,articulation,voice,fluency)affectingeducationalperformance.)
ForELLstudentsexplainELLSTATUS:HasLinguisticstatuschanged?YesNo
Health(Currentorpastmedicaldifficultiesaffectingeducationalperformance.)
Hearing/Vision(Auditory/visualproblemsthatwouldinterferewithtestingoreducationalperformance.Includedatesandresultsoflasthearing/visiontest.)
MotorAbilities(Fineandgrossmotorcoordinationdifficulties,functionalmobility,orstrengthandenduranceissuesaffectingeducationalperformance.)
Social/EmotionalStatus/SocialFunctioning(Informationregardinghowtheenvironmentaffectseducationalperformance--lifehistory,adaptivebehavior,independentfunctioning,personalandsocialresponsibility,culturalbackground.)
STUDENTNAME: DATEOFMEETING:
ELIGIBILITYDETERMINATION
ALLDISABILITIES(OTHERTHANSPECIFICLEARNINGDISABILITY)
DETERMINANTFACTORS
Thedeterminantfactorforthestudent’ssuspecteddisabilityis:
YesNo / Lackofappropriateinstructioninreading,includingtheessentialcomponentsofreadinginstruction(EvidenceProvided):
YesNo / Lackofappropriateinstructioninmath(EvidenceProvided):
YesNo / LimitedEnglishProficiency(EvidenceProvided):
Ifanyoftheaboveanswersis“yes,”thestudentisnoteligibleforservicesunderIDEAandtheteammustcompleteStep1and4below.Ifalloftheanswersare“no,”completeSteps1-4.
COMPLETEFORSTUDENTSSUSPECTEDOFHAVINGADISABILITYUNDERIDEA
STEP1–DISABILITY
NoDisabilityIdentify(CompleteStep4andwrite“NotEligibleforSpecialEducationServices”intheDisabilitysectionoftheConferenceSummaryReportpage.)
DisabilityIdentifiedBasedontheteam’sanalysis,identifythedisability(s):
Primary / Secondary / Primary / Secondary
Autism(O) / MultipleDisabilities(M)
Deaf/Blindness(H) / OrthopedicImpairment(C)
Deafness(G) / OtherHealthImpairment(L)
DevelopmentalDelay(3-9)(N) / SpeechorLanguageImpairment(I)
EmotionalDisability(K) / TraumaticBrainInjury(P)
HearingImpairment(F) / VisualImpairmentincludingBlindness(E)
IntellectualDisability(A)
Step2–ADVERSEEFFECTS
NoAdverseEffectIdentified.(CompleteStep4andwrite“NotEligibleforSpecialEducationServices”intheDisabilitysectionoftheConferenceSummaryReportpage.)
AdverseEffectIdentified.Foreachdisabilityidentified,describehowthedisabilityadverselyaffectsthestudent’seducationalperformance.
STEP3–EDUCATIONALNEEDS
Statetowhatextentthestudentrequiresspecialeducationandrelatedservicestoaddresseducationalneeds.
STEP4–ELIGIBILITY
Basedonthestepsabove,thestudentisentitledtospecialeducationandrelatedservices.
No(NotEligible) Yes(Eligible)
STUDENTNAME: DATEOFMEETING:
DOCUMENTATIONOFINTERVENTION/EVALUATIONRESULTS(SPECIFICLEARNINGDISABILITY)
Completeforinitialevaluations,reevaluations,orareviewofanindependentoroutsideevaluationwhenaspecificlearningdisability is suspected.
Aspartoftheevaluationprocess,relevantbehaviornotedduringobservationinthechild’sage-appropriatelearningenvironment,includingthegeneraleducationclassroomsettingforschool-agechildren,andtherelationshipofthatbehaviortothechild’sacademicfunctioningandeducationally relevant medical findings, if any, must be documented.
PROBLEMIDENTIFICATION/STATEMENTOFPROBLEM:
Usingbaselinedata,pleaseprovideaninitialperformancediscrepancystatementforallidentifiedareasofconcernintherelevantdomains[academic performance;functionalperformance;cognitivefunctioning,communicativestatus(forELLstudentsincludeanexplanationofELLstatusandanychangeinlinguisticstatus);social/emotionalstatus/functioning,motorabilities,health,hearingandvision]includinginformationaboutthestudent’sperformancediscrepancyprior tointervention.Attach evidence.
PROBLEMANALYSIS /STRENGTHSANDWEAKNESSES:
Describestudent’sskillstrengthsandweaknessesintheidentifiedarea(s)ofconcernwithintherelevantdomains.Attachevidence,includingevidenceof skills deficit versus performance deficit.
PLANDEVELOPMENT/INTERVENTION(S):
Describethepreviousandcurrentinterventionplan(core/Tier1,supplemental/Tier2,andintensive/Tier3)includingevidencethattheinterventionisscientifically based and was implemented with integrity.Attach plan/evidence.
PLANEVALUATION/EDUCATIONALPROGRESS:
Providedocumentation of studentprogressover time as aresultof theintervention.Attach evidence/graphs.
PLANEVALUATION /DISCREPANCY:
Statethecurrentperformancediscrepancyafterintervention,i.e.,thedifferencebetweenastudent’slevelofperformancecomparedtotheperformanceof peers or scientifically-based standards of expected performance.Attach evidence.
PLAN EVALUATION /INSTRUCTIONALNEEDS:
Summarizethe student’s needs in the areas ofcurriculum, instruction, and environment. Includeastatement of whether the student’s needs intermsofmaterials,planning,andpersonnelrequiredforinterventionimplementationaresignificantlydifferentfromthoseofgeneraleducationpeers.Attachevidence.
ADDITIONALINFORMATIONNECESSARYFORDECISION-MAKING (INCLUDEASAPPROPRIATE):
Reportanyeducationallyrelevantinformationnecessaryfordecision-making,includinginformationregardingeligibilityexclusionaryandinclusionarycriteria.Attachevidence.

