Fillable Printable Individualized Education Plan Process
Fillable Printable Individualized Education Plan Process
Individualized Education Plan Process
IDEA ‘97 Transition Requirements: A Guide
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Sample Individualized Education Program
Appendix A
A
Sample Individualized Education Plan (IEP)
The following IEP sample reflects but one way to present an IEP and contains
components that have worked well for some systems. It is critical to remember
that each IEP must be individualized and based on the needs of the particular
student. For a complete description of IEP content required by IDEA ’97, please
refer to the Final Regulations §300.347. In addition, be sure to check with your
district and/or state for recommended or required IEP forms or processes.
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Sample Individualized Education Program
Appendix A
IDEA ‘97 Transition Requirements: A Guide
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Sample Individualized Education Program
Appendix A
A
Individualized Education Program
A.
Student Name (Last, First, MI)
Schooler, Maureen H.
Birthdate (month/day/year)
12/27/83
Sex
[ ]
M
[X]
F
Current Grade
9
Student's Primary Language or Communication Mode
English
Current Address
1234 West Here Street
City
Nice Town
State
ND
Zip
12345
Phone Number
555-222-3333
Serving School
Desert Valley Senior High
City
Nice Town
State
ND
Zip
12345
Phone Number
555-123-4567
Resident School (If different from serving school)
Same
Student Social Security Number (Optional)
123-45-6789
School District of Residence (If different from serving
district)
Same
Check items that apply.
[X]
Open Enrolled in same district
[ ]
Agency Placed
[ ]
Open Enrolled in another district
[ ]
Home Education
B.
Name of Parent(s)
Teddy and Matilda Schooler
Home Telephone Number
555-222-3333
Other Telephone Number
None
Address (if other than Student's Current Address)
Same
Primary Language at Home
English
Is there a Guardian/Educational Surrogate/Foster Parent
[ ]
Yes
[X]
No Name:
[ ]
Guardian
[ ]
Educational Surrogate
[ ]
Foster Parent
Address
N/A
City
N/A
State
N/A
Zip
N/A
C.
IEP Case Manager
Henrietta Harvey
Telephone Number
555-999-8888
IEP Type
[ ]
Initial
[X]
Annual
Date of Last Comprehensive Individual Assessment Report (month/day/year)
5/23/98
D.
Date of IEP Meeting
(month/day/year)
5/16/99
List Names of All Team Members Check Attendance
*Parent
Teddy Schooler
[X]
Yes
[ ]
No
Parent
Matilda Schooler
[X]
Yes
[ ]
No
Student
Maureen Schooler
[X]
Yes
[ ]
No
Administrator/Designee
Joe Smith
[X]
Yes
[ ]
No
Special Ed Teacher
Jane Lakeman
[X]
Yes
[ ]
No
General Ed Teacher
Ellie Math
[X]
Yes
[ ]
No
Representative of district of residence
Carol Burkett, Special Education
[X]
Yes
[ ]
No
Vocational Rehabilitation Counselor
Christine Fullerton
[X]
Yes
[ ]
No
[ ]
Yes
[ ]
No
[ ]
Yes
[ ]
No
[ ]
Yes
[ ]
No
* If the parent did not attend the IEP meeting, describe effort to arrange a mutually agreed upon time and place. Include date, contact, and
outcome of each effort.
Adapted and used with permission of the North Dakota Department of Public Instruction, Office of Special Education.
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Sample Individualized Education Program
Appendix A
E. Students Desired Post School Outcomes, ages 14-21 (or younger, if appropriate)
Employment: I would like to work with or teach children who have disabilities; no job supports are anticipated.
Community Participation: I intend to remain independently involved in church and may volunteer with various community activities of interest.
Recreation & Leisure: I will stay active in group activities (bowling, music, sport events) and independent activities (sewing, reading, roller-blading)
with no need for supports.
Post Secondary Training & Learning Opportunities: I will attend a liberal arts college program to work with children; funding & academic
supports may be appropriate.
Independent Living: I will be capable of living independently in a dorm, apartment or alone.
