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Virginia Department of Educations Sample Transition IEP Form

For Use with Students Age Thirteen or Older, Younger as Appropriate TABLE OF CO TE TS
The Virginia Department of Education does not require that schools use this sample E! format" it is offered as a #est practice e$ample% The sample E! form is di&ided into two sections% The first section includes those pages that are the foundation of all E!s% The second section includes those pages that will #e added to the E! as needed and sample formats for other purposes% SECTIO !" Foundation of All Transition IEPs Co#er Page' This page contains general information a#out the student and documentation of those indi&iduals who participated in the de&elopment of the E!% (page )* Factors for IEP Team Considerations' This form ma+ #e used to document the team,s consideration of the matters that the applica#le regulations require the team to consider during the process of de&eloping the E!, along with an+ decisions made #+ the team regarding these matters% The documentation of these considerations, while not required, is #est practice% -owe&er, all mem#ers of the E! team must #e aware of the factors that need to #e considered #+ the E! team during the de&elopment of the E!% (page .* Present Le#el of Academic Ac$ie#ement and Functional Performance (pages /01* Diploma and Transition Status (page 2* %iddle & Secondar' Transition' This form includes the student,s postsecondar+ goals and transition ser&ices needed to facilitate mo&ement from school to post0school acti&ities #eginning not later than the first E! to #e in effect when the child is age 3.% (pages 4 (35) %easura*le Annual +oals, Progress -eports (page 33* Ser#ices, Accommodations&%odifications (page 36* Ser#ices, Participation in State and Di#ision(.ide Accounta*ilit'&Assessment S'stem (pages 3)03.* Ser#ices, Least -estricti#e En#ironment, Placement (page 3/031* Prior otice (page 32*

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536

!age 3 of 64

SECTIO /" Additional Forms as eeded


IEP Process C$ec0list" This e$ample list can #e used to facilitate the E! process% (page 39* IEP %eeting otice" (page 65* Consent to In#ite Agenc' Personnel" (page 63* Co#er Page 1 %edicaid Eligi*le Students' This page contains general information a#out the student and documentation of those indi&iduals who participated in the de&elopment of the E! and assists in meeting the documentation requirements for :edicaid students for which ser&ices are #illed% (pages 6606)* %easurea*le Annual +oals&Progress -eport, continued (page 6.* S$ort(term O*2ecti#es and&or Benc$mar0s" to *e used as needed (page 6/* Progress -eport Comments' This page can #e used to pro&ide comments on progress report codes% (page 61* E3tended Sc$ool 4ear Ser#ices' This page addresses ser&ices #e+ond the normal school +ear;da+, if needed% (page 62* Prior otice" (page 64*

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 6 of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% COVE- PA+E Student <ame========================================================================= !age === of === Student D <um#er======================================================================= >rade======= DO? ====;====;==== Age@ ======== Disa#ilit+(ies* (if identified* ============================================ !arent <ame================================================================================ -ome Address===================================================== !hone A (-* (====*================== ===================================================== !hone A (B* (====*================== Date of Transition E! meetingCCCCCCC%%%CCCCCCCCCCCCC%%%%%CC%%CCCC%%=====;=====;===== Date parent notified of Transition E! meetingCCCCCCCCCCCCCCCC%%%CCCCCC=====;=====;===== Date student notified of Transition E! meetingCCCCC%%CCCCCCC%%%CCCCCCCCC=====;=====;===== This Transition E! will #e re&iewed no later than CCC%%CCCCCCCCC%%CCC%CCCCC=====;=====;===== :ost recent eligi#ilit+ dateCCCCCCCCCCC%CCCCCCCCCCCCCC%CCCCC%=====;=====;===== <e$t re0e&aluation, including eligi#ilit+, must occur #efore CCC%%%%CCCCCC%%C%%CCCCC%%=====;=====;===== Dop+ of E! gi&en to parent;student #+ (<ame*==================================== On (Date*=====;=====;===== E! Teacher;:anager========================================= !hone <um#er (====*======================

The ndi&idualiEed Education !lan ( E!* that accompanies this document is meant to support the positi&e process and team approach% The E! is a worFing document that outlines the student,s &ision for the future, strengths and needs% The E! is not written in isolation% The intent of an E! is to #ring together a team of people who understand and support the student in order to come to consensus on a plan and an appropriate and effecti&e education for the student% <o two teams are aliFe and each team will arri&e at different answers, ideas and supports and ser&ices to address the student,s unique needs% The student and his;her famil+ mem#ers are &ital participants, as well as teachers, assistants, specialists, outside ser&ice pro&iders, and the principal% Bhen all team mem#ers are present, the &alua#le information shared supports the de&elopment of a rich student profile and education plan% PA-TICIPA TS I VOLVED' T$e list *elo. indicates t$at t$e indi#idual participated in t$e de#elopment of t$is Transition IEP and t$e placement decision7 it does not aut$ori8e consent9 Parent or student :age !; or older) consent is indicated on t$e < Prior otice&Consent= page9 A%E OF PA-TICIPA T ===================================================== ===================================================== ===================================================== ===================================================== >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> POSITIO ==================================== ==================================== ==================================== ==================================== >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

? T$e student and parent must *e informed at least one 'ear prior to turning !; t$at t$e IDEA procedural safeguards :rig$ts) transfer to t$e student at age !; and *e pro#ided .it$ an e3planation of t$ose procedural safeguards9 Date informed >>>>>&>>>>>&>>>>> Student Initials >>>>>>>>>> Parent Initials >>>>>>>>>>
Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age ) of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% FACTO-S FO- IEP TEA% CO SIDE-ATIO Student <ame================================================ Date ====;====;==== !age ===== of ===== Student D <um#er===========================================