STUDENTNAME: DATEOFMEETING:

ELIGIBILITYDETERMINATION(SPECIFICLEARNINGDISABILITY)

Completeforinitialevaluations,reevaluations,orareviewofanindependentoroutsideevaluationwhenaspecificlearning disabilityissuspected.

Thedeterminant factorforthestudent’s suspecteddisability is:

Yes / No / Lack ofappropriateinstructionin reading, including the essential components of reading instruction
Yes / No / (EvidenceProvided)
Lack ofappropriateinstructionin math (Evidence Provided)
Yes / No / Limited English Proficiency (Evidence Provided)

Ifanyoftheaboveanswersis“yes,”thestudentisnoteligibleforservicesunderIDEAandtheteammustcompletetheEligibilityDeterminationsection accordingly. If all of the answersare “no,” completethefollowingsections.

Theteamdeterminedthatthefollowingfactorsaretheprimarybasisforthestudent’slearningdifficulties.Documentthesourceofevidenceineacharea:

Yes / No / Avisual,hearingormotordisability:
Yes / No / IntellectualDisability:
Yes / No / Emotionaldisability:
Yes / No / Culturalfactors:
Yes / No / Environmentaloreconomicdisadvantage:

If anyof the boxesimmediatelyaboveis checked“yes,” thestudent cannothavea specific learning disability and the team must

completetheEligibility Determination sectionaccordingly.

Educational Progress (Over Time)

EvidenceintheDocumentationofEvaluationResultsshouldsupporttheteam’sanswertothisquestion.

Is the student progressing at a significantly slower rate than is expected in any areas of concern?

(SelectOne)

YesThestudentisprogressingatasignificantlyslowerratethanexpected

YesThestudentiscurrentlymakinganacceptablerateofprogressbutonlybecauseoftheintensityoftheinterventionthatisbeingprovided.

If yes, in which area(s)?

Discrepancy(AtOnePointinTime)

EvidenceintheDocumentationofEvaluationResultsshouldsupporttheteam’sanswertothisquestion.

Is the student’s performance significantly below performance of peers or expected standards in any areas of concern?

(SelectOne)

YesThe student’s performance is significantly discrepant.

YesThestudent’sperformance isnot currentlydiscrepantbutonly becauseof theintensityof the intervention thatisbeingprovided.

If yes, in which area(s)?