F. Present Levels of Educational Performance
The statement of present levels of educational performance is an integrated summary of information from all sources including the student's
family. Summarize and discuss parent information and student progress toward previous goals and objectives. Include the parents’
perspectives and insights about their child's learning strategies, social skills, interests, and any existing medical diagnoses that are important
contributions to creating a description of the whole child. The statement should include current information about the student's specific
strengths and weaknesses, progress in the general education curriculum, unique patterns of functioning, and implications of the problem
areas on the student's total functioning. Performance areas to be considered include the following:
✔ Cognitive functioning
✔ Communicative status
✔ Sensory status
✔ Emotional and social development, behavior skills (including
adaptive behavior, if applicable), and ecological factors
✔ Academic performance
✔ Motor ability
✔ Health/physical status
Maureen is currently functioning in the average range of intelligence according to the WISC III administered on 5-23-98.
Her strengths are in the area of short and long-term memory and problem solving. Her learning disability in the areas of
reading comprehension and written expression require accommodations in her general education classes described in
Section G. Maureen's oral expression skills are a strength for her as are her interpersonal skills. Academically, she has
maintained Bs with a C in Biology for the second semester of her 9
th
grade year. She met her IEP goals for the 98-99
academic year.
Address the present levels of performance in each of the following domains with documentation of student needs, preferences and
interests and identified by what method this information was obtained.
Jobs and Job Training
Maureen volunteered at the Busy Bee Child Development Center during her 9
th
grade year. She worked primarily with the
three-year-olds. Her supervisor reported that she was dependable and reliable and related very well with the students.
Based on the California Occupational Preference Survey (COPS), her goal of working in child care appears to be an
appropriate choice.
By what method was this obtained: Interview with job supervisor
Recreation and Leisure
Maureen is athletic; she is on a junior bowling league and enjoys rollerblading.
By what method was this obtained: Interview with Maureen and her parents
Home/Independent Living
Maureen is independent at home now and intends to pursue living on her own after graduation.
By what method was this obtained: Interview with Maureen and her parents
Woodcock-Johnson Scale of Independent Behavior
Community Participation
Maureen is quite active in church activities at this time.
By what method was this obtained: Interview with Maureen
Post-Secondary Training and Learning Opportunities
Maureen wishes to attend a post-secondary liberal arts college, majoring in Child Development. She is exploring both 2-
year and 4-year institutions at this time and considering earning an AA + certificate first.
By what method was this obtained: Interview with Maureen
Related Services
Maureen has not received related services since the elementary grades (K-3) when she received Speech and Language therapy
for 2x/week for 30 minutes. She was discharged at the end of third grade.
By what method was this obtained: Review of school records
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Sample Individualized Education Program
Appendix A
A
(F. Present Levels of Educational Performance, continued)
Considerations the IEP team must address
A. Does the student exhibit behaviors that impede his or her learning or that of others?
[X]
No
[ ]
Yes - Consider strategies including positive behavior interventions, strategies, and supports in the IEP.
If yes, what are recommendations to address these needs?
B. Does the student have limited English proficiency?
[X]
No
[ ]
Yes
If yes, what are recommendations to address these needs?
C. Is the student blind or visually impaired?
[X]
No
[ ]
Yes - but the student does not need Braille/Braille instruction based on the student’s current and future
reading and writing skills and needs.
[ ]
Yes - and the student needs Braille/Braille instruction based on the student’s current and future reading
and writing skills and needs.
If yes, what are recommendations to address these needs?
D. Is the student deaf or hearing impaired?
[X]
No
[ ]
Yes - Consider the child’s language and communication needs, opportunities for direct communication
with peers and professionals in the child’s language and communication mode, academic level,
and full range of needs including opportunities for direct instruction in the child’s language and
communication mode.
If yes, what are recommendations to address these needs?
E. Does the student have other communication needs?
[X]
No
[ ]
Yes - Consider the strategies to address communication needs of the student.
If yes, what are recommendations to address these needs?
F. Does the student require assistive technology devices and services?
[ ]
No
[X]
Yes - Consider the assistive technology needs of the student.
If yes, what are recommendations to address these needs?
Algebra: calculator for completion of assignments, quizzes and tests.
Child Development, English, Advanced Biology: tape recorder to record class lectures and demonstrations.
