Individualized Education Plan (IEP)

INFORMATION

STUDENT/PARENT INFORMATION ELIGIBILITY CATEGORY MEETING INFORMATION

__ Autism DATE OF MEETING: ________
Student :__ _______ Sex: _____________ _____Deaf/Blind DATE OF LAST IEP: __________
Birthdate: __ _ Grade: _ _ Student ID #_________ _ Developmental Delayed PURPOSE OF MEETING:
Student Primary Language___ ___ _____Emotional Disturbance _____ Interim IEP
Student English Proficiency Code(optional)_________________________________ _____Health Impairment _____Initial IEP
Address: __ __ _____Mental Retardation ___ Annual IEP
Student Phone: ____ ________________________ _____Orthopedic Impairment _____IEP Following 3-yr.Reevaluation
Parent/Guardian/ Surrogate: __ _____Specific Learning Disability _____Revision to IEP Date:____________
Parent Phone (Home): ___ ___________ Work: __ ___ __ Speech/Language Impairment _____Exit/Graduation:_______________
Mobile Phone/Cellphone No.: ______ __ _____Traumatic Brain Injury _____IEP Revision w/o a Meeting:
Primary Language Spoken at Home : _____ ____________________ _____Visual Impairment/Blind At the request of ___parent
Interpreter or Other Accommodations Needed: __________ _____________ _____Multiple Impairment _____School/District
Emergency Contact/Phone No: __ _________________ Eligibility Date OTHER ADDENDUM MEETING
Current School: ______________ District: ____________________ ____________ ____________ IEP Service will begin: ________________
ANTICIPATED: Anticipated:________________________
3-YEAR Duration of Services: _________________
REEVALUATION:_________ _ IEP Review Date: _______________
COMMENTS:
___________________________________
___________________________________

IEP PREPARATION

*Parent/Guardian/Surrogate: _____ _______________________ Speech/Language: ___________ ______________________________________

Therapist/Pathologist/Specialist :_____________________________________________
Student : _______________________________________ School Nurse: _____________________________
Interpreter: ______________________________________________________________
*Special Education teacher: ______________________________________ Other(name & role): __________________________________
*Regular Education Teacher: ________________________________________________ Other (name & role): ____________________________________ _____
*School Psychologist: __ ___________________________________________ Other (name & role): ____________________________________
*Required Participation
**Student must be invited when transition is discussed (beginning at age 14 or younger if appropriate)

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*** The IEP team must include at least one regular education teacher of the student. If the student is or may be participating in the regular education environment)

PROCEDURAL SAFEGUARDS

__ I have received a statement of procedural safeguards and these rights have been explained to me in my primary language
Parent’s Signature: _________________________________________________________________
AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, STUDENTS MUST BE INFORMED OF THEIR RIGHTS AND ADVISED THAT THESE RIGHTS WILL TRANSFER TO THEM AT AGE 18.

____Not applicable (Student will not be 18 within one year) _____ The student has been informed of his /her rights and advised of the transfer of rights at age 18

Distribution: _/_ Confidential Folder __/_ Parent/Guardian/ Surrogate _/___ Special Education Teacher___/__ Case Manager______ Diagnostic Center
Student: _ ___
Date: __ PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Consider results of the initial evaluation or most recent reevaluation, and the academic, development and functional needs of the student, which may include the following
areas: academic achievement, language/communication skills, social emotional behavior skills, cognitive abilities, health, motor skills, adaptive skills, prevocational skills, and
other skills as appropriate. For students who are 16 or older, or will turn 16 when this IEP is in effect, also consider the results of age appropriate transition assessments related
to training, employment and independent living skills (as appropriate).

ASSESSMENT CONDUCTED ASSESMENT RESULTS EFFECT ON STUDENT’S INVOLVEMENT AND PROGRESS IN

GENERAL EDUCATION CURRICULUM OR, FOR EARLY
CHILDHOOD STUDENTS, INVOLVEMENT IN
DEVELOPMENTAL ACTIVITIES

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 BUENAVISTA SPECIAL EDUCATION ELEMENTARY SCHOOL
INDIVIDUALIZED EDUCATION PROGRAM
EDUCATIONAL PERFORMANCE AND LONG RANGE PLANNING
____ Initial ___ Annual _____Triennial _____Transition ____ Other

NAME: __ Birthday: __ Age: __ Grade: __ __

Next Evaluation Date: __ _________ Date of IEP: From: __ _ to : _________________
Home Language: ___ _______ Student Language: __ ________________

AREAS DATE PRESENT LEVEL OF EDUCATIONAL PERFORMANCE

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SELF-HELP

CLASSROOM PERFORMANCE

BEHAVIOR

ACADEMIC

GROSS MOTOR

FINE MOTOR

Student : _____________________
Date: _______________

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STRENGTHS, CONCERNS, INTERESTS AND PREFERENCES

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STATEMENT OF STUDENT STRENGTH:

STATEMENT OF PARENT’S EDUCATIONAL CONCERNS:

STATEMENT OF STUDENT’S PREFERENCES AND INTERESTS (required transition services will be discussed, beginning at age 14 or younger if
appropriate)

CONSIDERATION OF SPECIAL FACTORS

1. Does the student’s behavior impede the Student’s learning or the learning of others? ____No action needed ____Yes, addressed in IEP
If yes, team must consider the use of positive behavioral interventions, support and other strategies, to address behavior.
2. Does the student have limited English proficiency? ____No action needed ____Yes, addressed in IEP
If yes, team must consider language needs of the student as those needs relate to the student’s IEP.
3. Is the student blind or visually impaired? ___No action needed ____Yes, addressed in IEP
If yes, team must evaluate reading and writing needs and provide for instruction in Braille unless determined not appropriate for the student.
4. Is the student deaf or hard of hearing? ____No action needed ___Yes, addressed in IEP
If yes, team must consider communication needs.
5. Does the student require assistive technology devices and services? ____No action needed ___Yes, addressed in IEP

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 If yes, team must determine nature and extent of devices and services.

IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS AND BENCHMARKS OR SHORT TERM OBJECTIVES

MEASURABLE ANNUAL GOAL (Including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress being made
(Continue)
2. Unsatisfactory Progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date

BENCHMARK OR SHORT –TERM OBJECTIVES

1.

2.

3.

MEASURABLE ANNUAL GOAL (Including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress being made
(Continue)
2. Unsatisfactory Progress being made
(need to review/revise)
3. Goal met (note date)

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Date Date Date

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 BENCHMARK OR SHORT –TERM OBJECTIVES
1.

2.

3.

MEASURABLE ANNUAL GOAL (Including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress being made
(Continue)
2. Unsatisfactory Progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date

BENCHMARK OR SHORT –TERM OBJECTIVES

1.

2.

3.

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MEASURABLE ANNUAL GOAL (Including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress being made
(Continue)
2. Unsatisfactory Progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date

BENCHMARK OR SHORT –TERM OBJECTIVES

1.

2.

3.

MEASURABLE ANNUAL GOAL (Including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress being made
(Continue)
2. Unsatisfactory Progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date

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 BENCHMARK OR SHORT –TERM OBJECTIVES
1.

2.

3.

MEASURABLE ANNUAL GOAL (Including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress being made
(Continue)
2. Unsatisfactory Progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date

BENCHMARK OR SHORT –TERM OBJECTIVES

1.

2.

3.

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MEASURABLE ANNUAL GOAL (Including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress being made
(Continue)
2. Unsatisfactory Progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date

BENCHMARK OR SHORT –TERM OBJECTIVES

1.

2.

3.

MEASURABLE ANNUAL GOAL (Including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress being made
(Continue)
2. Unsatisfactory Progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date

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 BENCHMARK OR SHORT –TERM OBJECTIVES
1.

2.

3.

Student: ___ _____ METHOD FOR REPORTING PROGRESS

Date: ______________ ____

METHOD FOR REPORTING THE STUDENT’S PROGRESS TOWSRD MEETING ANNUAL GOALS PROJECTED FREQUENCY OF REPORTS
(Check all methods that will be used) _____Quarterly ___ Semester
___IEP Goals Pages ___ Report Card _____Trimester ____ Other
___ Specialized Progress Report ___Parent Conferences
____Other :____________________________________________________________

SPECIAL EDUCATION SERVICES

SPECIALLY DESIGNED INSTRUCTION BEGINNING AND FREQUENCY OF LOCATION OF

ENDING DATES SERVICES SERVICES

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 SUPPLEMENTARY AIDS AND SERVICES

Includes aids, services and other supports provided in regular education classes or
other education-related settings to enable participation with non-disabled students

MODIFICATION, ACCOMODATION OR SUPPORT BEGINNING AND FREQUENCY OF LOCATION OF

FOR STUDENT PERSONNEL(Describe below or ENDING DATES SERVICES SERVICES
Select from supplemental “Modifications,
Accommodations and supports”

Student: ___ ____

Date: ______________ ___ RELATED SERVICES

RELATED SERVICES SERVICES TYPE BEGINNING AND FREQUENCY OF LOCATION OF

AND/OR ENDING SERVICES SERVICES
DESCRIPTION DATES

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____ Speech/Language

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 ____ Physical Therapy
____ Occupational Therapy
____ Transportation
____ Counseling
____ Psychological Services
____ Orientation & Mobility
____ Audiology
____ School Health Services
___ Medical Services for Diagnostic/
Or evaluation
____Recreation Therapy
____ Parent Counseling & Training
____ Social Work Services
____ School Nurse Services
_____ Other
EXTENDED SCHOOL YEAR SERVICES

Does the student require extended School year services?

___ _ No ___ Yes, if YES, IEP goals and benchmarks/short-term objectives and/or related services to be implemented in ESY must be identified
If need for ESY is to be determined at a later date, indicate date by which IEP decision will be made.

PLACEMENT

PLACEMENT CONSIDERATION % OF TIME IN REGULAR EDUCATION ENVIRONMENT

_____Selected ______ Rejected Regular class w/ supplementary aides and services
_____Selected _______Rejected Regular Class and SPED class combination
_____Selected _______Rejected Self-Contained
_____Selected _______Rejected Special School
_____Selected _______ Rejected Residential
______Selected ______ Rejected Hospital
______Selected ______Rejected Home
______Selected_____ _Rejected Other

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 JUSTIFICATION FOR PLACEMENT INVOLVING REMOVAL FROM REGULAR EDUCATION ENVIRONMENTS
Explain why IEP goals and objectives cannot be implemented in regular education environments, including the reason why team rejected a less
restrictive environment placement. Include an explanation of any harmful effects on the learning of this or other students which affected the
placement selection.

IEP IMPLEMENTATTION

___ As a parent, I agree with the components of this IEP, I understand that its provisions will be implemented as soon as possible after the IEP
goes into effect.
_____As a parent, I disagree with or part of this IEP, I understand that the School must provide me with written notice of any intent to
implement this IEP, If I wish to prevent the implantation of this IEP, I must submit a written request for a due to the school principal.

Parent’s Signature

________________ __________ _________________________ __________________________

SPED Teacher Therapist Other Service Provider

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