STUDENTNAME: DATEOFMEETING:
ELIGIBILITYDETERMINATION(SPECIFICLEARNINGDISABILITY)
InstructionalNeed
EvidenceintheDocumentationofEvaluationResultsshouldsupporttheteam’sanswertothisquestion.
Arethisstudent’sneedsinanyareasofconcernsignificantlydifferentfromtheneedsoftypicalpeersandofanintensityortypethatexceedsgeneraleducation resources?
(SelectOne)
No
Yes / The student’s instructional needs are significantly different and exceed general education resources.
Ifyes, in which area(s)?
Ifanyoftheboxesinthissection(InclusionaryCriteria)aremarked“No”,thestudentdoesnothaveaSpecificLearningDisability and the team must complete the Eligibility Determination section accordingly.
OptionalCriteria
Afterdeterminingthatthecriteriainthepreceding sectionaremet,thedistrictmaychoosetouseanIQ-achivementdiscrepancy model.Ifusingthismodel,completethissection.
IQ-AchievementDiscrepancy:
YesNo NA / Does aseverediscrepancyexistbetweenachievementandabilitythatisnotcorrectablewithoutspecialeducationand relatedservices?(Pleaserefer to evidencein Documentationof Evaluation Results)
Ifyes, in which area(s)?
ELIGIBILITYDETERMINATION
Step1:DisabilityAdverselyAffectingEducationalPerformance
Yes No / Basedontheanswerstothequestionsinthe“DeterminantFactors,ExclusionaryCriteria,”and“InclusionaryCriteria,”sections, does the student have a specific learning disability?
Iftheansweris“no”thestudentisnoteligibleforspecialeducationservicesunderthecategoryofSpecificLearningDisabilityandtheteammustcompleteStep2below.
Ifthe answeris “yes,” indicate the areabelowand completeStep 2.
Basicreadingskills / Mathematicalcalculation / Oral expression
Reading fluency skills / Mathematical problem solving / Listening comprehension
Reading comprehension / Writtenexpression
Step2:SpecialEducationandRelatedServices
Specializedinstruction is required in order forthestudenttomakeprogressand reducediscrepancy (Eligible)
Specializedinstruction isnot requiredinorder forthestudenttomakeprogress and reducediscrepancy(NotEligible)
Eachteammembermustsignbelowtocertifythatthereportreflectshis/herconclusionsforspecificlearningdisability.Anyparticipantwhodisagrees with the team’s decision must submitaseparatestatementpresentingher/his conclusions.
Yes / No / Yes / No
Yes / No / Yes / No
Yes / No / Yes / No
Yes / No / Yes / No
STUDENTNAME: DATEOFMEETING:
DATACHART(OPTIONAL)
REPORTOFPERFORMANCE(READING,WRITING,MATH)
Insert adatachartthatdisplaysthestudent’sperformanceinreading,writing,and/ormathrelativetohis/herpeergroup. Datachartsmaybe provided forotherareas,as well.
REPORTOFPERFORMANCE
(INSERTDATA CHART)
REPORTOFPERFORMANCE
(INSERTDATA CHART)
STUDENTNAME: DATEOFMEETING:
PRESENTLEVELSOFACADEMICACHIEVEMENTANDFUNCTIONALPERFORMANCE
Complete for initial IEPs and annual reviews.
Whencompletingthispage,includeallareasfromthefollowinglistthatareimpactedbythestudent’sdisability:academicperformance,social/emotionalstatus,independentfunctioning,vocational,motorskills,andspeechandlanguage/communication.Thismayincludestrengths/weaknesses identified in the most recent evaluation.
Student’s Strengths
ParentalEducational Concerns/Input
Student’s Present LevelofAcademicAchievement(Include strengthsandareasneeding improvement)
Student’s Present Levelsof FunctionalPerformance(Include strengthsandareasneeding improvement)
Describetheeffectofthisindividual’sdisabilityoninvolvementandprogressinthegeneraleducationcurriculumandthefunctionalimplicationsof the student’s skills.
•Fora preschool child, describe theeffect of thisindividual’sdisability oninvolvement inappropriateactivities.
•By age 14½,describe the effectof this individual’sdisability on thepursuitof post-secondaryexpectations (living, learning, andworking).
STUDENTNAME: DATEOFMEETING:
SECONDARYTRANSITION
Completeforstudentsage14½andolder,andwhenappropriateforstudentsyoungerthanage14½.Post-schooloutcomesshouldguide the development of the IEPfor students age 14½ and older.
AGE-APPROPRIATETRANSITIONASSESSMENTS
TRANSITIONASSESSMENTS
(Includingstudent and familysurvey/interview) / Assessment Type / ResponsibleAgency/Person / DateConducted
EMPLOYMENT
EDUCATION
TRAINING
INDEPENDENTLIVINGSKILLS
POST-SECONDARYOUTCOMES(AddressByAge141/2)
Indicateandprojectthedesiredappropriatemeasurablepost-secondaryoutcomes/goalsasidentifiedbythestudent,parentandIEPteam. Goalsarebaseduponageappropriatetransitionassessmentsrelatedtoemployment,educationand/ortraining,andindependentlivingskills.
EmploymentOutcomes/Goals(e.g.,competitive,supportedshelter,non-paidemploymentasavolunteerortrainingcapacity,military):AND
Post-SecondaryEducation Outcomes/Goals(e.g., communitycollege, 4-year university, technical/vocational/tradeschool): AND/OR
Post-SecondaryTrainingOutcomes/Goals(e.g.,vocationalorcareerfield,vocationaltrainingprogram,independentlivingskillstraining,apprenticeship,OJT,job corps):AND
IndependentLivingOutcomes/Goals(e.g.,independentliving,health/safety,self-advocacy/futureplanning,transportation/mobility,socialrelationships, recreation/leisure, financial/income needs):
COURSE OFSTUDY(addressbyage 14 1/2)
Identifyacourseofstudythatisalong-rangeeducationalplanormulti-yeardescriptionoftheeducationalprogramthatdirectlyrelatestothestudent’santicipatedpost-schoolgoals,preferencesandinterestsasdescribed above.
Year1 / Year2 / Year3 / Year4 / Extended
STUDENTNAME:DATEOFMEETING:
TRANSITIONSERVICES(addressbyage141/2)
Pleaseinclude,ifappropriate,neededlinkagesforoutsideagencies,(e.g.,DMH,DRS,DSCC,PAS,SASS,SSI,WIC,DHFS,etc.)
INSTRUCTION (e.g., tutoring, skills training, prep for college entrance exam,accommodations,adultbasiceducation.) / ProviderAgencyandPosition
Goal#(s)ifappropriate
Date/YeartobeAddressed
Date/YearCompleted
RELATEDSERVICES(e.g.,transportation,socialservices,medicalservices,technology,supportservices) / ProviderAgencyandPosition
Goal#(s)ifappropriate
Date/YeartobeAddressed
Date/YearCompleted
COMMUNITYEXPERIENCES(e.g.,jobshadow,workexperiences,banking,shopping,transportation,tours of post-secondary settings) / ProviderAgencyandPosition
Goal#(s)ifappropriate
Date/YeartobeAddressed
Date/YearCompleted
DEVELOPMENTOFEMPLOYMENTANDOTHERPOST-SCHOOLADULTLIVING
OBJECTIVES(e.g.,careerplanning,guidancecounseling,jobtry-outs,registertovote,adult benefits planning) / ProviderAgencyandPosition
Goal#(s)ifappropriate
Date/YeartobeAddressed
Date/YearCompleted
APPROPRIATEACQUISITIONOFDAILYLIVINGSKILLSAND/ORFUNCTIONAL
VOCATIONAL EVALUATION (e.g., self-care, home repair, home health, money,independent living, / joband career interests,aptitudesand skills) / ProviderAgencyandPosition
Goal#(s)ifappropriate
Date/YeartobeAddressed
Date/YearCompleted
LINKAGESTO AFTER GRADUATION SUPPORTS/SERVICES (e.g. DRS, DMH,DSCC,PAS,SASS,SSI,WIC,DHFS,CILs) / ProviderAgencyandPosition
Goal#(s)ifappropriate
Date/YeartobeAddressed
Date/YearCompleted
HOME-BASEDSUPPORTSERVICESPROGRAM
Yes No / Thestudenthasadevelopmentaldisabilityandmaybecomeeligiblefortheprogramafterreachingage18andwhennolonger receivingspecial education services.
Ifyes,completethefollowing statements:
Plansfordetermining thestudent’seligibility for home-based services:
Plansfor enrolling thestudent in the programof home-based services:
Plansfordevelopingaplanforthestudent’smosteffectiveuseofhome-basedservicesafterreachingage18andwhennolongerreceivingspecial education services:
STUDENTNAME: DATEOFMEETING:
FUNCTIONALBEHAVIORALASSESSMENT(ASAPPROPRIATE)
Completewhengatheringinformationaboutastudent’sbehaviortodeterminetheneedforaBehavioralInterventionPlan.WhenusedindevelopingaBehavioralInterventionPlan,theFunctionalBehavioralAssessmentmustbereviewedatanIEPmeetingand should be attached to the IEP.
TheFunctionalBehavioralAssessmentmustincludedatacollectedthroughdirectobservationofthetargetbehavior.Attachdocumentationof data collection.
Student’sStrengths–Includeadescriptionofbehavioralstrengths(e.g.,ignoresinappropriatebehaviorofpeers,positiveinteractionswithstaff,acceptsresponsibility,etc.)
OperationalDefinition of Target Behavior–Includea description of thefrequency,duration andintensityof thebehavior.
Setting–Includeadescription of thesettinginwhich the behavior occurs (e.g., physical setting,time of day, personsinvolved.)
Antecedents –Includea descriptionof therelevantevents that preceded thetargetbehavior.
Consequences–Includeadescriptionoftheresultofthetargetbehavior(e.g.removedfromclassroomanddidnotcompleteassignment.Whatis the payoffforthestudent?)
EnvironmentalVariables–Includeadescriptionofanyenvironmentalvariablesthatmayaffectthebehavior(e.g.,medication,weather,diet,sleep,socialfactors.)
HypothesisofBehavioralFunction-Includeahypothesisoftherelationshipbetweenthebehaviorandtheenvironmentinwhichitoccurs.
STUDENTNAME: DATEOFMEETING:
BEHAVIORALINTERVENTIONPLAN(ASAPPROPRIATE)
Complete when the team has determined a Behavioral Intervention Plan is needed.
TargetBehavior
Isthisbehaviora SkillDeficitora PerformanceDeficit?
SkillDeficit:Thestudentdoesnotknowhowtoperformthedesiredbehavior.
PerformanceDeficit:Thestudentknowshowtoperformthedesiredbehavior,butdoesnotconsistentlydoso.
Student’sStrengths–Describestudent’sbehavioralstrengths.
HypothesisofBehavioralFunction–IncludehypothesisdevelopedthroughtheFunctionalBehavioralAssessment(attachcompletedform).Whatdesired thing(s)is thestudenttryingtoget?ORWhatundesired thing(s)is thestudenttryingtoavoid?
SummaryofPreviousInterventionsAttempted–Describeanyenvironmentalchangesmade,evaluationsconducted,instructionalstrategyor curriculumchangesmade or replacement behaviors taught.
ReplacementBehaviors– Describe which new behaviors or skills will be taught to meet the identified function of the target behavior (e.g.studentwill slap hisdesk toreplacestriking outat others). Include description ofhow these behaviors/skills willbe taught.
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STUDENTNAME: DATEOFMEETING:
BEHAVIORALINTERVENTIONPLAN(ASAPPROPRIATE)
BehavioralInterventionStrategiesandSupports
Environment–How cantheenvironment orcircumstancesthattriggerthetargetbehavior be adjusted?
Instructionand/orCurriculum–Whatchangesininstructionalstrategiesorcurriculumwouldbehelpful?
PositiveSupports–Describealladditionalservicesorsupportsneededtoaddressthestudent’sidentifiedneedsthatcontributetothetarget behavior.
Motivators and/or Rewards– Describehow the student willbe reinforced to ensure thatreplacement behaviors are moremotivating thanthetargetbehavior.
Restrictive Disciplinary Measures– Describeanyrestrictivedisciplinary measuresthatmaybe usedwiththestudentandanyconditionsunder which suchmeasuresmay beused (include necessarydocumentationand timelineforevaluation.)
Crisis Plan – Describe howanemergency situation orbehavior crisiswillbehandled.
DataCollection Procedures and Methods– Describe expected outcomesof the interventions,howdata will be collected and measured,timelinesfor and criteriato determine success or lackof success of the interventions.
ProvisionsForCoordinationwithCaregivers–Describehowtheschoolwillworkwiththecaregiverstoshareinformation,providetrainingtocaregivers ifneeded,andhowoften thiscommunication will take place.
STUDENTNAME: DATEOFMEETING:
GOALSANDOBJECTIVES/BENCHMARKS
CompleteforinitialIEPsandannualreviews.(AnyoneresponsibleforimplementingtheIEP(e.g.,goalsandobjectives/benchmarks,accommodations,modificationsandsupports)mustbenotifiedofher/hisspecificresponsibilities.)
REPORTINGONGOALS
Theprogressonannualgoalswillbemeasuredbytheshort-termobjectives/benchmarks.Checkthemethodsthatwillbeusedtonotifyparentsofthestudent’sprogressonannualgoalsandiftheprogressissufficienttoachievethegoalsbytheendoftheIEPyear:
ReportcardProgressreportsParentconferenceOther(specify)
CURRENTACADEMICACHIEVEMENTANDFUNCTIONALPERFORMANCE
Resultsoftheinitialormostrecentevaluationandresultsondistrict-wideassessmentsrelevanttothisgoal;performanceincomparisontogeneraleducationpeersandstandards.
GOALSANDOBJECTIVES/BENCHMARKS
Thegoalsandshort-termobjectivesorbenchmarksshallmeetthestudent’seducationalneedsthatresultfromthestudent’sdisability,includinginvolvementinandprogressinthegeneralcurriculum,orforpreschoolstudents,participationinappropriateactivities.
GoalStatement#of IndicateGoalArea:Academic Functional Transition IllinoisLearningStandard: #
Title(s)ofGoalImplementer(s)
Short-TermObjective/BenchmarkforMeasuringProgressontheAnnualGoal
EvaluationCriteria / / EvaluationProcedures / / Schedulefor DeterminingProgress / DatesReviewed/ExtentofProgress
%Accuracy
/#ofattempts
Other(specify) / ObservationLog
Data Charts
Tests
Other(specify) /

