Individualized Education Program (IEP) for

Student
1. Student Information
Student
Jack Black
DOB

10/01/2002

IEP Meeting

02/12/2015

IEP Due

02/11/2016

Eligibility Date

02/10/2011

Next Re-Evaluation
Completed By

02/10/2017

Attending School

Copley Middle School

Home Language

English

Student Language

English

Classification

Specific Learning Disability

Grade

6th

2. Present Levels of Academic Achievement and functional

Performance
Reading
Jack is a 6th grade student presently receiving
services for a specific learning disability. Jack
receives modified content instruction in the areas of
reading, writing, and math, in the special education
classroom.
As of 01/20/2015, when given a DIBELS 4th grade test
of oral reading fluency, Jack read at a rate of 80
words per minute with 89% accuracy. This places
Jack below the 6th grade benchmark for oral reading
fluency which negatively impacts Jacks ability to
progress in the general education curriculum at the
same rate and level of rigor as his peers without
disabilities. Therefore, Jack requires direct and
intensive instruction. Jack routinely, independently,
and effectively uses accommodations such as
extended time, scratch paper, and spell check during
classroom instruction and testing to progress in the
general curriculum.
Writing
Jack appears to enjoy oral storytelling but has
difficulty brainstorming and creating drafts for
writing assignments, as evidenced by teacher
observations. Jack frequently misspells basic words
and does not capitalize proper nouns. As of

Math

Social/Behavior

01/20/2015, when given a CBM writing prompt, Jack

scored 37 total words written with 25 correct word
sequences. According to this data, Jack is
performing below grade level and requires direct and
intensive instruction to progress in the general
education curriculum at the same rate and level of
his peers.
Jack has made improvements on multiplication and
division. Jack continues to work hard to complete
math assignments and turns in work when given
extended time on math assignments. As of
01/20/2015, when given the MCOMP, Jack scored 32
points on the 4th grade level. According to the AIMS
Web National Norms, this places Jack in the 25th
percentile. In order to progress in the general
curriculum, Jack requires direct and intensive math
instruction, the accommodation of extended time on
assignments and tests, and scratch paper.
Jack can be helpful, friendly, and personable, and
relates well with adults and his peers. Jack
experiences difficulty staying on task. Jacks on task
behavior is 40%, in comparison to his peers who are
on task 85%, during a 20 minute observation time.
Jacks off task behavior is negatively impacting his
progress in the general curriculum.

3. The IEP Team considered the following Special Factors

[ ] Student needs
[ ]Student does not [ X]Student needs
Behavior

Language

Braille

Communication

behavioral
strategies because
his behavior
impedes his
learning and/or the
learning of others.
[ ]Student has
special language
needs addressed in
his IEP because he
is an limited
English proficient
student
[ ]Student needs
Braille instruction
because he is blind
or visually
impaired.
[ ]Student has
special
communication
service needs such

need behavioral
strategies.

behavioral
strategies are
addressed in his
IEP.

[ X]Student does
not have special
language needs

[ ]Students special
language needs are
addressed in his
IEP.

[ X]Student does
not need Braille
Instruction.

[ ] Student needs
for Braille
instruction are
addressed in his
IEP.
[ ]Student needs
for special
communication
services are

[X]Student does
not need any
special
communication

Assistive
Technology

as a student who is
deaf or hard of
hearing.
[ ]Student needs
assistive
technology devices
and/or services
without which
she/he would not
benefit from
special education.

services.

addressed in his
IEP.

[X ]Student does
not need assistive
technology devices
and/or services to
benefit from
special education.

[ ]Student needs
for assistive
technology devices
and/or services are
addressed in his
IEP.

4. Measurable Annual goals

1. Student progress towards his annual goals
will be measured using

Curriculum based
measurements and
samples of student
work.
Progress reports.

