INDIVIDUALIZED EDUCATION PLAN

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PART I: STUDENT INFORMATION

Student’s Full Name       DOB      

Parent(s)/Guardian(s)       Age      
Surrogate Parent       Grade      
Address       WVEIS#      
(Address continued)      
Telephone Home:       Work:       Cell:      

Initial Annual Review Reevaluation Review Amendment

Other      

Transfer: (from)       Date      

PART II: Planning for the Future (optional)

Parent expectations for all students:

Home      
     
School      
     
Community      
     

PART III: Documentation of Attendance (sign only if present at the IEP Team meeting)

Signature Alternate Method of Position

Participation
      Parent
      Parent
      Student
      Regular Education Teacher
      Special Education Teacher
      Birth to Three Representative
      Chairperson
           
           
           

West Virginia Department of Education

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PART IV: PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

West Virginia Department of Education

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PART V: ANNUAL GOALS, Part A

• Denotes critical skill(s) to consider for extended school year.

Evaluation Mastery/Progress
Timeframe Condition Behavior Procedure Codes (optional)
with Criteria (per Grade Period)
     
Grading Period:  
     
Mastery Code:  
     
Progress Code:   
     
Date:      
     
     
Grading Period:  
     
Mastery Code:  
     
Progress Code:   
     
Date:      
     
     
Grading Period:  
     
Mastery Code:  
     
Progress Code:   
     
Date:      
     
     
Grading Period:  
     
Mastery Code:  
     
Progress Code:   
     
Date:      
     
• Mastery Code: 0 = Regression 1 = Maintained 2 = Recouped
• Student Progress Code: P = Progress Sufficient A = Achieved
IP = Insufficient Progress NA = Not Applicable

West Virginia Department of Education

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PART V: ANNUAL GOALS, Part A

• Denotes critical skill(s) to consider for extended school year.

SHORT-TERM OBJECTIVES
* Denotes critical skill(s) to consider for extended school year.

Evaluation Mastery/Progress
Timeframe Condition Behavior Procedure Codes (optional)
with Criteria (per Grade Period)

Grading Period:  

Mastery Code:  

Progress Code:   

Date:      

Grading Period:  

Mastery Code:  

Progress Code:   

Date:      

Grading Period:  

Mastery Code:  

Progress Code:   

Date:      

Grading Period:  

Mastery Code:  

Progress Code:   

Date:      

• Mastery Code: 0 = Regression 1 = Maintained 2 = Recouped

• Student Progress Code: P = Progress Sufficient A = Achieved
IP = Insufficient Progress NA = Not Applicable

West Virginia Department of Education

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PART VI: TRANSITION PLANNING (for students beginning no later than the first IEP to be in effect when the
student is 16)

Transition Planning Considerations:

How were the student’s preferences and interests considered? (Check all that apply):
Student interview/survey Interest inventory (specify)      
Parent interview/survey Other (specify)      
Functional vocational evaluation      

Transition Assessments Reviewed (specify):

     
     

Post-Secondary Goals

Anticipated post-secondary education goals:      

Anticipated post-secondary employment goals:      
Anticipated post-secondary adult living goals:      
The student’s educational program will lead to a: standard diploma modified diploma

Career Pathway/Cluster/Major the student selected on the Individualized Student Transition Plan (ISTP) is:

Pathway Cluster Major

Health      
Entry Human Services      
Skilled Business/Marketing      
Professional Science/Natural Resources      
Engineering/Technical      
Arts and Humanities      

Transition Services: Indicate areas identified through IEP goals.

Instruction Employment and other adult living objectives

Related Services Daily living skills (if appropriate)
Community experiences Functional vocational evaluation (if appropriate)

Activities/Linkages: Identify services needed for attaining post-secondary outcomes and the lead party/agency
responsible for those services.

Lead Party/Agency
Parent / Post-
Activities/Linkages Description of Service Student School School
Agency
Instruction/education      
Vocational aptitude/interest assessment      
Career awareness/work-based learning      
Employment      
Independent living/mobility      
Agency referral/application      
West Virginia Department of Education
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PART VII: SERVICES

A. Supplementary Aids, Initiation

Duration
Services/Program Location of Services Extent/Frequency Date
m/y
Modifications per m/d/y
Oral Testing Core Classes, Electives For Ch Tests and Major
Quizzes
Extend Time Core Classes, Electives On Tests and Quizzes

Location of Services
* Regular Education
Direct / Initiation
Environment = REE Duration
B. Special Education Services Indirect Extent/Frequency Date
(D or I) * Special Education m/y
per m/d/y
Environment = SEE
* Other =
Math Calculation and D SEE 225
Operations

Location of Services
* Regular Education
Direct / Initiation
Environment = REE Duration
C. Related Services Indirect Extent/Frequency Date
(D or I) * Special Education m/y
per m/d/y
Environment = SEE
* Other =
N/A

West Virginia Department of Education

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PART VIII: CONSIDERATION OF FACTORS FOR IEP DEVELOPMENT, Part A

• Acceleration (Gifted Only)

Will the student be accelerated? Yes No
If yes, what is the effect on graduation?      

• Age of Majority (for students reaching age 17 within the next 12 months)
The student has been informed of the transfer of his/her educational rights that will occur on reaching age 18.
Yes No Date _____________ Student Initials ____ Parent Initials ____

• Assistive Technology Services/Devices

Does the student have assistive technology needs? Yes No
If yes, the IEP team must document the nature and amount of services and the provisions for home use.

• Behavior
Does the student’s behavior, regardless of the student’s exceptionality, impede his/her learning or that of
others? Yes No If yes, the IEP team must consider the use of positive behavior
interventions and supports, and other strategies, to address that behavior.

• Braille (Blind and Partially Sighted Only)

Will braille be integrated in the student’s educational program? Yes No

• Communication Needs
Does the student have communication needs? Yes No
If yes, the IEP team must address the student’s needs in this area.

• Evaluation
Have the results of the most current evaluation(s) been considered? Yes No
Is additional evaluation needed? Yes No
If yes, specify.      

• Extended School Year

Does the student need extended school year services? Yes No
ESY determination deferred until      
Critical skills to be addressed (must link to present levels of academic achievement and functional performance
and annual goals)      
Duration       Minutes per Week       Location      
The parent(s)/guardian(s)/student accept(s) reject(s) extended school year services.

• Limited English Proficiency

Does the student have limited English proficiency? Yes No
If yes, the IEP team must consider the student’s language needs as they relate to the IEP.

• Progress
How and when will the student’s progress toward the IEP goals be reported to the parent(s)? Specify.
How? Progress reports When? Mid term and end of grading period

• The IEP team has considered the following:

o strengths of the student and concerns of the parent Yes No
o results on statewide assessments Yes No

West Virginia Department of Education

 o academic, developmental and functional needs of the child Yes No

West Virginia Department of Education

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PART VIII: CONSIDERATION OF FACTORS FOR IEP DEVELOPMENT, Part B

 State/District Achievement Testing:

The student will participate in the WV Measures of Academic Progress through:
1) Standard Conditions Yes No
2) Standard Conditions with Accommodations Yes No
3) Alternate Assessment Yes No
If yes, justify. Student is in the ninth grade
WVEIS Standard Conditions with Accommodations Specify the test or
Code the part of the test
Presentation
P02 Have test read aloud verbatim (except WESTEST R/LA)      
P03 Use Braille or other tactile form of print      
P06 Have test presented through sign language (except WESTEST R/LA)      
P13 Have test presented through text-talk converter (VI)      
P15 Have directions only read aloud (acceptable for WESTEST R/LA)      
P16 Have directions presented through sign language (acceptable for WESTEST R/LA)      
P17 Use secure electronic Braille notetaker (for directions & test stimulus materials)      
P18 Have directions rephrased by trained examiner      
P19 Use large print edition (when it is typical access)      
Response
R02 Indicate responses to a scribe (selected-response items)      
R03 Use Braille or other tactile form of print (when it is typical response mode)      
R04 Indicate responses to a scribe, specify all elements to be scored (constructed-response items)      
R05 Use an abacus (acceptable for the blind on all parts of WESTEST math)      
R11 Use computer, typewrite or other assistive technology device to respond      
R13 Provide physical support (if routine) by aide who is trained examiner      
R14 Use electronic translator or sign-dictionary (except WESTEST R/LA)      
R15 Use electronic translator or sign-dictionary to present directions only (acceptable for WESTEST R/LA)      
R16 Mark responses on large-print test booklet      
Timing
T03 Take more breaks (no studying)      
T04 Use extra time for any timed test (WESTEST not timed)      
T07 Flexible scheduling, extra time within the same day (no studying)      

An IEP Team may request permission to use other accommodations not listed above. The request must be in writing through
either the county test coordinator or the county special education director.

WV Measures of Academic Progress

WESTEST Grades 3 – 8, 10 Alternate Assessment Grades 3 – 8, 10

Writing Assessment Grades 4, 7, 10 NAEP Grades 4, 8, 12
ACT EXPLORE Grade 8 ACT PLAN Grade 10
End-of-Course Technical Skills Test Grades 9 - 12

West Virginia Department of Education

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PART IX: PLACEMENT

Explain the extent, if any, to which the student WILL NOT participate with non-exceptional students in the regular
classroom and/or extracurricular and other non-academic activities. Present levels of academic achievement and
functional performance must explain why full participation is not possible in the areas checked.

For School Age Students: For Preschool: Other:

Reading Mathematics Cognitive Assemblies
Writing Science Communication Home Room
Spelling Social Studies Fine Motor Meals
English Foreign Gross Motor Recess
Listening/ Language Self-help Other
Speaking Physical Social/Emotional
Education      

Percentage of time in: Regular Education Environment

Special Education Environment

Placement Options

Ages 6 - 21 Ages 3 - 5

Regular Education: Full-Time (FT) less than 21% (0) Home (A)
Regular Education: Part-Time (PT) 21 to 60% (1) Early Childhood Setting (B)
Special Education: Separate Class (SC) more than 60% (2) Part-Time Early Childhood/Part-Time
Special Education: Special School (SS) (3 or 4) Early Childhood Special Education
Special Education: Out-of-School Environment (OSE) (5) Setting (C)
Special Education: Residential Facility (RF) (6 or 7) Early Childhood Special Education
Setting (E)
Itinerant Service Outside the Home (F)

Least Restrictive Environment Considerations

The school the student would normally attend, if not exceptional, was considered.
Only schools and classroom settings that are appropriate to the student’s chronological age were considered.
Education in a regular classroom with the use of supplementary aids and services were considered.
The potentially harmful effects on the exceptional student and the quality of the student’s services which might
result from particular educational environments/placement were considered.
Integration with age-appropriate non-exceptional peers was considered.

West Virginia Department of Education

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PART X: CONSENT

Complete only for initial placement.

I give my consent to my child’s initial special education placement:

Parent Signature _________________________________________________ Date __________________

Parent Signature _________________________________________________ Date __________________

West Virginia Code 18-2-5b, effective March 15, 1990, provides that the county boards of education will maximize
federal Medicaid reimbursement for special education and health related services. Medicaid cannot cover
duplication in billing for services. If a parent/guardian chooses to have audiological, speech therapy, occupational
therapy, physical therapy and/or psychological services by providers outside the schools system, the parent/guardian
must notify the school district in writing not to seek Medicaid reimbursement for the relevant services. Otherwise,
the county board will bill Medicaid for the covered services.

Medicaid number:      

West Virginia Department of Education