Daily

Weekly

Quarterly Semester

Other(specify)

Short-TermObjective/BenchmarkforMeasuringProgressontheAnnualGoal
EvaluationCriteria / / EvaluationProcedures / / Schedulefor DeterminingProgress / DatesReviewed/ExtentofProgress
%Accuracy
/#ofattempts
Other(specify) /

Observation Log

DataCharts

Tests
Other(specify) / Daily
Weekly
Quarterly
Semester
Other(specify)
Short-TermObjective/BenchmarkforMeasuringProgressontheAnnualGoal
EvaluationCriteria / EvaluationProcedures / Schedulefor DeterminingProgress / DatesReviewed/ExtentofProgress
%Accuracy
/#ofattempts
Other(specify) /

Observation Log

DataCharts

Tests
Other(specify) / Daily
WeeklyQuarterly Semester
Otherspecify)
STUDENTNAME: DATEOFMEETING:
EDUCATIONALACCOMMODATIONSANDSUPPORTS
CompleteforinitialIEPsandannualreviews. (Anyoneresponsibleforimplementingtheeducationalaccommodationsmustbe notified of her/his specific responsibilities).
CONSIDERATIONOFSPECIALFACTORS
Checktheboxestoindicateifthestudentrequiresanysupplementaryaidsand/orservicesduetothefollowingfactors.Foranyboxchecked“yes,”specifythespecialfactorsinthe“SupplementaryAids,AccommodationsandModifications”sectionand/ortheLinguistic and CulturalAccommodations section listed below.
YesNo / assistive technology devicesand services
YesNo / communicationneedsincludingstudentswhoaredeaf/hardofhearing.Ifyes,completelinguisticandculturalaccommodationssectionbelow.
YesNo / limited English proficiency – language needs
YesNo / blind/visually impaired – provisionof Braille instruction
YesNo / Behaviorimpedesstudent’slearningorthatofothers. Ifyes,theteammustconsiderstrategies,includingpositivebehavioral
interventionsandsupportstoaddressbehavior.ThismayincludeaFunctionalBehavioralAssessmentand/oraBehavioralIntervention Plan. If so, attach any completed forms.
LINGUISTICANDCULTURALACCOMMODATIONS
YesNo / ThestudentrequiresaccommodationsfortheIEPtomeether/hislinguisticandculturalneeds.Thisincludesstudentswhoare
deaf/hard of hearing.If yes, specify any neededaccommodations:
Yes No / SpecialeducationandrelatedserviceswillbeprovidedinalanguageormodeofcommunicationotherthanorinadditiontoEnglish.
Thisincludesservicesprovidedtostudentswhoaredeaf/hardofhearing.Ifyes,specify any needed accommodations:
Forstudentswhoaredeaf/hardofhearingandothers,asapplicable:
•Identifythelanguageandcommunicationneed(s): ASLAuditory/OralCuedSpeechSpeechGeneratedDeviceTactile
SignedEnglishOther(pleasedescribe)
•Listtheopportunitiesfordirectcommunication/interactionwithpeersandprofessionalpersonnelinthechild’slanguageandcommunicationmode:
•Listtheidentifiedmodeofcommunicationaccessibleinacademicinstruction,schoolservices,andextracurricularactivitiesthatthestudentwillreceive:
SUPPLEMENTARYAIDS,ACCOMMODATIONS,ANDMODIFICATIONS
Specify whataids,accommodations, and modifications are needed forthechild tomake progress toward annual goals, toprogress in thegeneral education curriculum,participateinextracurricularandothernon-academicactivities,andtobeeducatedandparticipatewithotherchildrenwithdisabilitiesand/ornondisabledchildren(e.g.,accommodationsfordailywork,environmentalaccommodations,movingfromclasstoclass,etc.).Supplementaryaids,accommodations, and modifications must be based upon peer-review research to the extent practicable.
SUPPORTSFORSCHOOLPERSONNEL
Yes No / Programtrainingsand/orsupportsforschoolpersonnelareneededforthestudenttoadvanceappropriately
towardattainingtheannualgoals,participateinthegeneralcurriculum,andbeeducatedandparticipatewithotherstudentsineducationalactivities.Ifyes,specifywhattrainingsand/orsupportsareneeded,includingwhenappropriate,theinformationthatclarifieswhenthetrainingsand/orsupportswillbeprovided,bywhom,inwhatlocation,etc.