During the E! meeting, the following factors must #e considered #+ the E! team% ?est practice suggests that the E! team document that the factors were considered and an+ decision made relati&e to each% The factors are addressed in other sections of the E! if not documented on this page% (for e$ample' see !resent Ge&el of Academic Achie&ement and Functional !erformance* 3% 8esults of the initial or most recent e&aluation of the student"
==============================================================================================================

6% The strengths of the student"


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)% The academic, de&elopmental, and functional needs of the student"


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.% The concerns of the parent(s* for enhancing the education of their child"
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/% The communication needs of the student"


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1% The student,s needs for #enchmarFs or short0term o#Hecti&es"


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2% Bhether the student requires assisti&e technolog+ de&ices and ser&ices"


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4% n the case of a student .$ose *e$a#ior impedes $is or $er learning or t$at of ot$ers , consider the use of positi&e #eha&ioral inter&entions, strategies, and supports to address that #eha&ior"
==============================================================================================================

9% n the case of a student .it$ limited Englis$ proficienc', consider the language needs of the student as those needs relate to the student,s E!" =================================================================================================== 35% n the case of a student .$o is *lind or is #isuall' impaired, pro&ide for instruction in ?raille and the use of ?raille unless the E! team determines after an e&aluation of the student,s reading and writing sFills, needs, and appropriate reading and writing media, including an e&aluation of the student,s future needs for instruction in ?raille or the use of ?raille, that instruction in ?raille or the use of ?raille is not appropriate for the student" Bhen considering that ?raille is not appropriate for the child the E! team ma+ use the Functional Vision and Gearning :edia Assessment for Students who are !re0Academic or Academic and Visuall+ mpaired in >rades I036 (FVG:A* or similar instrument" and =================================================================================================== 33% n the case of a student .$o is deaf or $ard of $earing, consider the student,s language and communication needs, opportunities for direct communications with peers and professional personnel in the student,s language and communication mode, academic le&el, and full range of needs, including opportunities for direct instruction in the student,s language and communication mode% The E! team ma+ use the Virginia Dommunication !lan when considering the studentJs language and communication needs and supports that ma+ #e needed% ===================================================================================================

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age . of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% P-ESE T LEVEL OF ACADE%IC AC@IEVE%E T A D F5 CTIO AL PE-FO-%A CE Student <ame========================================================== Date====;====;==== !age ===of=== Student D <um#er=====================================================

The !resent Ge&el of Academic Achie&ement and Functional !erformance summariEe the results of assessments that identif+ the student,s interests, preferences, strengths and areas of need% t also descri#es the effect of the student,s disa#ilit+ on his or her in&ol&ement and progress in the general education curriculum, and for preschool children, as appropriate, how the disa#ilit+ affects the student,s participation in appropriate acti&ities% This includes the student,s performance and achie&ement in academic areas such as writing, reading, math, science, and histor+;social sciences% t also includes the student,s performance in functional areas, such as self0determination, social competence, communication, #eha&ior and personal management% Test scores, if included, should #e self0e$planator+ or an e$planation should #e included, and the !resent Ge&el of Academic Achie&ement and Functional !erformance should #e written in o#Hecti&e measura#le terms, to the e$tent possi#le% There should #e a direct relationship among the desired goals, the !resent Ge&el of Academic Achie&ement and Functional !erformance, and all other components of the E!% >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age / of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) P-ESE T LEVEL OF ACADE%IC AC@IEVE%E T A D F5 CTIO AL PE-FO-%A CE, Continued Student <ame======================================================== Date ====;====;==== !age ===of=== Student D <um#er================================== P-ESE T LEVEL OF ACADE%IC AC@IEVE%E T A D F5 CTIO AL PE-FO-%A CE, continued9

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 1 of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) DIPLO%A A D T-A SITIO STAT5S Student <ame======================================================== Date ====;====;==== !age ===of=== Student D <um#er==================================

DIPLO%A&P-O+-A% CO%PLETIO STAT5S' Discuss at least annuall+, more often as appropriate% This student is a candidate for a(n*' K L Ad&anced Studies Diploma K L :odified Standard Diploma@ K L Special Diploma K L Standard Diploma K L Dertificate of !rogram Dompletion K L >ED Dertificate (>eneral Educational De&elopment K L >AD (>eneral Achie&ement Diploma* (onl+ for those who meet requirements of the >ED program* K L <ot discussed at this time Pro2ected +raduation&E3it Date" ================ s the student proHected to graduate;e$it school this +earM >>> o >>>4es f +es, inform the student and parents that a Summary of Performance will #e pro&ided prior to graduating;e$iting school% ? The :odified Standard Diploma will not #e an option for students with disa#ilities who enter the ninth grade for the first time
after 65360653)%

OTE" Special education and related ser&ices end upon recei&ing an Ad&anced Studies Diploma, or Standard Diploma% f the student recei&es a :odified Standard Diploma, Special Diploma, Dertificate of !rogram Dompletion, a >AD or a >ED Dertificate, the student remains entitled to a free appropriate pu#lic education through age 63% f the student will graduate with an ad&anced or standard diploma during the term of the E!, prior written notice on page 64 must #e completed% Summar' of Performance Bill the student #e graduating with a Standard, Technical, or higher le&el diploma or e$ceeding the age of eligi#ilit+ this +earM >>> o >>>4es f +es, a Summar+ of !erformance must #e pro&ided to the student prior to graduating or e$ceeding the age of eligi#ilit+% Interagenc' -elease of Information Form s there a current signed (#+ parent or adult student* release of confidential information on file with the schoolM >>>4es f <o, discuss form for transition planning with student and famil+

>>> o

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 2 of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) %IDDLE & SECO DA-4 T-A SITIO Student <ame======================================================= Date====;====;==== !age ===of=== Student D <um#er ===================================

%EAS5-ABLE POST SECO DA-4 +OALS and T-A SITIO SE-VICES


(To #e de&eloped no later than the E! to #e in effect at age 3., or earlier, if appropriate*

DOC5%E TATIO OF T-A SITIO ASSESS%E TS


Are the postsecondar+ goals #ased upon age0appropriate formal and informal transition assessmentsM >>> o >>>4es f +es, identif+ these assessments in the !resent Ge&el of Academic Achie&ement and Functional !erformance or indicate which age0appropriate transition assessments were conducted for the de&elopment of measura#le postsecondar+ goals and transition acti&ities, as well as the date the+ were conducted'

Formal and informal Assessments :list name of assessment and date administered)" =================================================================================== =================================================================================== ================================================================================ %EAS5-ABLE POSTSECO DA-4 E%PLO4%E T +OAL"

Descri*e $o. t$e students courses of stud' support attainment of t$is postsecondar' goal" >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Transition Acti&ities;Ser&ices (including acti&ities that linF the student to adult ser&ices* nstruction 8elated Ser&ices Dommunit+ E$periences Emplo+ment Functional Vocational E&aluation Dail+ Gi&ing SFills Adult Gi&ing OT-E8
Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time

8esponsi#le ndi&idual; Descri#e 8esponsi#ilities

Date to #e Dompleted

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 4 of 64

%EAS5-ABLE POSTSECO DA-4 ED5CATIO +OAL:S) (e%g%, higher education, and continuing;adult education*'

Descri*e $o. t$e students courses of stud' support attainment of t$is postsecondar' goal" >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Transition Acti&ities;Ser&ices (including acti&ities that linF the student to adult ser&ices* nstruction 8elated Ser&ices Dommunit+ E$periences Emplo+ment Functional Vocational E&aluation Dail+ Gi&ing SFills Adult Gi&ing OT-E8
Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time

8esponsi#le ndi&idual; Descri#e 8esponsi#ilities

Date to #e Dompleted

%EAS5-ABLE POST SECO DA-4 T-AI I + +OAL:S) (e%g%, career and technical education, militar+ ser&ice, on0the0Ho# training, apprenticeship*'

Descri*e $o. t$e students courses of stud' support attainment of t$is postsecondar' goal" >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Transition Acti&ities;Ser&ices (including acti&ities that linF the student to adult ser&ices* nstruction 8elated Ser&ices Dommunit+ E$periences Emplo+ment Functional Vocational E&aluation Dail+ Gi&ing SFills Adult Gi&ing OT-E8
Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time

8esponsi#le ndi&idual; Descri#e 8esponsi#ilities

Date to #e Dompleted

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 9 of 64

%EAS5-ABLE I DEPE DE T LIVI +&CO%%5 IT4 PA-TICIPATIO +OAL:S)"


Donsidered, #ut not appropriate at this time

Descri*e $o. t$e students courses of stud' support attainment of t$is postsecondar' goal" >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Transition Acti&ities;Ser&ices (including acti&ities that linF the student to adult ser&ices* nstruction 8elated Ser&ices Dommunit+ E$periences Emplo+ment Functional Vocational E&aluation Dail+ Gi&ing SFills Adult Gi&ing OT-E8
Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time Donsidered, #ut not appropriate at this time

8esponsi#le ndi&idual; Descri#e 8esponsi#ilities

Date to #e Dompleted

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 35 of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) %EAS5-ABLE A 5AL +OALS, P-O+-ESS -EPO-T

Student <ame======================================================= Date====;====;==== !age ===of=== Student D <um#er================================ Area of <eed======================================== A >>>>> %EAS5-ABLE A 5AL +OAL"

T$e IEP team considered t$e need for s$ort(term o*2ecti#es&*enc$mar0s9 S$ort(term o*2ecti#es&*enc$mar0s are included for t$is goal9 (8equired for students participating in the VAA!* S$ort(term o*2ecti#es&*enc$mar0s are not included for t$is goal9
Does t$is annual goal $elp t$e student ma0e progress to.ard a postsecondar' goalB If 4ES, .$ic$ postsecondar' goalB

4es

@o. .ill progress to.ard t$is annual goal *e measuredB :c$ec0 all t$at appl') ==== Dlassroom !articipation ==== O#ser&ation ==== DhecFlist ==== Special !roHects ==== Driterion0referenced test'========================= ==== Dlass worF ==== Tests and NuiEEes ==== <orm0referenced test' =========================== ==== -omeworF ==== Britten 8eports ==== Other' =======================================

Progress on t$is goal .ill *e reported to t$e parent or adult student using t$e follo.ing codes9 Attac$ comments using progress report comment form located in section t.o9

Anticipated Date of Progress -eport? Actual Date of Progress -eport Progress Code SP 0The student is maFing Sufficient Progress to achie&e this annual goal within the duration of this E!% ES ( The student demonstrates Emerging SFill #ut ma+ not achie&e this goal within the duration of this E!% % 0The student has %astered this annual goal% ? Progress reports .ill *e pro#ided at least as often as parents are informed of t$e progress of t$eir c$ildren .it$out disa*ilities9 IP (The student has demonstrated Insufficient Progress to meet this annual goal and ma+ not achie&e this goal within the duration of this E!% I (The student has ot #een pro&ided Instruction on this goal%

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 33 of 64

T-A SITIO

I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP)

SE-VICES 1 LEAST -EST-ICTIVE E VI-O %E T 1 PLACE%E T ACCO%%ODATIO S&%ODIFICATIO S Student <ame========================================================= Date====;====;==== !age ===of=== Student D <um#er===================================

This student will #e pro&ided access to general education classes, special education classes, other school ser&ices and acti&ities including nonacademic acti&ities and e$tracurricular acti&ities, and education related settings' === with no accommodations;modifications === with the following accommodations;modifications Accommodations;modifications pro&ided as part of the instructional and testing;assessment process will allow the student equal opportunit+ to access the curriculum and demonstrate achie&ement% Accommodations;modifications also pro&ide access to nonacademic and e$tracurricular acti&ities and educationall+ related settings% Accommodations;modifications #ased solel+ on the potential to enhance performance #e+ond pro&iding equal access are inappropriate% Accommodations ma+ #e in, #ut not limited to, the areas of time, scheduling, setting, presentation and response% The impact of an+ modifications listed should #e discussed% ACCO%%ODATIO S&%ODIFICATIO S (list, as appropriate* Accommodation:s)&%odification:s) FreCuenc' Location (name of school @* Instructional Setting Duration m&d&' to m&d&'

@ E! teams are required to identif+ the specific school site (pu#lic or pri&ate* when the parent e$presses concerns a#out the location of the ser&ices or refuses the proposed site% A listing of more than one anticipated location is permissi#le, if the parents do not indicate that the+ will o#Hect to an+ particular school or state that the team should identif+ a single school% Additional Supports for Sc$ool Personnel" (Descri#e supports such as equipment, consultation, or training for school staff to meet
the unique needs for the student*

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Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 36 of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) SE-VICES 1 LEAST -EST-ICTIVE E VI-O %E T 1 PLACE%E T, Continued PA-TICIPATIO I T@E STATE A D DIVISIO (DIDE ACCO5 TABILIT4&ASSESS%E T S4STE% Student <ame======================================================== Date ====;====;==== !age ===of=== Student D <um#er==================================

This student,s participation in state and di&ision0wide assessments must #e discussed annuall+% During the duration of this E!' Bill the student #e at a grade le&el or enrolled in a course for which the student must participate in a state and;or di&ision0wide assessmentM If yes, continue to next question. ?ased on the !resent Ge&el of Academic Achie&ement and Functional !erformance, is this student #eing considered for participation in the Virginia Alternate Assessment !rogram (VAA!*, which is #ased on Aligned Standards of GearningM If yes, complete the VAAP Participation Criteria. Does the student meet the VAA! participation criteriaM If yes, refer to the Aligned Standards of earning for de!elopment of annual goals and short"term o#$ecti!es or #enchmar%s. ?ased on the !resent Ge&el of Academic Achie&ement and Functional !erformance, is this student #eing considered for participation in the Virginia Su#stitute E&aluation !rogram (VSE!*M If yes, complete the VS&P Participation Criteria for each content considered. Does the student meet the OVSE! participation criteriaPM f +es, determine for specific content area. ?ased on the !resent Ge&el of Academic Achie&ement and Functional !erformance, is this student #eing considered for participation in the Virginia >rade Ge&el Alternati&e (V>GA*M If yes, complete the V' A Participation Criteria for each content considered and attach $ustification statement. Does the student meet the V>GA participation criteriaM f +es, determine for specific content area. ?ased on the !resent Ge&el of Academic Achie&ement and Functional !erformance, is this student #eing considered for participation in the Virginia :odified Achie&ement Standards Test (V:AST*M If yes, complete the V(AS) Participation Criteria for each content considered. Does the student meet the V:AST participation criteriaM f +es, determine for specific content area. Note: )he V(AS) assessments *ill only #e a!aila#le to eligi#le students *ith disa#ilities during the +,-+"+,-. and +,-."-/ school years. 0eginning in +,-/"+,-1, the V(AS) *ill no longer #e a!aila#le as a separate alternate assessment% Yes <o Yes <o Yes <o Yes <o Yes <o Yes <o Yes <o Yes <o

Yes <o

If <'es= to an' of t$e a*o#e, c$ec0 t$e assessment:s) c$osen and attac$ :or maintain in students educational record) t$e assessment page:s), .$ic$ .ill document $o. t$e student .ill participate in Virginias accounta*ilit' s'stem and an' needed accommodations and&or modifications9 State Assessments' === SOG Assessments and retaFe (SOG* 8eading :ath Science -istor+;Social Science Briting === Virginia Su#stitute E&aluation !rogram@ (VSE!* 8eading :ath Science -istor+;Social Science Briting === Virginia >rade Ge&el Alternati&e@ (V>GA* Science -istor+;Social Science Briting === Virginia :odified Achie&ement Standards Test@ (V:AST* :ath 8eading === Virginia Alternate Assessment !rogram@@ (VAA!* === Other State Appro&ed Su#stitute(s*' ============================== Di#ision(.ide Assessment :list)" ==================================================================================================== ========================================================================================= @ 8efer to !rocedures for Determining !articipation in the Assessment Domponent of Virginia,s Accounta#ilit+ S+stem and the mplementation :anuals for V>GA, VSE! and;or V:AST% <ote' The V>GA is no longer a&aila#le in reading and math for students with disa#ilities%

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 3) of 64

@@ 8efer to Virginia Alternate Assessment !rogram (VAA!* !articipation Driteria and mplementation :anual% T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) PA-TICIPATIO I T@E STATE A D DIVISIO (DIDE ACCO5 TABILIT4&ASSESS%E T S4STE% :continued) Student <ame======================================================== Date ====;====;==== !age ===of=== Student D <um#er==================================

PA-TICIPATIO I STATEDIDE ASSESS%E TS


Assessment T'pe? Test
(SOG, V>GA, VSE!, V:AST3, VAA!, or ?oard of Education Appro&ed Su#stitute*

Accommodations??

If 'es, list accommodation:s)

8eading

========================================== <ot Enrolled in Dourse w; EOD Assessment

Yes <o

:ath

========================================== <ot Enrolled in Dourse w; EOD Assessment

Yes <o

Science

========================================== <ot Enrolled in Dourse w; EOD Assessment

Yes <o

-istor+;SS

========================================== <ot Enrolled in Dourse w; EOD Assessment

Yes <o

Briting

========================================== <ot Enrolled in Dourse w; EOD Assessment

Yes <o

@ An E! team ma+ not e$empt a student from participation in a content area assessment, onl+ determine how the student will #e assessed%

@@ Accommodation(s* must #e #ased upon those the student generall+ uses during classroom instruction and assessment% For the accommodations that ma+ #e considered, refer to OAccommodations;:odificationsP page of the E!% Di#ision(.ide Assessment :list)" ==================================================================================================== ==================================================================================================== ==================================================================================================== EEPLA ATIO FO- O (PA-TICIPATIO I -E+5LA- STATE O- DIVISIO (DIDE ASSESS%E TS f an E! team determines that a student must taFe an alternate assessment instead of a regular state or di&ision0wide assessment, e$plain in the space #elow wh+ the student cannot participate in this regular assessment" wh+ the particular assessment selected is appropriate for the student, including that the student meets the criteria for the alternate assessment" and how the student,s nonparticipation in the regular assessment will impact the child,s promotion, graduation with a modified standard, standard, or ad&anced studies diploma" or other matters% 8efer to the VDOE,s !rocedures for !articipation of Students with Disa#ilities in Virginia,s Accounta#ilit+ S+stem for guidance%
Alternate;Alternati&e !articipation Driteria is attached or maintained in the student,s educational record

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>


Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 3. of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) SE-VICES 1 LEAST -EST-ICTIVE E VI-O %E T 1 PLACE%E T, Continued Student <ame======================================================== Date====;====;==== !age ===of=== Student D <um#er =================================== Least -estricti#e En#ironment :L-E) Bhen discussing the least restricti&e en&ironment and placement options, the following must #e considered' To the ma$imum e$tent appropriate, the student is educated with children without disa#ilities% Special classes, separate schooling or other remo&al of the student from the regular educational en&ironment occurs onl+ when the nature or se&erit+ of the disa#ilit+ is such that education in regular classes with the use of supplementar+ aids and ser&ices cannot #e achie&ed satisfactoril+% The student,s placement should #e as close as possi#le to the child,s home and unless the E! of the student with a disa#ilit+ requires some other arrangement, the student is educated in the school that he or she would attend if he or she did not ha&e a disa#ilit+% n selecting the G8E, consideration is gi&en to an+ potential harmful effect on the student or on the qualit+ of ser&ices that he;she needs% The student with a disa#ilit+ shall #e ser&ed in a program with age0appropriate peers unless it can #e shown that for a particular student with a disa#ilit+, the alternati&e placement is appropriate as documented #+ the E!% Free Appropriate Pu*lic Education :FAPE) Bhen discussing FA!E for this student, it is important for the E! team to remem#er that FA!E ma+ include, as appropriate' Educational !rograms and Ser&ices !roper Functioning of -earing Aids Assisti&e Technolog+ Transportation <onacademic and E$tracurricular Ser&ices and Acti&ities !h+sical Education E$tended School Year Ser&ices Gength of School Da+

SE-VICES' dentif+ the ser&ice(s*, including frequenc+, duration and location that will #e pro&ided to or on #ehalf of the student in order for the student to recei&e a free appropriate pu#lic education% These ser&ices are the special education ser&ices and as necessar+, the related ser&ices, supplementar+ aids and ser&ices #ased on peer0re&iewed research to the e$tent practica#le, assisti&e technolog+, supports for personnel@, accommodations and;or modifications@ and e$tended school +ear ser&ices@ the student will recei&e that will address area(s* of need as identified #+ the E! team% Address an+ needed transportation and ph+sical education ser&ices including accommodations and;or modifications% Ser#ice:s) FreCuenc' Location
(name of school @@*

Instructional Setting

Duration m&d&' to m&d&'

E$tended School Year Ser&ices' (see attached summar+ sheet as a means to document discussion*

The E! team determined that the student needs ESY ser&ices% The E! team determined that the student does not need ESY ser&ices% Descri#e%
@ These ser&ices are listed on the OAccommodations;:odificationsP page and OE$tended School Year Ser&icesP page, as needed% @@ E! teams are required to identif+ the specific school site (pu#lic or pri&ate* when the parent e$presses concerns a#out the location of the ser&ices or refuses the proposed site% A listing of more than one anticipated location is permissi#le, if the parents do not indicate that the+ will o#Hect to an+ particular school or state that the team should identif+ a single school%

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 3/ of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) SE-VICES 1 LEAST -EST-ICTIVE E VI-O %E T 1 PLACE%E T, Continued Student <ame========================================================= Date====;====;==== !age ===of=== Student D <um#er===================================

PLACE%E T <o single model for the deli&er+ of ser&ices to an+ population or categor+ of children with disa#ilities is accepta#le for meeting the requirement for a continuum of alternati&e placements% All placement decisions shall #e #ased on the indi&idual needs of each student% The team ma+ consider placement options in conHunction with discussing an+ needed supplementar+ aids and ser&ices, accommodations;modifications, assisti&e technolog+, and supports for school personnel% n considering the placement continuum options, checF those the team discussed% Then, descri#e the placement selected in the PLACE%E T DECISIO section #elow% Determination of the Geast 8estricti&e En&ironment (G8E* and placement ma+ #e one or a com#ination of options along the continuum% Placement Continuum Options Considered :c$ec0 all t$at $a#e *een considered)" Ser#ices pro#ided in" === general education class(es* === special class(es* === special education da+ school === state special education program ; school === residential facilit+ === home0#ased === hospital === other (descri#e*'

PLACE%E T DECISIO " >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> ?ased upon identified ser&ices and the consideration of least restricti&e en&ironment (G8E* and placement continuum options, descri#e in the space #elow the placement% Additionall+, summariEe the discussions and decision around G8E and placement% This must include an e$planation of wh+ the student .ill not #e participating with students without disa#ilities in the general education class(es*, programs, and acti&ities% Attach additional pages as needed% E3planation of Placement Decision"

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 31 of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO

P-O+-A% :IEP)

P-IO- OTICE A D PA-E T CO SE T Student <ame========================================================== Date====;====;==== !age ===of=== Student D <um#er===================================

P-IO- OTICE The school di&ision proposes to implement this E!% This proposed E! will allow the student to recei&e a free appropriate pu#lic education in the least restricti&e en&ironment% This decision is #ased upon a re&iew of current records, current assessments and the student,s performance as documented in the !resent Ge&el of Academic Achie&ement and Functional !erformance% Other options considered, if an+, and the reason(s* for reHection is attached, or can #e found in the !lacement Decision section of this E!% Additionall+, other factors, if an+ that are rele&ant to this proposal are attached% !arent and adult student rights are e$plained in the !rocedural Safeguards% f +ou, the parent(s* and adult student, need another cop+ of the !rocedural Safeguards or need assistance in understanding this information please contact ================================ at (===* ============ or e0mail ================================ or ================================ at (===* ============ or e0mail ================================ % ==== !arent(s* initials here indicate that the parent(s* has read the a#o&e prior notice and attachments, if an+, #efore gi&ing permission to implement this E!% PA-E T&AD5LT ST5DE T CO SE T' ndicate +our response #+ checFing the appropriate space and sign #elow% === gi&e permission to implement this E!% === do not gi&e permission to implement this E!%
======================================================== ====;====;====

!arent Signature or Adult Student Signature (if appropriate* Date T-A SFE- OF -I+@TS AT T@E A+E OF %AFO-IT4 :age !;)" ndicate the date that the student and parent were informed of the transfer of parental rights under DEA to the adult student at the age of 34% This must occur at least one +ear prior to the age of 34%

===================== Date

=================================================== School Official Signature

was informed of the parental rights under DEA and that these rights transfer to me at age 34%

===================== Date

=================================================== Student Signature

was informed of the parental rights under DEA that transfer to m+ child at age 34%

===================== Date

=================================================== !arent Signature

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 32 of 64

SECTIO / Additional Forms To Be 5sed As eeded

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 34 of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) P-OCESS C@ECGLIST

%eeting otices sent to parent, student, and agenc' representati#es, as appropriate AcCuire .ritten consent from parent or age of ma2orit' student for an agenc' representati#e attend t$e IEP meeting Delcome and introductions of team mem*ers -e#ie. purpose of meeting -e#ie. meeting agenda -e#ie. rig$ts and procedural safeguards pertaining to special education and t$e IEP meeting -e#ie. of special factors to *e considered *' t$e IEP team De#elop Present Le#el of Academic Ac$ie#ement and Functional Performance Determine postsecondar' goals7 *ased upon age appropriate transition assessment Determine if Virginia Alternate Assessment Program :VAAP) is a consideration (VAA! !articipation Driteria must #e completed to maFe this decision%* Discuss sc$ool graduation&e3it and secondar' transition status Determine postsecondar' goals and transition ser#ices (#eginning no later than the +ear student turns age 3., or +ounger* De#elop measura*le annual goals (Discuss progress report on pre&ious annual goals, as needed%* Determine progress report sc$edule Document t$at t$e IEP team considered t$e need for s$ort(term o*2ecti#es or *enc$mar0s for students ot$er t$an t$ose .$o ta0e alternate assessments aligned to alternate ac$ie#ement standards De#elop s$ort(term o*2ecti#es or *enc$mar0s for t$e annual goals, as needed Determine an' needed accommodations and&or modifications in instruction and assessment Determine participation in state and di#ision(.ide assessments Determine ser#ices and placement Determine if student needs ES4 ser#ices -e#ie. an' reCuests proposed and&or refused Pro#ide prior .ritten notice and o*tain parental :or adult student) consent Identif' $o. staff .ill *e informed of t$eir responsi*ilities for implementation of t$e IEP If t$e student .ill *e lea#ing FAPE7 pro#ide a Summar' of Performance
!age 39 of 64

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536

SA%PLE

School Di&ision Getterhead


E! :EET <> <OT DE
Date' To' ==================================== and ======================================
!arent(s*;Adult Student Student (if appropriate or if transition will #e discussed*

You are in&ited to attend an E! meeting regarding ============================================ Student,s <ame P5-POSE OF %EETI + (checF all that appl+*"

E! De&elopment or 8e&iew E! Amendment Transition' !ostsecondar+ >oals, Transition Ser&ices :anifestation Determination Other' ================================================================================
The meeting has #een scheduled for'
Date Time Gocation

:eetings are scheduled at a mutuall+ agreed upon place and time #+ +ou and the school di&ision% f +ou are una#le to attend this meeting +ou ma+ request participation through other means% f +ou are una#le to attend this meeting, please contact'
E! Dase :anager Title !hone

You and the school di&ision ma+ in&ite indi&iduals to participate in the E! team meeting who ha&e Fnowledge or e$pertise a#out the student,s educational needs% The determination of the Fnowledge or special e$pertise shall #e made #+ the part+ who in&ited the indi&idual% f the di&ision intends to in&ite a representati&e of an agenc+ that is liFel+ to #e responsi#le for pro&iding or pa+ing for transition ser&ices to the E! meeting, written consent of the parent or adult student is required% ?elow is a list of the participants (#+ name or position* the di&ision will #e in&iting to attend the E! meeting'

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 65 of 64

SA%PLE

School Di&ision Getterhead


DO<SE<T TO <V TE A>E<DY !E8SO<<EG Date' =============
f the di&ision intends to in&ite a representati&e of an+ agenc+ that is liFel+ to #e responsi#le for pro&iding or pa+ing for transition ser&ices to the E! meeting, written consent from the parent or adult student is required prior to the meeting date%

>>>>> gi&e m+ consent for an agenc+ representati&e(s* named on the meeting notice to #e in&ited to the E! meeting%

=====

do not gi&e m+ consent for an agenc+ representati&e(s* named on the meeting notice to #e in&ited to the E! meeting%

!arent;Adult Student Signature

Date

========================================
!arent;Adult Student Signature

======================
Date

??Please sign and return t$is page to 'our c$ilds IEP Case %anager9

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 63 of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) COVE- PA+E 1 %EDICAID ELI+IBLE ST5DE TS Student <ame========================================================================= !age === of === Student D <um#er======================================================================= >rade======= DO? ====;====;==== Age@ ======== Disa#ilit+(ies* (if identified* ============================================ !arent <ame================================================================================ -ome Address===================================================== !hone A (-* (====*================== ========================================================= !hone A (B* (====*================== Date of Transition E! meetingCCCCCCC%%%CCCCCCCCCCCCC%%%%%CC%%CCCC%%=====;=====;===== Date parent notified of Transition E! meetingCCCCCCCCCCCCCCCC%%%CCCCCC=====;=====;===== Date student notified of Transition E! meetingCCCCC%%CCCCCCC%%%CCCCCCCCC=====;=====;===== This Transition E! will #e re&iewed no later than CCC%CCCCCCCCC%%CCC%CCCCC=====;=====;===== :ost recent eligi#ilit+ dateCCCCCCCCCCC%CCCCCCCCCCCCCC%CCCCC%=====;=====;===== <e$t re0e&aluation, including eligi#ilit+, must occur #efore CCC%%%%CCCCCC%%C%%CCCCC%%=====;=====;===== Dop+ of E! gi&en to parent;student #+ (<ame*==================================== On (Date*=====;=====;===== E! Teacher;:anager========================================= !hone <um#er (====*====================== PA-TICIPA TS I VOLVED' The list #elow indicates that the indi&idual participated in the de&elopment of this E! and the placement decision" it does not authoriEe consent% !arent or student (age 34 or older* consent is indicated on the O !rior <oticeP page% A%E OF PA-TICIPA T ===================================================== ===================================================== ===================================================== ===================================================== =====================================================
For %edicaid Eligi*le Students Onl' 1 -eCuired for Billa*le Ser#ices !h+sician <ame =========================================== !hone (======* ================== DD9 Dode ==============================

POSITIO ==================================== ==================================== ==================================== ==================================== ====================================

:edicaid Discharge !lan;Disposition ==========================

? T$e student and parent must *e informed at least one 'ear prior to turning !; t$at t$e IDEA procedural safeguards :rig$ts) transfer to t$e student at age !; and *e pro#ided .it$ an e3planation of t$ose procedural safeguards9

Date informed >>>>>&>>>>>&>>>>>

Student Initials >>>>>>>>>>>>>>

Parent Initials >>>>>>>>>>>>>>

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 66 of 64

PA-E TAL CO SE T FO- BILLI + P5BLIC I S5-A CE LA +5A+E FO- T@E IEP or IEP A%E D%E T

For %edicaid or FA%IS :Famil' Access to %edical Insurance Securities) Insured Onl' Donsent to 8elease nformation' consent for ======================(GEA* to release information a#out m+ child,s participation in ser&ices #illed to :edicaid to participating ph+sicians, other health care pro&iders, the Department of :edical Assistance Ser&ices, and an+ Department of :edical Assistance Ser&ices #illing agents, and an+ GEA #illing agent as necessar+ to process :edicaid claims for reim#ursement :edicaid co&ered health0 related ser&ices and the e&aluations for ser&ices outlined in the E!% !rocedural Safeguard' understand m+ right to den+ consent for the school s+stem to access m+ childJs :edicaid co&erage to seeF reim#ursement for the health0related ser&ices pro&ided will not affect deli&er+ of these ser&ices to m+ child% understand that m+ permission is &oluntar+ and ma+ #e re&oFed at an+time% also understand that ha&e the right to request a cop+ of the records disclosed% gi&e consent for claims to #e su#mitted to the State :edicaid Agenc+, as descri#ed a#o&e, for the ser&ices outlined in the ndi&idualiEed Education !rogram ( E!*, including duration and frequenc+ and;or e&aluations for E! ser&ices% do not gi&e consent

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 6) of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) %EAS5-ABLE A 5AL +OALS, P-O+-ESS -EPO-T, continued

Student <ame======================================================= Date====;====;==== !age ===of=== Student D <um#er================================ Area of <eed========================================

A >>>>> %EAS5-ABLE A

5AL +OAL"

T$e IEP team considered t$e need for s$ort(term o*2ecti#es&*enc$mar0s9 S$ort(term o*2ecti#es&*enc$mar0s are included for t$is goal9 (8equired for students participating in the VAA!* S$ort(term o*2ecti#es&*enc$mar0s are not included for t$is goal9

@o. .ill progress to.ard t$is annual goal *e measuredB :c$ec0 all t$at appl') ==== O#ser&ation ==== Dlassroom !articipation ==== Special !roHects ==== Driterion0referenced test'========================= ==== DhecFlist ==== Tests and NuiEEes ==== <orm0referenced test' =========================== ==== Dlass worF ==== Britten 8eports ==== Other' ========================================

==== -omeworF

Progress on t$is goal .ill *e reported to t$e parent or adult student using t$e follo.ing codes9 Attac$ comments using progress report comment form located in section t.o9

Anticipated Date of Progress -eport? Actual Date of Progress -eport Progress Code SP 0The student is maFing Sufficient Progress to achie&e this annual goal within the duration of this E!% ES ( The student demonstrates Emerging SFill #ut ma+ not achie&e this goal within the duration of this E!% % 0The student has %astered this annual goal% ? Progress reports .ill *e pro#ided at least as often as parents are informed of t$e progress of t$eir c$ildren .it$out disa*ilities9 IP (The student has demonstrated Insufficient Progress to meet this annual goal and ma+ not achie&e this goal within the duration of this E!% I (The student has ot #een pro&ided Instruction on this goal%

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 6. of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) S@O-T TE-% OBFECTIVES O- BE C@%A-GS, as determined #+ E! Team :-eCuired for students participating in t$e VAAP) Student <ame========================================================== Date====;====;==== !age ===of=== Student D <um#er================================ >oal A ===== Area of <eed' =========================== S$ort Term O*2ecti#es or Benc$mar0s, as needed O#Hecti&e;?enchmarF A===

O#Hecti&e;?enchmarF A===

O#Hecti&e;?enchmarF A===

O#Hecti&e;?enchmarF A===

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 6/ of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP)


P-O+-ESS -EPO-T CO%%E TS, Continued :T$is document is optional) Student <ame========================================================== Date====;====;==== !age ===of=== Student D <um#er================================

>oal A===

!rogress 8eport Dode ===

>oal A===

!rogress 8eport Dode ===

>oal A===

!rogress 8eport Dode ===

>oal A===

!rogress 8eport Dode ===

>oal A===

!rogress 8eport Dode ===

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 61 of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) EETE DED SC@OOL 4EA- SE-VICES :ES4) :Optional) Student <ame========================================================= Date====;====;==== !age ===of=== Student D <um#er===================================

SummariEe the E! team,s discussions and decision a#out ESY'

f ESY ser&ices are to #e pro&ided identif+ which goals in the current E! will #e addressed #+ the ESY ser&ices'

dentif+ the E$tended School Year ser&ices needed to meet these goals' Ser#ice:s) FreCuenc' Location (name of school @@* Instructional Setting Duration m&d&' to m&d&'

@@ E! teams are required to identif+ the specific school site (pu#lic or pri&ate* when the parent e$presses concerns a#out the location of the ser&ices or refuses the proposed site% A listing of more than one anticipated location is permissi#le, if the parents do not indicate that the+ will o#Hect to an+ particular school or state that the team should identif+ a single school%

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 62 of 64

T-A SITIO I DIVID5ALI6ED ED5CATIO P-O+-A% :IEP) P-IO- OTICE Student <ame========================================================== Date====;====;==== !age ===of=== Student D <um#er===================================

Descri#e the action that the school di&ision proposes or refuses to taFe' (8equired upon graduation with a standard or ad&anced diploma*

E$planation of wh+ the school di&ision is proposing or refusing to taFe action'

Description of each e&aluation procedure, assessment, record or report the school di&ision used in deciding to propose or refuse the action'

Description of an+ other choices that the ndi&idualiEed Education !rogram ( E!* team considered and the reasons wh+ those choices were reHected'

Description of other reasons or other factors rele&ant as to wh+ the school di&ision proposed or refused the action'

8esources for the parent to contact for help in understanding the ndi&iduals with Disa#ilities Education Act ( DEA* and the related federal and Virginia 8egulations'

f this notice is not the initial referral for e&aluation, document when the parent was pro&ided a cop+ of the procedural safeguards and how a cop+ ma+#e o#tained, if the parent requests an additional cop+'

Virginia Department of Education 00 Sample Transition E! Form78e&ised Octo#er 32, 6536 !age 64 of 64