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Individualized Education Program |
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Parent and/or Student
Concerns
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Student
Strengths and Key Evaluation Results Summary |
Vision
Statement: What is the vision for this student? Consider the next 1 to 5 year period when developing
this statement. Beginning no later than age 14, |
IEP 1
Individualized Education Program
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IEP Dates: from |
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Student Name: |
DOB: |
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ID#: |
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Present
Levels of Educational Performance
A: General Curriculum
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Check all that apply. |
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General curriculum area(s) affected by this
students disability(ies): |
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English Language Arts |
Consider the language, composition, literature
(including reading) and media strands. |
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History and Social Sciences |
Consider the history, geography, economic and civics
and government strands. |
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Science and Technology |
Consider the inquiry, domains of science, technology
and science, technology and human affairs strand. |
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Mathematics |
Consider the number sense, patterns, relations and
functions, geometry and measurement and statistics and probability strands. |
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Other Curriculum Areas |
Specify: |
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How does the disability(ies)
affect progress in the curriculum area(s)? |
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What type(s) of accommodation, if any, is necessary for the student to make effective progress? |
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What type(s) of specially designed instruction, if any, is necessary for the student
to make effective progress? |
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Check the necessary instructional modification(s) and
describe how such modification(s) will be made. |
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Use multiple copies of this form as needed.
IEP 2
Individualized Education Program
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IEP Dates: from |
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Student Name: |
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DOB: |
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ID#: |
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How does the disability(ies)
affect progress in the indicated area(s) of other educational needs? |
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What type(s) of accommodation, if any, is necessary for the student to make effective progress? |
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What type(s) of specially designed instruction, if any, is necessary for the student
to make effective progress? |
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Check the necessary instructional modification(s) and
describe how such modification(s) will be made. |
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Content: |
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Methodology/Delivery of Instruction: |
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Performance Criteria: |
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Use
multiple copies of this form as needed.
IEP 3
Individualized Education Program
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IEP Dates: from |
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Student Name: |
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DOB: |
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ID#: |
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Current Performance Levels/Measurable Annual Goals |
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Goal # |
Specific Goal Focus: |
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Current Performance Level: What can the student
currently do? |
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Measurable Annual Goal: What challenging, yet attainable,
goal can we expect the student to meet by the end of this IEP period? |
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Benchmark/Objectives: What will the student need to do to complete
this goal? |
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Goal # |
Specific Goal Focus: |
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Current Performance Level:
What can the student currently do? |
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Measurable Annual Goal: What
challenging, yet attainable, goal can we expect the student to meet by the end
of this IEP period? |
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Benchmark/Objectives: What
will the student need to do to complete this goal? |
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Progress Reports are required to be sent to parents at
least as often as parents are informed of their nondisabled childrens
progress. Each progress report must answer the following two questions for
each goal: |
1. What
is the students progress toward the annual goal? 2. Is
the progress sufficient to enable the student to achieve the annual goal by
the end of the IEP period? |
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Use multiple copies of this form as needed.
IEP
4
Individualized Education Program
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IEP Dates: from |
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Student Name: |
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DOB: |
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ID#: |
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Service Delivery |
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What are the total service
delivery needs of this student? |
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Include
services, related services, program modifications and supports (including
positive behavioral supports, school personnel and/or parent
training/supports). Services should assist the student in reaching IEP goals,
to be involved and progress in the general curriculum, to participate in
extracurricular/nonacademic activities and to allow the student to
participate with nondisabled students while working towards IEP goals. |
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5 day cycle |
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6 day cycle |
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10 day cycle |
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other: |
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A. Consultation (Indirect Services to School
Personnel and Parents) |
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Focus
on |
Type
of Service |
Type
of Personnel |
Frequency
and |
Start
Date |
End
Date |
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B. Special Education and Related Services in General Education Classroom
(Direct Service) |
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Focus
on |
Type
of |
Type
of |
Frequency
and |
Start
Date |
End
Date |
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C. Special Education and Related Services in
Other Settings (Direct Service) |
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Focus
on |
Type
of |
Type
of |
Frequency
and |
Start
Date |
End
Date |
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Use multiple copies of this form as needed.
IEP
5
Individualized Education Program
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IEP Dates: from |
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to |
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Student Name: |
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DOB: |
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ID#: |
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IEP
6
Individualized Education Program
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IEP Dates: from |
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to |
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Student Name: |
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DOB: |
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ID#: |
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State or District-Wide Assessment |
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Identify
state or district-wide assessments planned during this IEP period: |
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Fill out the table below. Consider any state or
district-wide assessment to be administered during the time span covered by
this IEP. For each content area, identify the students assessment
participation status by putting an X in the corresponding box for column 1,2, or 3. |
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1. Assessment participation:
Student participates in |
2. Assessment participation:
Student participates in |
3. Assessment participation:
Student participates in alternate assessment in this content area. (See below) |
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CONTENT AREAS |
COLUMN 1 |
COLUMN 2 |
COLUMN 3 |
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English Language Arts |
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History and Social Sciences |
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Mathematics |
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Science and Technology |
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For each content area
identified by an X in the column 2 above: note in the space below, the
content area and describe the accommodations necessary for participation in
the on-demand testing. Any accommodations used for assessment purposes should
be closely modeled on the accommodations that are provided to the student as
part of his/her instructional program. |
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For each content area
identified by an X in column 3 above: note in the space below, the content
area, why the on-demand assessment is not appropriate and how that content
area will be alternately assessed. Make sure to include the learning standards
that will be addressed in each content area, the recommended assessment
method(s) and the recommended evaluation and reporting method(s) for the
students performance on the alternate assessment. |
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NOTE |
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When state
model(s) for alternate assessment are adopted, the district may enter use of
state model(s) for how content area(s) will be assessed. |
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IEP
7
Individualized Education Program
|
IEP Dates: from |
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to |
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Student Name: |
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DOB: |
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ID#: |
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IEP
8