STUDENTNAME: DATEOFMEETING:

ASSESSMENT

CLASSROOM-BASED ASSESSMENTS

Student will participate in classroom assessments with no accommodation(s).

Student will participate in classroom assessments with accommodation(s). (Complete Assessment Accommodations).

Districtdoesnotadministerdistrict-wideassessments.

Districtdoesnotadministerdistrict-wideassessmentsatthisgradelevel.

Studentwill:

Notparticipateintheentiredistrict-wideassessment.

Participateintheentiredistrict-wideassessmentwithnoaccommodation(s).

Participateinentireassessmentwithaccommodation(s).(CompleteAssessmentAccommodationssection)

Participateinpart(s)ofthedistrict-wideassessment(specifywhichpart(s)andwhat,ifany,accommodationsarerequired).(CompleteAssessmentAccommodationssectionontheIEP).

Participateinthedistrict-widealternateassessmentwithoutaccommodation(s).

Participate in the district-wide alternate assessment with accommodation(s). (Complete Assessment Accommodations)

Indicatewhichstateacademicassessment(s)studentwilltakeand,ifapplicable,ifaccessibilityfeature(s)and/oraccommodation(s)areneeded.

State academic assessmentsare not administeredat thisgradelevel:

1.PartnershipforAssessmentofReadiness forCollege andCareers (PARCC)(grades 3-8)

ThePARCCassessment isnot appropriate. (Go to#2)

Studentwill:

ParticipateinPARCC withnoaccessibility featuresturned oninadvanceand noaccommodation(s).

ParticipateinPARCC assessmentwithaccessibility featuresturned oninadvanceand/or accommodation(s). (Complete

PARCCAccessibilityFeaturesandAccommodationsformand attach).

2.DynamicLearningMaps(DLM)(ELA/L,Math,Science)(Alternateassessmentgrades3-8,and11)

TheDLM ParticipationGuidelineswere met.(CompletetheDLM ParticipationGuidelinesand attach).

Ifmet,thestudentwill:

Participate inDLMwithnoaccessibility features/accommodation(s).

ParticipateinDLMwithaccessibilityfeatures/accommodation(s).(CompletetheDLMAccessibilityFeaturesandAccommodationsformandattach)

3.ScholasticAptitude Test (SAT)(Grade11 HighSchoolonly)

Notadministeredatstudent’scurrentgradelevel.

ParticipateinSATassessmentwithnoaccommodation(s).

ParticipateinSATassessmentwithaccommodation(s). (CompleteSATaccommodationssection)

4.IllinoisScienceAssessment(ISA)(Grades5,8,HighSchool(Biology)

Notadministeredatstudent’scurrentgradelevel.

Participateinscienceassessmentwithnoaccommodation(s).

Participateinscienceassessmentwithaccommodation(s).(CompleteScienceAssessmentAccommodationssection)

Willnotparticipateinthephysicalfitnessassessment(Explain):

6.Kingergarten Individual Development Survey (KIDS)

The KIDS Assessment is not appropriate.

Participate in KIDS with no accommodation(s). Indicate which subsets: 1 2 3

Participate in KIDS with accommodation(s). Indicate which subsets: 1 2 3 (Complete Assessment

Accommodation Section)

ThestateassessmentsoflanguageproficiencyforEnglishLearners(EL)ingradesK-12include:AccessingComprehensionandCommunicationinEnglishStatetoState(ACCESS)andtheAlternateACCESS.

Yes NoEnglishlearner(EL).If“NO”,skiptonextsection

Ifyes,thestudentwill:

ParticipateintheACCESSwithnoaccommodation(s).