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Sample Individualized Education Program
Appendix A
G. Statement of Transition Service Needs (ages 14-21, or younger if appropriate)
School
Year
Grade
Level
List Courses to be taken each year
Credits
Earned
Grade 8
Grade 9
6
99-00 Grade 10 Child Development (1/2), English 10 (1), Band (1), Phy Ed (1/2), Spanish I (1), Algebra (1), Adv.
Biology (1), Resource Room (1)
7 (13)
00-01 Grade 11 English 11 (1), Spanish II (1), Geometry (1), Band (1), Phy Ed (1/2), Family & Consumer Science I
(1/2), Chemistry (1), Resource Room (1)
7 (19)
01-02 Grade 12 Psychology (1/2), English 12 (1), Algebra II (1), Band (1), Cooperative Work Experience (11/2), Phy
Ed (1/2), US History (1/2), Resource Room (1)
6 (24)
Ages 18-21
Total number of credits required by this district for graduation:
21 Anticipated
month and year of graduation: May
2002
Will this student graduate with fewer credits than required of all students by the district? [ ] Yes [X] No
If yes, identify graduation adaptations
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Sample Individualized Education Program
Appendix A
A
H. Statement of Needed Transition Services (ages 16-21, or younger if appropriate)
Transition
Services
Needs &
Activities
Agency(ies) &
Responsibilities
Provider &
Payer
Instruction:
• Sp Ed supports in identified classes
• Modified ACT testing
• Post secondary supports (academic)
• School district
• School district
• College of choice & Maureen
• School district will
p
rovide identified su
pp
orts
• School district
• College of choice
Community
Experiences:
• Three job shadow experiences with
children
• Visit three colleges which offer
program of interest
• Open a checking/saving account at
bank
• Coordinated by Case Manager and
Maureen
• Maureen & parents
• Maureen & parents
• School District will provide services
• Maureen and her parents will be responsible
for any expenses incurred to visit colleges
• Maureen and her parents will be responsible
for any expenses incurred.
Employment:
• Job preparation skills & review
• Part time employment by personal job
search and/or with assistance from
Job Service if necessary
• Coordinated by case manager and
Maureen
• Maureen & Job Service Counselor
• School district will provide services
• Maureen will incur any expenses to locate
and find part time employment
Related Services:
Maureen’s IEP team
identified no long-term
needs in related services
at this time.
Adult Living &
Post School:
• Apply for all possible college financial
aid
• Vocational Rehabilitation referral to
determine eligibility for tuition
assistance for college
• Participate in home skills (make
clothing & misc. purchases, cook 1
meal/week, help with laundry &
misc. household chores)
• Apply for college/DSS no later than
12/01.
• Maureen, parents, school guidance
office
• Maureen, parents and VR staff
• Maureen and parents
• Maureen and parents
• School will provide services within limits of
building, and Maureen/parents will incur
expenses for mailings, etc.
• There is no expense to apply for VR services
• Maureen and her parents will be responsible
for any expense of this activity
• Maureen and parents
Daily Living:
(if appropriate)
Functional
Vocational
Assessment:
(if appropriate)
• Review CHOICES to reaffirm
vocational goal and review college
information
• Complete community & Independent
living assessment
• Maureen, Guidance office, Case
Manager
• School district will provide this service there is
no expense
• There is no expense for this activity for the
district.
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Sample Individualized Education Program
Appendix A
Agency Collaboration & Responsibilities* (ages 16-21, or younger if appropriate)
School
Year
Grade
Level
Needed
Service(s)
Agency &
Contact Person
Who will contact
& when
Timeline for
delivery of
service(s)
Results &
Outcomes
99-00 10
Job seeking/placement
assistance
Job service Counselor
John Olson
Maureen, June 99 Summer 1999 to
Spring 2000
Part time employment for
summer 1999 & possibly to
continue through school year
00-02 11-12
Eligibility
determination
Vocational
Rehabilitation
Counselor Sue Smith
Maureen & parents December 2000 Possible eligibility for
services (tuition for college)
00-01 11 Referral to Independent
Living Center
ILC Counselor Mary
Jones
Case Manager,
Maureen
May 2001 Independent Living and
Community assessment to
determine strengths and
prepare for college/advocacy
01-02 12
Post-secondary academic
supports
College Disability
Support Services Staff
Maureen & parents March 2002 Classroom & testing
accommodations in college
* If any agency identified by the IEP team fails to provide services, the IEP team must reconvene as soon as possible to identify alternate
strategies and amend the IEP as necessary. Document date of reconvened IEP meeting and results.
IDEA ‘97 Transition Requirements: A Guide
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Sample Individualized Education Program
Appendix A
A
I. Annual Goals, Short-Term Objectives, and Characteristics of Services
Use one page for each annual goal. Thoroughly state the annual goal. Annual goals should be reasonably achieved in one year and should be
unique to the student. Related Services should appear ONLY as objectives that are integrated into the student's instructional program.
Annual Goal (behavior or skill, desired ending level of achievement, intent or purpose of the behavior): Goal #
1
of
goals
Maureen will fully participate in her Child Development course during her sophomore year, attaining the
prescribed competencies with 80% accuracy or better.
Short-Term Instructional Objectives and Characteristics of Services:
List objectives for each goal including conditions under which the behavior is performed, the specific behavior,
measurable criteria, evaluation procedures, and schedules for determining if objectives are being achieved
(initiation date, dates for progress checks). The person responsible for monitoring progress will be added upon
completion of Section J.
For each objective, consider and document the following characteristics of services information:
Does the performance specified in the objective(s) promote the child's involvement and progress in the general
education curriculum?
How might services be modified to enable greater involvement and progress in the curriculum? Describe the
needed modifications or adaptations.
If the child will not participate in the general education curriculum, provide a justification for the alternative
selected. Describe the specially designed instruction (e.g., specially designed driver education) or supportive
training related to the disability (e.g., braille instruction/occupational therapy).
Who will provide the modifications/adaptations OR the specially designed instruction/supportive training
related to the disability described above?
Given each district-prescribed competency, Maureen will complete the competency with 80% accuracy or better.
Data will be collected via classroom observation work samples, teacher and practicum supervisor, anecdotal
records, portfolio, and teacher-made tests. Biweekly progress checks will be conducted and written reports sent
to Maureen's parents based on the district's competency list for child development.
Progress reporting to parents will occur at least as often as reporting in general education (report cards). Written reports will be provided
every:
[ ]
6 weeks
[X]
9 weeks
[ ]
Other schedule (specify: Biweekly )
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Sample Individualized Education Program
Appendix A
J. Adaptation of Educational Services
Describe changes in educational services that will be made to permit successful accommodation and education of this student (e.g.
credits, staff, transportation, facilities, materials, braille, equipment, technology, adaptive devices, curriculum, methods and other
services). Include procedures for monitoring equipment, if applicable.
Maureen will be provided with extended time on tests in her Child Development, Algebra and Advanced
Biology classes. She will be provided with preferential seating in Spanish I. She will be provided with
taped texts for English 10 and multiple choice or short answer tests rather than essay. She may tape record
lectures in Child Development, English 10, and Advanced Biology and use a calculator for Algebra. She
may also have syllabi in advance and guided notes if desired.
Assistive Technology MUST be considered for each student with a disability.
Does the student need assistive technology devices and services to access the general education curriculum (or FAPE)?
[ ]
No
[X]
Yes If "Yes" is checked, explain.
Algebra: calculator for completion of assignments, quizzes and tests.
Child Development, English, Advanced Biology: tape recorder to record class lectures and demonstrations.
Describe the student's participation in district-wide and statewide assessment.
[ ]
Student will participate without accommodations.
[X]
Student will participate with accommodations specified below: [Note: Some students may participate in portions of
district/statewide assessments.]
Scheduling: extended time only
[ ]
Student will participate in alternate assessment. Justification for not participating in district or statewide assessments and the
description of alternate assessment must be provided.
Positive Behavior Interventions and Strategies.
Do the Present Levels of Educational Performance include a description of problem behavior that
impedes the student's learning or the learning of others?
[ ]
Yes
[X]
No
Does the student's disability limit his/her understanding of school rules and consequences?
