Document date:

IEP Services & Other Considerations

Students Name: Alexander Jackson

Native Lang: English
District: Jefferson

Page of

District ID:
State ID:
Grade: P
Sex: M
Ethnicity: Asian
Birth Date: 2/10/12
Age: 3
School: Jefferson Elementary Speech and Lang Clinic

1. IEP SERVICES
Position
Responsible

Service

Location

OT

05

Speech

05

PT

02

Location Codes:
01 Gen Ed Classroom
02 Sp Ed Classroom
03 Home
04 Hospital
05 Community
06 Therapy Room

Freq.
2x a
week
3x
week
?

M
Code

Total Service per

Week
Hrs
Min

Start
Date

Anticipated
Duration

45

Years

30

Years

Frequency Codes:
01 Daily
02 Weekly
03 Bi-Weekly
04 Monthly
05 Times Per
06 Times Per

Medicaid (M)
Codes:
IN = Individual
HQ = Group
HO = Professional
HM = Parapro
TD = Reg Nurse
LP = LPN

Statement of Service Delivery:

2. OTHER CONSIDERATIONS

A. Special transportation is considered a related service. The student requires [x] Regular [] Special [] No
transportation. Describe if necessary: Bus pick up at the door.
B. Are extended school year (ESY) services required for this student? [x] Yes [] No [] TBD.
If Yes, complete 1 6 below.
If TBD, when: , and amend IEP by specified date.
1. What are the skills this student will lose as a result of an interrupted educational program and will be unable to
recoup so as to make reasonable progress toward achieving the goals and benchmarks/objectives in the IEP?
Social skills and communication skills.
2. What skills are emerging that require ESY services in order to make reasonable gains? Speaking
3. What acquisition of a critical life skill that aids the students ability to function independently would be
threatened by an interruption in services?
4. In what way are the above skills critical to the overall progress of the student?
5. Specify which goals and objectives/benchmarks should be part of the IEP for ESY services.
6. Begin and end dates of ESY: . Hours per week:
C. Does the student have limited proficiency in English? [x] Yes [] No. If yes, what native language? English.
Explain what considerations are necessary: He is not speaking where children his age are.
D. If hearing impaired/deaf, is hearing aid monitoring required? [] Yes [x] No [] Not hearing impaired/deaf. If yes,
explain what considerations are necessary:
E. If visually impaired/blind, is Braille required? [] Yes [] No [x] Not visually impaired/blind. If yes, explain what
considerations are necessary:

January 2007

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