ParticipateintheACCESSwithaccommodation(s).(CompleteAssessmentAccommodationssection). ParticipateinthealternateACCESSwithnoaccommodation(s).

Participate in the alternateACCESS with accommodation(s). (CompleteAssessmentAccommodations section of the IEP).

Ifthestudentwillparticipateinassessmentswithaccommodations,otherthanPARCC,DLM,and/orISA,documentanyneededaccommodationsforthecontentarea(s)inthesectionbelow.

Classroom-BasedAssessments

District-BasedAssessments

SATAssessment

ScienceAssessment

KIDSAssessment

Indicatewhichaccommodationsareneeded:

CommunicationDevices Braille Enlarged Print/pictures FM System Adapted Writing Utensils Adapted Scissors

ACCESS/AlternateACCESS

STUDENTNAME: DATEOFMEETING:

EDUCATIONALSERVICESANDPLACEMENT

InitiationDate:// DurationDate://

The IEPmust address all content areas, classes, and specify if the student will participate in general physical education.

GeneralEducationwithNoSupplementaryAids
(Specifycontentareas,classes,whetherornotthechildwillparticipateingeneralphysicaleducation,andextracurricularandothernonacademicactivities.) / MinutesPerWeekInSetting(Optional)
GeneralEducationwithSupplementaryAids(asspecifiedintheSupplementaryAidssection)
Specifycontentareas,classes,whetherornotthechildwillparticipateingeneralphysicaleducation,andextracurricularandothernonacademicactivitieswithsupports,ifapplicable.) / MinutesPerWeekInSetting(Optional)
SpecialEducationandRelatedServiceswithintheGeneralEducationClassroom
(Specifycontent areas and classes in which thechild will participatewith the provision of special educationand relatedservices.Listeach special educationand relatedservicethat willbe providedduringeach class.) / MinutesPerWeekInSetting
PARTICIPATIONINSPECIALEDUCATIONCLASSES/SERVICES
The IEPmust address all special education and related services.
SpecialEducationServices–OutsideGeneralEducation / MinutesPerWeekInSetting
A.
RelatedServices–OutsideGeneralEducation / MinutesPerWeekInSetting
B.
EducationalEnvironment(EE)Calculation(Ages3-5)
1. Minutesspent in regularearly childhood program
2. Minutesspentreceivingspecialeducationand relatedservicesoutside regularearly childhood(A+B) / EducationalEnvironment(EE)Calculation(Ages6-21)
1.TotalBelltoBellMinutes
2.Total Numberof MinutesOutside of theGeneralEducationSetting(A+B)
3.Total Numberof Minutesinside theGeneralEducationSetting(line #1 minus line#2)
4.Percentageof time inside theGeneralEducationEnvironment(line #3dividedbyline#1)
STUDENTNAME: DATEOFMEETING:
EDUCATIONALSERVICESANDPLACEMENT
EDUCATIONALENVIRONMENTCONSIDERATIONS
Tothemaximumextentappropriate,allstudentsshallbeeducatedandparticipatewithstudentswhoarenon-disabled. Provideanexplanationoftheextent,if any,towhichthestudentwillnotparticipateingeneraleducationclassesandactivities.
YesNo / Specialeducationclasses,separateschooling,orremovalfromtheregulareducationenvironmentisrequiredbecausethenatureorseverityofthestudent’sdisabilityissuchthateducationingeneralclasseswiththeuseofsupplementaryaidsandservicescannotbeachievedsatisfactorily.
Explain:
YesNo / Willparticipateinnonacademicactivitieswithnondisabledpeersandhavethesameopportunitytoparticipateinextracurricularactivitiesasnondisabledpeers?.
Ifno,explain:
YesNo / Willattendtheschoolheorshewouldattendifnondisabled?
Ifno,explain:
PLACEMENTCONSIDERATIONS
Whendeterminingtheplacement,consideranypotentiallyharmfuleffecteitheronthestudentorthequalityofservicesthathe/sheneeds.Afterdeterminingthestudent’splacement,completethe“Placement”sectiononthiscoversheet.
YesN/A / Forachildwhoisdeaf,hardorhearing,blindorvisuallyimpaired,parentshavebeeninformedofexistenceoftheIllinoisSchoolfortheDeafortheIllinoisSchoolfortheVisuallyImpaired,andotherlocalschoolsthatprovidesimilarservices.
PLACEMENTOPTIONSCONSIDERED / POTENTIALLYHARMFULEFFECT/REASONSREJECTED / TEAMACCEPTSPLACEMENT
YesNo
YesNo
YesNo
TRANSPORTATION
Checkallthatapply
YesNo / Specialtransportation is requiredto and fromschoolsand/orbetween schools.
YesNo / Specialtransportation is required inandaround school buildings.
YesNo / Specializedequipment (such as specialoradaptedbuses,lifts, and ramps) is required.
Pleaseexplainand/ordetailtransportationplan:
EXTENDEDSCHOOLYEARSERVICES
YesNo / Extendedschoolyearservicesareneeded.TheIEPteammustdocumenttheconsiderationoftheneedforextendedschoolyearservicesandthebasisforthedetermination.