[ ]
Yes
[X]
No
Does the student's disability limit or influence his/her ability to follow school rules?
[ ]
Yes
[X]
No
If "Yes" is checked for any of the above questions, then the components of a Behavior Intervention Plan must be documented.
Documentation of Behavior Intervention Plan can be found:
[ ]
in goals and objectives
[ ]
in adaptations section
[ ]
in an attachment.
K. Description of Activities with Students Who Are Not Disabled
Physical Education. Indicate type of physical education program that the student receives:
[X]
regular P.E.
[ ]
adaptive/specially designed P.E. (include specific goals and objectives in Section I)
Participation in Academic and Nonacademic Activities:
Check any program options in the boxes below in which the student will be participating with students who do not have
disabilities.
Program Options. Comments:
[ ]
Art.
[ ]
Industrial Arts
[X]
Music (Band)
[X]
Vocational Education (Child Development)
[ ]
Home Economics
[X]
Other (English 10, Algebra, Advanced Biology, Spanish I)
Nonacademic and Extracurricular Services and Activities. Comments:
[ ]
Counseling
[ ]
Meals
[X]
Employment Referrals
[ ]
Recess
[X]
Athletics (Tennis Team)
[ ]
Recreation
[ ]
School Sponsored Clubs
[ ]
Special Interest Groups
[ ]
Transportation
[ ]
Other_______________
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Sample Individualized Education Program
Appendix A
A
L. Least Restrictive Environment Justification
This page is intended as a SUMMARY for all Goals, Objectives, Characteristics of Services, Adaptations, and Special Education and Related
Services information included in sections I, J & L. Check all settings in which the special education and related services will be provided.
SETTING: Percent of
time/week
[X] A. Regular Education Classroom
6 periods
86%
[ ] B. Limited special services in Regular Education classroom
[X] C. Resource Room
1 period
14%
[ ] D. Separate Class
[ ] E. Public separate school (day) facilities
[ ] F. Private separate school (day) facilities
[ ] G. Public residential facilities
[ ] H. Private residential facilities
[ ] I. Correction facilities
[ ] J. Homebound/hospital environments
TOTAL: 100%
Before a disabled child can be placed outside of the regular educational environment, the full range of supplementary aids and services that
if provided would facilitate the students placement in the regular classroom setting must be considered. In all cases, placement decisions
must be individually determined on the basis of each child1s abilities and needs, and not solely on factors such as category of disability,
significance of disability, availability of special education and related services, configuration of the service delivery system, availability of space
or administrative convenience. Explain why options selected above are the most appropriate and the least restrictive. Describe other options
considered and provide reasons those options were rejected.
Maureen will participate in one period per day of Special Education Services in the resource room for the
purpose of academic support in her regular education classes. Given her current course load this period of
support is necessary. Removal from the regular education setting during this time will not be harmful.
Is there a potential harmful effect to the student with this placement? [ ] Yes [X] No
Is there a potential harmful effect to the student’s peers with this placement?
[ ] Yes [X] No
If yes to either question, make sure the explanation for the selection of the placement option documents this concern for potential harmful
effect.
M. Special Education and Related Services
*Services Min./
Week
Starting Date
Ending Date
Service Provider and Telephone
Location of Services Building Name
AND Room (if another school
district, provide district name)
Resource Room
Rehabilita-
tion
Counseling
45
Minutes
1 x/mo
45
Minutes
5/16/99-
5/16/00
9/16/99-
5/16/00
Jane Lakeman
Christine Fullerton
Desert Valley High School
Room C 25
ND Rehabilitation Services
* The duration of these services may not exceed one year (12 months) from the date of this IEP.
Length of school day:
[X] The student will attend for the full school day.
[ ] The student will attend for a shorter or longer school day than peers. (Explain why this is necessary.)
Extended school year MUST be considered for each student with a disability. Justification for the decision made MUST BE STATED
BELOW.
[ ] The review of each goal indicates that an extended school year is needed.
[X] The review of each goal indicates that services will be in effect for the normal school year.
[ ] The team needs to collect further data before making this determination and will meet again by __________________________________.
Justification for the above decision:
