Fillable Printable Individual Education Plan Sample
Fillable Printable Individual Education Plan Sample
Individual Education Plan Sample
I N D I V I D U A L I Z E D E D U C A T I O N P R O G R A M
STUDENT’S NAME
DOB
SCHOOL YEAR
-
GRADE
-
IEP INITIATION/DURATION DATES FROM TO
THIS IEP WILL BE IMPLEMENTED DURING THE REGULAR SCHOOL TERM UNLESS NOTED IN EXTENDED
SCHOOL YEAR SERVICES.
STUDENT PROFILE – WILL INCLUDE GENERAL STATEMENTS REGARDING:
Strengths of the student –
Include information regarding the student’s strengths in academic and functional areas.
Parental concerns for enhancing the education –
Include all information regarding the parental concerns for enhancing the education of their child.
Student Preferences and/or Interests –
This area includes information obtained from parent, teacher(s), and the student regarding preferences and interests.
Include all information concerning student preferences and/or interests including transition information.
Results of the most recent evaluations –
Include all information concerning evaluation results. This information should be written in meaningful terms so that
the parent and service providers have a clear understanding of the evaluation results.
The academic, developmental, and functional needs of the student –
Include all information concerning how the student’s disability affects his/her involvement and progress in the general
education curriculum, and, for preschool age children, how the disability affects his/her participation in age-appropriate
activities.
Other –
Include any information pertinent to the development of the IEP that was not included anywhere else on the
Student Profile page.
For the child transitioning from EI to Preschool, justify if the IEP will not be implemented on the child’s 3
rd
birthday –
This should only be completed if the child is not being served under IDEA on the child’s third birthday. (e.g., if a child’s
birthday is during the summer or holiday(s) justification is required).
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I N D I V I D U A L I Z E D E D U C A T I O N P R O G R A M
STUDENT’S NAME: DOB:
SPECIAL INSTRUCTIONAL FACTORS
Items checked “YES” will be addressed in this IEP:
Does the student have behavior which impedes his/her learning or the learning of others?
YES
[ ]
NO
[ ]
Does the student have a Behavioral Intervention Plan?
[ ] [ ]
Does the student have limited English proficiency?
[ ] [ ]
Does the student need instruction in Braille and the use of Braille?
[ ] [ ]
Does the student have communication needs?
[ ] [ ]
Does the student need assistive technology devices and/or services?
[ ] [ ]
Does the student require specially designed P.E.?
[ ] [ ]
Is the student working toward alternate achievement standards and participating in the
Alabama Alternate Assessment? [ ] [ ]
Are transition services addressed in this IEP?
[ ] [ ]
TRANSPORTATION
Student’s mode of transportation:
[ ] Regular bus [ ] Bus for special needs [ ] Parent contract [ ] Other:
Does the student require transportation as a related service?
[ ] YES [ ] NO
If yes, check any transportation needs:
[ ] Bus assistance: [ ] Adult support [ ] Medical support
[ ] Preferential seating
[ ] Behavioral Intervention Plan
[ ] Wheelchair lift and securement system
[ ] Restraint system
Specify type:
[ ] Other. Specify:
[ ] Bus driver and support personnel are aware of the student’s behavioral and/or medical concerns.
NONACADEMIC and EXTRACURRICULAR ACTIVITIES
Will the student have the opportunity to participate in nonacademic/extracurricular activities with his/her nondisabled
peers?
[ ] YES.
[ ] YES, with supports. Describe:
[ ] NO. Explanation must be provided:
METHOD/FREQUENCY FOR REPORTING PROGRESS OF ATTAINING GOALS TO PARENTS
Annual Goal Progress reports will be sent to parents each time report cards are issued (every
weeks).
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INDIVIDUALIZED EDUCATION PROGRAM
STUDENT’S NAME: DOB:
Transition: Beginning not later than the first IEP to be in effect when the student is 16, or earlier if appropriate, and
updated annually thereafter. For all students entering 9th grade regardless of their age, transition must be addressed.
[ ] This student was invited to the IEP Team meeting.
[ ] After prior consent of the parent or student (Age 19) was obtained, other agency representatives were invited to
the IEP Team meeting.
[ ] Transition services based on the student’s strengths, preferences, and interests that will reasonably enable the
student to meet the postsecondary goals are addressed on the transition goal page in this IEP.
Age-appropriate Transition Assessments:
(Select the assessment(s) used to determine the student’s measurable postsecondary transition goals.)
[ ] Student Interview [ ] Career Awareness [ ] Interest Inventory
[ ] Parent Interview [ ] Student Portfolio [ ] Interest Learning Profile
[ ] Student Survey [ ] Vocational Assessment [ ] Career Aptitude
[ ] Other
Enter the assessment(s) used to determine the student’s selected long-term postsecondary transition goals:
Postsecondary Education/Training Goal
Assessment: Date:
Assessment: Date:
Long-Term Goal:
If Other is selected, specify:
Employment/Occupation/Career Goal
Assessment: Date:
Assessment: Date:
Long-Term Goal:
If Other is selected, specify:
Community/Independent Living Goal
Assessment: Date:
Assessment: Date:
Long-Term Goal:
If Other is selected, specify:
[ ] This student is in a middle school course of study that will help prepare him/her for transition.
Anticipated Date of Exit: Month: Year:
Selected Pathway to the Alabama High School Diploma:
[ ]
General Education Pathway (Intended to prepare student for college and career)
[ ]
Essentials/Life Skills Pathway (Intended to prepare student for a career/competitive employment)
[ ] Alternate Achievement Standards Pathway (AAS) (Intended to prepare students for supported/competitive
employment)
Program Credits to be Earned (Complete for students in grades 9-12)
For each course taken indicate program credits to be
earned next to the appropriate pathway.
ENGLISH MATH SCIENCE
SOCIAL
STUDIES
General Education Pathway
Essentials/Life Skills Pathway
Alternate Achievement Standards Pathway
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Elective(s) (enter total number of electives)
INDIVIDUALIZED EDUCATION PROGRAM
ANNUAL TRANSITION GOAL(S)
STUDENT’S NAME: DOB:
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE:
Based on the student’s strengths, preferences, interests, and needs related to the postsecondary goals (include a description
of age-appropriate transition assessments).
( L i n k t o T r a n s i t i o n S t a n d a r d s )
MEASURABLE ANNUAL POSTSECONDARY TRANSITION GOALS:
Academic areas may be written separately or embedded within the transition goal. Address transition services, activities,
and person(s)/agency involved for each goal area. (If more than one goal is needed in any one goal area below, additional
goal pages can be added.)
Postsecondary Education/Training Goal: Date of Completion/Mastery:
*Transition Service(s):
Transition Activity(s):
(Enter a numbered list of all activities to assist the student in achieving his/her long-term Postsecondary
Education/Training goal.)
1.
2.
Person(s)/Agency Involved:
Employment/Occupation/Career Goal: Date of Completion/Mastery:
*Transition Service(s):
Transition Activity(s):
(Enter a numbered list of all activities to assist the student in achieving his/her long-term Employment/Occupation/Career
goal.)
1.
2.
Person(s)/Agency Involved:
Community/Independent Living Goal: Date of Completion/Mastery:
*Transition Service(s):
Transition Activity(s):
(Enter a numbered list of all activities to assist the student in achieving his/her long-term Community/Independent Living
goal.)
1.
2.
Person(s)/Agency Involved:
*Transition Services: Consider these service areas:
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Vocational Evaluations (VE), Community Experiences (CE), Personal Management (PM), Transportation (T), Employment
Development (ED), Medical (M), Postsecondary Education (PE), Living Arrangements (LA), Linkages to Agencies (LTA),
Advocacy/Guardianship (AG), Financial Management (FM), and if appropriate, Functional Vocational Evaluation (FVE).
I N D I V I D U A L I Z E D E D U C A T I O N P R O G R A M
STUDENT’S NAME: DOB:
Identify the area the MEASURABLE ANNUAL GOAL will address. The area may be an academic content area (e.g.,
math, science) and/or a functional area (e.g., behavior, organization). For all students working on Extended Standards
(following the Alternate Achievement Standards pathway), each content area (e.g., reading, math, science, language arts,
and social studies) must be addressed.
AREA:
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE:
State how the student’s disability affects his/her involvement and progress in the general education curriculum for this
particular area of instruction, or for preschool age students, how the disability affects the student’s participation in age-
appropriate activities.
(Link to Curriculum Guides)
MEASURABLE ANNUAL GOAL related to meeting the student’s needs:
Target the individual needs of the student resulting from the student’s disability and how the student’s disability affects
his/her involvement and progress in the general education curriculum. Describe what a student can reasonably be
expected to accomplish within one school year.
DATE OF MASTERY:
TYPE(S) OF EVALUATION FOR ANNUAL GOAL:
Check each type of evaluation that will be used to evaluate the MEASURABLE ANNUAL GOAL. (At least one
must be chosen.)
[ ] Curriculum Based Assessment [ ] Teacher/Text Test [ ] Teacher Observation [ ] Grades
[ ] Data Collection [ ] State Assessment(s) [ ] Work Samples
[ ] Other: [ ] Other:
BENCHMARKS:
Include at least two Benchmarks for students working on Extended Standards or for students in public agencies that
require Benchmarks. Benchmarks are required for all students working on Extended Standards. This includes academic
goals and functional goals, regardless of whether it is a testing year.
1. Date of Mastery:
2. Date of Mastery:
3. Date of Mastery:
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4. Date of Mastery:
I N D I V I D U A L I Z E D E D U C A T I O N P R O G R A M
STUDENT’S NAME: DOB:
SPECIAL EDUCATION AND RELATED SERVICE(S): (Special Education, Supplementary Aids and Services,
Program Modifications, Accommodations Needed for Assessments, Related Services, Assistive Technology, and Support
for Personnel.)
Special Education
Service(s)
Anticipated
Frequency of
Service(s)
Amount
of time
Beginning/Ending
Duration Dates Location of Service(s)
to
to
Related Services [ ] Needed [ ] Not Needed
Service(s)
Anticipated
Frequency of
Service(s)
Amount
of time
Beginning/Ending
Duration Dates Location of Service(s)
to
to
Supplementary Aids and Services [ ] Needed [ ] Not Needed
Service(s)
Anticipated
Frequency of
Service(s)
Amount
of time
Beginning/Ending
Duration Dates Location of Service(s)
to
to
Program Modifications [ ] Needed [ ] Not Needed
Service(s)
Anticipated
Frequency of
Service(s)
Amount
of time
Beginning/Ending
Duration Dates
Location of Service(s)
to
to
Accommodations Needed for
Assessments [ ] Needed [ ] Not Needed
Service(s)
Anticipated
Frequency of
Service(s)
Amount
of time
Beginning/Ending
Duration Dates Location of Service(s)
to
to
Assistive Technology [ ] Needed [ ] Not Needed
Service(s)
Anticipated
Frequency of
Service(s)
Amount
of time
Beginning/Ending
Duration Dates Location of Service(s)
to
to
Support for Personnel [ ] Needed [ ] Not Needed
Service(s)
Anticipated
Frequency of
Service(s)
Amount
of time
Beginning/Ending
Duration Dates Location of Service(s)
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to
to
I N D I V I D U A L I Z E D E D U C A T I O N P R O G R A M
STUDENT’S NAME: DOB:
TRANSFER OF RIGHTS
(Beginning not later than the IEP that will be in effect when the student reaches 18 years of age.)
Date student was informed that the rights under the IDEA will transfer to him/her at the age of 19
EXTENDED SCHOOL YEAR SERVICES (ESY)
The IEP Team has considered the need for extended school year services.
[ ] Yes [ ] No
LEAST RESTRICTIVE ENVIRONMENT
Does this student attend the school (or for a preschool-age student, participate in the environment) he/she would attend if
nondisabled? [ ] Yes [ ] No
If no, explain:
Does this student receive all special education services with nondisabled peers? [ ] Yes [ ] No
If no, explain (explanation may not be solely because of needed modifications in the general curriculum):
[ ] 6-21 YEARS OF AGE [ ] 3-5 YEARS OF AGE
Least Restricted Environment:
COPY OF IEP COPY OF SPECIAL EDUCATION RIGHTS
Was a copy of the IEP given to parent/student (age 19) at
the IEP Team meeting?
[ ] Yes [ ] No
Was a copy of the Special Education Rights given to
parent/student (age 19) at the IEP Team meeting?
[ ] Yes [ ] No
If no, date sent: If no, date sent:
Date copy of amended IEP provided/sent to parent/student (age 19):
THE FOLLOWING PEOPLE ATTENDED AND PARTICIPATED IN THE MEETING TO DEVELOP THIS IEP.
Position Signature Date
Parent
Parent
General Education Teacher
Special Education Teacher
LEA Representative
Someone Who Can Interpret the Instructional
Implications of the Evaluation Results
Student
Career/Technical Education Representative
Other Agency Representative
information from people not in attendance
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Position Name Date
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