Republic of the Philippines

Department of Education
School ID # 131534

INDIVIDUALIZED EDUCATION PLAN

First Name

Middle Name

Surname

PWD School
ID
Previous
School

Gender

Enrolment Date

Exceptionalit
y

Special Education Program

and Placement
__ Regular
__ Modified
__ Mainstreamed
__ Self-Contained

CUSTODIAL DETAILS
Parent/Guardian Name:

Date of birth

Residential Address:

DATE
Consent for Initial
Evaluation

Photo of the
Learner

Mobile Number:

Vision

Hearing Screening

Recommended Placement
Program
Recommendation
School Placement
School Address
Grade level and class
Teacher
Name

Notice
Provided to

IEP ATTENDANCE
Position
Signature
Teacher
Evaluator
Parent
From

Date

Date

Method

Parents were provided a copy of IEP? Yes___ No____

Parents were provided a copy of the Parental Rights in Primary Language?
Yes _____ No _____
TEACHERS INPUT

PUPILS STRENGTHS

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND

HEALTH/ PHYSICIAN STATUS:
Vision screening Date: ____________ Result: ___Pass
___Fail
Is the Student blind or visually impaired? Yes___ No___
Hearing Screening Date: ____ Pass _____ Fail
____Pending
Is the student deaf or hard of hearing? _____Yes ____No
Does the childs health/physical condition affect the childs involvement and
progress in the general curriculum and general education and other
education related settings? ___Yes ___No

Does this student have a health care plan? ___Yes

___No

COGNITIVE ABILITIES

LANGUAGE ARTS
VISION
COMPENSATORY
FINE MOTORS

TRANSVOCATIONAL SKILLS
How does this students performance differ from same person?
Strengths

Needs

AREA

GOALS and BENCHMARKS/ OBJECTIVES

GOAL
BASELINE
BENCHMARK/OBJE
CTIVES

PROGRAM ACCOMODATION/ PARTICIPATION IN DISTRICT AND

SCHOOL ASSESSMENT

School Assessment

Asses1
Assess2

SCHOOL ASSESSMENT
The IEP team has determined this student will assessed as follows:
AREA
Reading
Math
Writing
Social Studies
Science

TYPE OF ASSESSMENT

ACCOMODATIONS
Accommodations will be used in general education and special education
settings when state assessments are administered. Accommodations will be
used in the special and general education classroom settings.
Reading
0 Separate, quiet, or individual setting
provide
3 large print edition of the assessment
provided
4 Visual magnification is used by the
student

Math
0 Separate, quiet, or individual setting
provide
3 large print edition of the assessment
provided
4 Visual magnification is used by the
student

Writing
0 Separate, quiet, or individual setting
provide
3 large print edition of the assessment
provided
4 Visual magnification is used by the
student

Social Studies
0 Separate, quiet, or individual setting
provide
3 large print edition of the assessment
provided
4 Visual magnification is used by the
student

Science
0 Separate, quiet, or individual setting
provide
3 large print edition of the assessment

provided
4 Visual magnification is used by the
student
GENERAL EDUCATION / LEAST RESTRICTIVE ENVIRONMENT
How does this students exceptionality affect his/her involvement and
progress in the general education curriculum (K-12) or developmentally
appropriate activities for preschool children?

Answer 1

Provide an explanation of the extent, if any, to which this student will not
participate in the general education classes and the general education
curriculum.

Answer 2

List the non-academic or extra-curricular school sponsored activities which

the student plans to participate.

Answer 3

Describe the potential harmful effects of the recommended placement and

services to the student. Explain how the positive effects of the placement
outweigh the potential harmful effects.

Answer 4

STATEMENT OF NEEDED TRANSITION SERVICES AGE 14

AND OVER (MAY BE COMPLETED FOR YOUNGER
STUDENTS IF APPROPRIATE)
INSTRUCTIONAL SERVICES
RELATED SERVICES
RELATED SERVICES