If yes, the IEPmust indicate the type, amount and duration of services to be provided.
SPECIALEDUCATIONSERVICE(S) / LOCATION / AMOUNT/FREQUENCYOFSERVICES / INITIATIONOFSERVICES / DURATIONOFSERVICES / GOAL(S)ADDRESSED
STUDENTNAME: DATEOFMEETING:
MANIFESTATIONDETERMINATION(ASAPPROPRIATE)
Complete when determining whether a student’s behavior was a manifestation of her/his disability.
Disability:
Incident(s)thatResultedin DisciplinaryAction
The Student’s IEPand Placement (include a review of all relevant information in the child’s file, including the child’s IEP)
ObservationsoftheStudent(includeareviewofstaffobservationsregardingthestudent’sbehavior)
InformationprovidedbytheParents(includeareviewofanyrelevantinformationprovidedbytheparent(s)
Basedupontheaboveinformation,theteamhasdeterminedthat:
YesNo / Theconduct was caused byorhad a direct and substantialrelationshiptothe student’sdisability.
YesNo / Theconduct was the direct result of theschool district’s failureto implement theIEP.
If “Yes” to either of the above, the behavior must be considered a manifestation of the student’sdisability.
Checktheappropriatebox:
Thestudent’sbehaviorWASNOTamanifestationofher/hisdisability.Therelevantdisciplinaryproceduresapplicabletostudentswithoutdisabilitiesmaybeappliedtothestudentinthesamemannerinwhichtheyareappliedtostudentswithoutdisabilities.Ifthedistrictinitiatesdisciplinaryproceduresapplicable toallstudents,thedistrict shallensurethatthespecialeducation anddisciplinary recordsofthestudentwithadisability aretransmitted for consideration by the person or persons making the final determination regarding the disciplinary action.
Thestudent’sbehaviorWASamanifestationofher/hisdisability.Theteammustreviewandrevisethestudent’sIEPasappropriateandthedistrictmusttakeappropriateaction.Afunctionalbehavioranalysiswillorhasbeencompleted.Thebehaviorinterventionplanshallbecompletedormodified/reviewed as required to address behavior.
STUDENTNAME: DATEOFMEETING:
ADDITIONAL NOTES/INFORMATION
34-54S (8/17)Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENTNAME: DATEOFMEETING:
REPORTOFPROGRESSONANNUALGOALS(Option1)
Specifytheextenttowhichthestudent’sprogressissufficienttoenablethestudenttoachievethegoalsbytheendoftheIEPyear.DistrictsmayusethispagetoreportonstudentprogressORmayusetheoptiontwopagethatwouldincludedatachartstoindicateastudent’sprogress.
Student’sName / Type ofReport
Date / ReportCard 1 2 3 4 Quarter
StaffName / ProgressReport 1 2 3 4 Quarter
Title / ParentConference
GOAL NUMBER / MEASURABLE ANNUAL GOAL / REPORT OF PROGRESS / ADDITIONAL COMMENTS
Completed / Making Expected Progress / Not Making Expected progress
STUDENTNAME: DATEOFMEETING:
REPORTOFPROGRESSONANNUALGOALS(Option1)
Specifytheextenttowhichthestudent’sprogressissufficienttoenablethestudenttoachievethegoalsbytheendoftheIEPyear.DistrictsmayusethispagetoreportonstudentprogressORmayusetheoptiontwopagethatwouldincludedatachartstoindicateastudent’sprogress.
Student’sName /
Type ofReport
Date / ReportCard 1 2 3 4 Quarter
StaffName / ProgressReport 1 2 3 4 Quarter
Title / ParentConference
GOAL
NUMBER / MEASURABLE ANNUAL GOAL / REPORT OF PROGRESS
(Insert Data Charts)
STUDENTNAME: DATEOFMEETING:
AUTISMCONSIDERATIONS
InaccordancewithSection14-8.02oftheSchoolcode,“Inthedevelopmentoftheindividualizededucationprogramforastudentwhohasadisabilityontheautismspectrum(whichincludesautisticdisorder,Aspergerdisorder,pervasivedevelopmentaldisordernototherwisespecified,childhooddisintegrativedisorder,andRettSyndrome,asdefinedinthe[(DSM-IV,2000)],theIEPteamshallconsiderallthefollowingfactors.”
1. / Verbalandnonverbalcommunicationneeds
StudentNeeds:
SupportsIdentified:
2. / Socialinteractionskillsandproficiencies
StudentNeeds:
SupportsIdentified:
3. / Needsresultingfromunusualresponsestosensoryexperience
StudentNeeds:
SupportsIdentified:
4. / Needsresultingfromresistancetoenvironmentalchangeorchangeindailyroutines
StudentNeeds:
SupportsIdentified:
5. / Needsresultingfromengagementinrepetitiveactivitiesandstereotypedmovements
StudentNeeds:
SupportsIdentified:
6. / Needsforanypositivebehavioralinterventions,strategiesandsupports
StudentNeeds:
SupportsIdentified:
7. / Otherneedswhichimpactprogressingeneralcurriculum,includingsocialandemotionaldevelopment
StudentNeeds:
SupportsIdentified: