INDIVIDUAL EDUCATION PROGRAM
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| Name: __________________________________ | | |
Date of Birth (mm/dd/yyyy): __________ | Grade Level ___ | q Male q Female |
| Student ID #: _______________ | Parent/Guardian: _________________________________ |
Child/Student Address: _________________________________________________________ |
Parent Address: _______________________________________________________________ |
| Home Phone: _______________ | Work Phone: _______________ | | | |
| Effective IEP Dates from: __________ to: __________ |
q Initial IEP q Periodic Review | | | | |
District of Residence: ___________________ | District of Service: ____________________ |
| Step | 1 | | | | | Discuss future planning. |
| | | | | (Family and student preferences & interests) |
| Step | 2 | | | | | Discuss future planning. |
| | | | (What do we know about this child, & how does that relate in the context of content standards, or for preschool children, in the context of appropriate activities & how the disability affects the student's involvement in the general education curriculum.) |
Annual Goals & Short-Term Objectives
Step 3: Identify needs that require specially designed instruction |
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Step 4: Identify measurable annual goals, including academic & functional goals |
Goal #________ Content are addressed: _______________________________________ |
| Benchmarks or short-term objectives |
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Student Progress (Include a description of how the child's progress toward meeting annual goals will be measured & when periodic reports on the progress the child is making toward meeting the annual goals will be provided.) |
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Step 5: Identify services |
Service:__________________ Initiation data:___________ Expected duration:________ Frequency:_______________ (Identify all services needed for the child to attain the annual goal & programs in the general education curriculum. Services may include specially designed instruction, related services, supplementary aids, or, on behalf of the child, a statement of program modifications, testing accommodations, or supports for school personnel.) |
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Step 6: Determine least restrictive environment |
Determine where services will be provided (An explanation of the extent, if any, to which the child will not participate with nondisabled children in the regular class.) |
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Special Factors
Based on discussions of the information provided regarding relevant special factors & other considerations as noted below, the following is applicable & incorporated into the IEP.
Other Considerations
| Physical education | q |
| Extended school year services | q |
Beginning at age 14...transition service needs which focus on the student's courses of study [See IEP page ___] | q |
| Transition services statement, no later than age 16 [See IEP page ___] | q |
Testing & assessment programs, including proficiency tests [See IEP page ___] | q |
| Transfer of rights beginning at least one year before the student reaches the age of majority under state law (Ohio law is age 18) | q |
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Relevant Information/Suggestions (e.g., medical information, other information):
Children/Students with Visual Impairments
CHILD/STUDENT________________________ GRADE LEVEL _____ SERVICE ____________
INSTRUCTIONS: This form shall be completed during the IEP meeting for each child/student who has a visual impairment, as defined by Ohio's Amended Substitute House Bill Number 164, which requires a statement specifying one or more reading and writing media in which instruction is appropriate to meet the child's/student's educational needs. A copy of this completed form is part of, and must be attached to, the child's/student's IEP form.
| | Yes | No |
| 1. Annual assessment of reading & writing skills was conducted with each child/student in all media considered appropriate. The results of these assessments are included in "Present Levels of Development/Functioning/Performance" on the IEP & indicate both strengths & weaknesses. | q | q |
| 2. The IEP contains a requirement for instruction in Braille reading & writing when that medium is appropriate & is indicated by adding "Standard English Braille" as a special service in Step 4, listing the data initiated & the anticipated duration of services. | q | q |
| 3. Instruction in Braille reading & writing was carefully considered for this child/student & pertinent literature describing the educational benefits of instruction in Braille reading & writing was reviewed by the persons developing this child's/student's IEP. | q | q |
| 4. The following visual condition(s) was taken into account & discussed in making the above decision: | | |
Condition is degenerative & progressive loss is expected. Condition is currently unpredictable in nature & will be reviewed if change in visual condition is noted. Condition is temporary & is expected to improve. Condition is stable & will be monitored. | q q q q | q q q q |
| 5. Indicate the appropriate instructional media: | | |
Standard English Braille Large Print Regular Print Tape/auditory Pre-reader | q q q q q | q q q q q |
| 6. Complete if Braille reading & writing ARE appropriate at this time: | | |
Annual goals provided Short-term objectives provided Date of initiation indicated Frequency & duration of instructional sessions indicated Level of competency to be achieved annually indicated Objective determinants used to measure achievement provided | q q q q q q | q q q q q q |
| 7. Reasons Braille reading & writing ARE NOT appropriate this time: | | |
Documented visual acuity allowing the choice of larger type/regualr type Child/student is considered a pre-reader Other | q q q | q q q |
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Discuss & Document a Statement of Needed Transition Sservices
Name of Student _________________________ Date (mm/dd/yyyy) ________ Person(s) Responsible for Coordinating Transition Services ________________________ |
Write a statement of transition service needs that focus on the student's courses of study during his/her secondary school experiences (beginning at age 14 or younger, if appropriate). |
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| FOR 16 YEARS & OLDER | | | | COMPLETED AFTER IEP DEVELOPMENT |
EMPLOYMENT & POSTSECONDARY LONG-TERM OUTCOMB: _________________________ |
Current Year Activities & Services | | Responsible Person/Provider | | Initiation/Duration (Specify Date) | | Goals/Objectives that Support Activities/Services |
| POSTSCHOOL/ADULT LIVING LONG-TERM OUTCOME: ______________________________ |
Current Year Activities & Services | | Responsible Person/Provider | | Initiation/Duration (Specify Date) | | Goals/Objectives that Support Activities/Services |
| COMMUNITY PARTICIPATION LONG-TERM OUTCOME: ______________________________ |
Current Year Activities & Services | | Responsible Person/Provider | | Initiation/Duration (Specify Date) | | Goals/Objectives that Support Activities/Services |
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Functional Vocational Evaluation qNeeded qNot Needed Date Completed ____________
Statewide & Districtwide Testing
Student Name: ___________________________ Student ID: _____________________
Student Grade (when scheduled to take this test): ________
School Year: ___________ IEP Meeting Date (mm/dd/yyyy): ______________
| | | Statewide Testing | | Districtwide Testing |
Areas of Assessment | Grade Level of Test to be Administered | | Will Take Test without IEP Accomm. | Will Take Test with IEP Accomm. | | Will Participate in Alternate Assessment | | Grade Level of Test to be Administered | Will Take Test without Accomm. | Will Take Test with Accomm. | Will Participate in Alternate Assessment |
| Reading | | | | | | | | | | | |
| Writing | | | | | | | | | | | |
| Math | | | | | | | | | | | |
| Science | | | | | | | | | | | |
| Citizenship | | | | | | | | | | | |
| Technology | | | | | | |
ITAC | | | | | | |
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A statement of why the child cannot participate in the regular assessment & will be taking alternate assessment: _______________________________________________________________________________ Excused from the consequences associated with not passing the test (Graduation Test) in the following area(s) of assessment: |
Met participation requirements qYes qNo Date _________________ (Graduation Tests) |
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Areas of Assessment | | List Accommodations to Assessment | | Area of Assessment | | List Accommodations |
| Reading | | | | Other (Specify) | | |
| Writing | | | | Other (Specify) | | |
| Math | | | | Other (Specify) | | |
| Science | | | | Other (Specify) | | |
| Citizenship | | | | Other (Specify) | | |
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Name _____________________________ IEP effective dates (mm/dd/yyyy) from __________ to __________
Date of next IEP review (mm/dd/yyyy) __________
IEP Team Meeting Participants |
Check one of the following: This IEP Team meeting was a qFace to face meeting qVideo conference qPhone Conference/Conference Call |
| (signature/title)________________ | qParticipated qExcused | | (signature/title)________________ | qParticipated qExcused |
| (signature/title)________________ | qParticipated qExcused | | (signature/title)________________ | qParticipated qExcused
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| (signature/title)________________ | qParticipated qExcused | | (signature/title)________________ | qParticipated qExcused |
| (signature/title)________________ | qParticipated qExcused | | (signature/title)________________ | qParticipated qExcused |
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Summary of special education services:_______________________________________________
| Consent for Change in Placement/Partial Implementation of the IEP/Revoke Consent | | Periodic Review Agreement |
q I give consent for the change of placement as identified in this IEP.* q I give consent for the special education & related services specified in this IEP except for _____________________________________ q I do not give consent for a change of placement as identified in this IEP. q I revoke consent for Special Education services. | | q I am signing to show my attendance/participation at the IEP team meeting but I do not agree with the special education & related services specified in this IEP. q I give consent to implement this IEP & I agree with this IEP. |
Parent Signature __________________________________ Date (mm/dd/yyyy): _______________ | | Parent Signature _____________________________________ Date (mm/dd/yyyy): _______________ |
* This IEP serves as prior written notice if there is agreement. ** If there is not agreement, the district must provide prior written notice to the parents. | | Reason for Placement in Separate Facility (If applicable) Having considered the continuum of services & the needs of the student, this IEP team has decided that placement in a separate facility is appropriate because: |
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