Individualized Education Program (IEP) Cover

Document date: 10/21/15

This IEP is an:

[x] Initial

[] Annual Review

Students Name: Alexander Jackson

Native Lang: English
District: Jefferson

[] Amended

Page of

Projected Triennial Re-evaluation Date:

District ID:
State ID:
Grade: Pk Sex: M
Ethnicity: Asian
Birth Date: 2/10/12
Age: 3
School: Jefferson Elementary, Kidz Corner

Parent/Guardian Name: Sherrie Jackson

Address:
Native Language: English

Home Phone: 702-810-2191

Parent/Guardian Name: Jamie Jackson

Address:
Native Language: English

Home Phone:

1. IEP INFORMATION
Case Manager Name:
Chelsea Smaellie
Eligibility Category:

Daytime Phone:

Daytime Phone:
Telephone Number:
435-225-0412
Medical Information:

2. IEP TEAM INFORMATION

Position or Title
(Signature, if signed, DOES NOT
indicate agreement)

Names of All IEP Team Members

Invited to Attend
Brittney Sullivan

Developmental Specialist

IEP Meeting Attendance

(Check DOES NOT
indicate agreement)
[] Yes [x] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No
[] Yes [] No

January 2007

Form 410a
Copy to the confidential folder, each service provider, and the parent or adult student.