2. Student progress will be reported to his

parents using
3. Student progress will be reported as often as
progress is reported for children without
disabilities.
4.1 Reading
Annual Goal 1
When given a 5th grade level reading passage, Jack
will read at a rate of 102 words per minute with 90%
accuracy on 3 out of 3 consecutive progress
monitoring assessments.
4.2 Writing
Annual Goal 1
When given a 6th grade writing prompt, Jack will write
a minimum of 50 total words with 33 correct writing
sequences on 3 out of 3 consecutive progress
monitoring assessments.
4.3 Math
Annual Goal 1
When given a 5th grade math computation
assessment, Jack will score a minimum of 23 points
on 2 out of 3 consecutive assessments.
4.4 Behavior
Annual Goal 1
Jack will demonstrate 80% on task behavior on 4 out
of 5 consecutive school days as measured by a daily
tracker for on task behavior.
5. Service plus Adaptation
Special education service student needs to achieve his annual goals
and advance in the general curriculum:
Service
Location
Minutes/Frequency
Reading Basic Skills
Special Education
74 m every other day
Math Basic Skills
Special Education
74 m every other day

Written Expression

Special Education

74 m every other day

Related Services student requires to benefit from his Special Education:

Service
Location
Minutes/Frequency
Program Modifications, supports for schools personnel and/or
supplementary aids in his regular education programs:
Modifications
Frequency
Extended Time
As Needed
Minimize Distractions
As Needed
Scratch Paper
As Needed
Spell Check
As Needed
Check if transportation will be provided as a related service.
Are the post-secondary transition services, experiences, and/or
specialized instruction listed above likely to be provided or paid by
other agencies?
Not Applicable
No, Considered and not needed
Yes
Projected initiation of services:
Anticipated duriation:
6. Participation in State & District Assessment
See addendum
7. Regular Curriculum, Extra- Curricular & Non Academic Activities
Except for special education class times noted in the services section
of this IEP the student will participate in the regular class, regular PE,
extra-curricular and non-academic activities to the same extent as
children without disabilities, or with other exceptions (explain and
specify below).

8. Transition Plan
Not Applicable
9. Special Requirements for Graduation
Not Applicable
10. Notices & Participants

Extended School Year (ESY) services: Extended School Year (ESY)

services are provided to a child with a disability when the IEP team
determines that without ESY services, the educational program would
be of little or no benefit to the child, due to the lack of services during
the break between the normal school year and the next. Data will be
considered in determining eligibility for ESY services for your child. The
IEP team has determined that:
You child _is not____ eligible for ESY services.
Placement Review: [ ] Initial placement [X]Maintain current
placement [ ]Change current placement
Parent Prior Notice for Free Appropriate Public Education: The
IEP team proposes to implement this program based on the student's
needs and represents the free, appropriate public education the
student will be provided. You have received and have protection under
the Procedural Safeguards and Annual Notifications, which were sent to
you upon the student's referral for evaluation and in conjunction with
this meeting. You may receive another copy of the Procedural
Safeguards and Annual Notifications from the special education
teacher. lf you have any questions regarding this notice or the
Procedural Safeguards and Annual Notifications, contact the special
education teacher at the student's school. Parent/guardian signature
on this form indicates that parent/guardian has received a copy of this
IEP and a copy of your Procedural Safeguards and Annual Notifications,
which includes annual notices for Child Find, Carson Smith Special
Needs Scholarship, Destruction of Records and Medicaid.
Note: Each teacher and service provider must be informed of his or her
specific responsibilities related to implementation of this IEP for the
student, and the specific accommodations, modifications, and supports
that must be provided for him in accordance with this lEP.
IEP Team Participants:
Jack Black
Student
Mary Black
Parent
Miss. Wendy
Special Education Teacher
Miss. Elliot
General Education Teacher

Date
02/12/2015
Date
02/12/2015
Date
02/12/2015
Date
02/12/2015

Mr. Pan
LEA

Date
02/12/2015

[X]The IEP team has reviewed the previous year IEP in preparation for
the development of the current lEP.
Note: lf parent signature is missing, provide them with a copy of the
IEP and the Procedural Safeguards and Annual
Notifications and indicate a reason: