PURPOSE: The IEP is designed to clearly communicate to the parents, the student, and providers the type and

d amount of special education and any necessary related services or

supports that will be made available to the student. The most recent evaluation report is used to develop the IEP. The IEP is individualized to reflect the unique needs of the student and
how these needs will be addressed to permit the student to be included and progress in the general education curriculum.
INDIVIDUALIZED EDUCATION PROGRAM
Student name Student I! "o. !ate of IEP meeting #$%$&'
(irthdate )&$&)$*))# +ge , -rade . IEP annual review date #$%$&/
Eligibility category +utism !ate of most recent eval
0ace$Ethnicity White Primary language English 0eevaluation due date
!istrict Seattle 0esident School Thornton 1ree2 Ele Serving School 3if different4
Parent3s4 name3s4 f Primary language at home English
Parent interpreter needed5 6es "o Surrogate parent: Yes No If yes, name
Primary staff contact name Title
PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
POINTS THAT MUST BE
CONSIDERED IN
Form 6c - IEP (without Transition) Page 1 +ugust *))# (Rev. 10/2013)
DEVELOPING THE IEP
(refer to WAC 392!"2A
#3!!#$%
0esults of the most current
evaluation, and the
academic, developmental,
and functional needs of the
student.
Positive behavioral supports
and interventions, if the
student7s behavior impedes
the student7s learning or that
of others.
8anguage needs of students
with limited English
proficiency as they relate to
the child7s IEP.
Supports for blind$visually
impaired students, include
(raille instruction.
1ommunication needs of
the student, including the
needs for deaf and hard of
hearing students.
+ssistive technology
devices and services.
Supplementary
aids$services, program
modifications, and support
for school personnel.
General Background, Updated 8/7/14
Communcaton
Student7s communication s2ills were assessed using classroom observations. "o standardized testing was completed at this
time.
Student is a verbal communicator. 9e uses single words, phrases 3':/ words4 and occasionally longer sentences to
communicate : as2 questions, ma2e comments, answer questions and protest. 9is length of utterance is highly dependent
on his motivation and interest in the tas2$activity.
+t times Student does not respond or comply with questions and$or requests. 9e can remain silent or wal2$run away.
Student needs to have questions$requests repeated *:; times to gain his attention if he is focused on something else.
Student occasionally 3& < * times per morning4 verbalizes using techno =argon 3specifically cellular phone and computer
language4 when by himself and during conversations with adults. >hen requested to use standard$conventional words his
compliance varied and was dependent on his motivation$interest in his present activity.
To more effectively communicate, verbally and physically, with adults and individuals in the classroom, Student needs
instruction, activities and requests to be presented in multiple formats, orally, written format and technological 3iPad,
computer4 and limited to an average of /:&) minutes. +dditionally, requests and instructions need to be limited to ? ' steps
and time provided to allow Student to act on them with adult supervision and minimal delay.
!at"
Student has written numbers 3with up to ; digits4 upon request.
9e demonstrates ability to identify, write and add addends with up to ; digit numbers using both the standard algorithm as
well as horizontal number sentences with no borrowing or carrying over.
Student7s subtraction s2ills are continuing to develop, however, he does not complete subtraction problems 3word and
algorithm4 as quic2ly as he does addition.
9e has memorized some multiplication facts.
Student adds and subtracts quic2ly 3using the standard algorithm and interpreting word problems4 but does not share his
thin2ing 3verbally or in writing4 or respond to direct questions as he completes this wor2. Student needs to continue using
Touch@ath curriculum.
Form 6c - IEP (without Transition) Page 2 +ugust *))# (Rev. 10/2013)
!otor
Student has demonstrated fine motor control by pic2ing up small ob=ects, e.g. marshmallows and to2ens 3paper tic2ets4 and
can successfully balance himself on the edge of the playgroup wall. "o additional updates.
Readng
Student confidently reads teAts at ':,
th
grade levels. In isolation he correctly identifies word meanings and is able to spell
most words on demand. Student is ma2ing progress on retelling and identifying the beginning and ending events of
recently read short stories, but struggled to retell the middle event. To improve his comprehension s2ills and ability to retell
events, he needs to continue wor2ing on eAtracting meaning from passages or paragraphs by ordering$sequencing events
3beginning, middle and end4.
Socal Be"a#or
Student chooses to wor2 independently but will engage with adult individuals using electronic devices and$or which he has
established familiarity. 9e will sit or visit certain students but does not engaged with them, but does engage with their
lesson$activity, which is typically s2ills he has mastered.
$rtten %anguage
9e is a very fast writer so his writing can be difficult to read. 9e does not often follow standard writing conventions. 9e
often forgets to put spaces between his words, miAes capital and lower case letters and does not use punctuation.
>hen he was as2ed to write dictated sentences, he wrote two 'th grade level sentences, two /th grade sentences and missed
one word and he correctly spelled a ,th grade level sentence. Student can receptively and eApressively identify coins names
and can receptively identify coin values. 9e is currently wor2ing on eApressive identification of coin values and is
averaging *)B. Student can receptively and eApressively identify time to the hour and is wor2ing on time to the half hour.
9e is currently averaging ,&B.
Pre&ent le#el& o' 'unctonal per'ormance (i.e. communication, motor, social, behavior, life/adaptive skills, etc.)
E''ect o' t"e d&a(lt) on t"e &tudent*& n#ol#ement and progre&& n t"e general educaton currculum +or 'or pre&c"ool c"ldren, a&
approprate, "o, t"e d&a(lt) a''ect& t"e c"ld*& partcpaton n approprate act#te&-:
Form 6c - IEP (without Transition) Page 3 +ugust *))# (Rev. 10/2013)
CO.S/0ER12/O. O3 SPEC/1% 31C2ORS:
1. Does this student require special
transportation?
Yes No
If yes, describe (if not addressed on the service matrix):
3. Does this student require Extended School
Year (ESY) services?
Yes No
Will be determined by
the IEP team by:
If ESY is determined by the IEP team to be necessary, complete and
attach the ESY addendum.
Date:
4. Does the students behavior negatively impact
his/her learning or the learning of others?
Yes No
If yes, consider the students need for positive behavioral supports/
interventions, a Functional Behavioral Assessment, and/or a
Behavioral Intervention Plan.
5. Does this student require the use of aversive
interventions?
Yes No If yes, complete and attach the Aversive Intervention Plan addendum.
6. Are there any other factors not already
addressed (such as medical concerns or other
issues), or other adaptations needed?
Yes No
If yes, describe:
Form 6c - IEP (without Transition) Page 4 +ugust *))# (Rev. 10/2013)
PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the student7s educational needs that result
from the student7s disability to enable the student to be involved and ma2e progress in the general education curriculum. In order to be measurable, the goal should include a
(a&elne, a target, and a unt o' mea&ure4 Cor students who will be assessed through the >++S Portfolio this year, the IEP team should use the D@easurable +nnual -oal3s4
with Short:term Eb=ectives$(enchmar2sF page 3see neAt page4.
MEASURABLE ANNUAL GOAL(S$
Goal
#
!ea&ura(le 1nnual Goal
!et"od/Crtera 'or
E#aluatng Progre&&
ire!t(if not addressed in a
separate document)
Progre&& .ote& (if not maintained separatel")
POINTS TO
CONSIDER%
Date Date Date Date
@easurable
annual goals stem
from the
recommendations
for specially
designed
instruction in the
evaluation report.
@easurable
annual goals must
relate to the
general education
curriculum or, for
preschool
students,
participation in
appropriate
activities.
@easurable
annual goals must
also address other
educational needs
that result from
the student7s
disability.
The IEP must
include a
description of
how the district
will measure the
student7s progress
and when
progress will be
reported to
parents
3concurrent with
the issuance of
report cards4.
11/30/14 2/28/15 5/30/15
1. COMMUNICATION -
attention/listening
By 08/14/2015, when given the cue
"listen" student will stop activity and/or
speaking and look at teacher, improving
social communication skills from 1/5
opportunities to 4/5 opportunities as
measured by systematic observation
How will progress toward this goal be
reported? (check all that apply)
X Written in Progress Report
How often will progress be reported?
Monthly Quarterly X Trimester Semester
Other:
2. READING
!irect observation of
Student7s responses and
immediate behavior ,
recorded per tally
mar2s
Gse of graphic
organizer to record
Student7s reponses to
questions about the
Form 6c - IEP (without Transition) Page 5 +ugust *))# (Rev. 10/2013)
By 08/14/2015, when given a reading
passage at his level student will read the
passage and answer 3 comprehension
questions about the passage improving
his reading comprehension skills from
0/3 trials to 3/3 trials as measured
bysystematic observation
How will progress toward this goal be
reported? (check all that apply)
X Written in Progress Report
How often will progress be reported?
Monthly Quarterly X Trimester
events in the story.
Systematic
observation$notes.
3. SOCIAL/BEHAVIOR
By 08/14/2015, when given a 2 step
routine group instruction student will
follow the direction without additional
prompting improving his classroom
behavior from 1/5 opportunities per day
to 4/5 opportunities per day as measured
by teacher created data collection system
How will progress toward this goal be
reported? (check all that apply)
X Written in Progress Report and
Tracking Sheets
How often will progress be reported?
Monthly Quarterly X Trimester Semester
Other:
Student
successfull
y
completed
a two step
direction,
&$/
opportunitit
es.
Copy additional pages as necessary
Form 6c - IEP (without Transition) Page 6 +ugust *))# (Rev. 10/2013)
PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the student7s educational needs that result
from the student7s disability to enable the student to be involved and ma2e progress in the general education curriculum. Cor students who ta2e alternate assessments aligned to
alternate achievement standards 3>++S Portfolio4, benchmar2s or short:term ob=ectives in the areas being assessed must also be included. In order to be measurable, the goal
should include a (a&elne, a target, and a unt o' mea&ure4
MEASURABLE ANNUAL GOAL(S$ WITH SHORTTERM OB&ECTIVES'BENCHMAR(S
Goal
#
!ea&ura(le 1nnual Goal
!et"od/Crtera 'or
E#aluatng Progre&&
(if not addressed in a
separate document)
Progre&& .ote& (if not maintained separatel")
POINTS TO
CONSIDER%
Date Date Date Date
@easurable annual
goals stem from the
8/31/14
Form 6c - IEP (without Transition) Page 7 +ugust *))# (Rev. 10/2013)
recommendations
for specially
designed instruction
in the evaluation
report.
@easurable annual
goals must relate to
the general
education
curriculum or, for
preschool students,
participation in
appropriate
activities.
@easurable annual
goals must also
address other
educational needs
that result from the
student7s disability.
The IEP must
include a description
of how the district
will measure the
student7s progress
and when progress
will be reported to
parents 3concurrent
with the issuance of
report cards4.
1. READING When given a
reading passage at his level Student
will read the passage and answer 3
comprehension questions about the
story and/or order of events in the
passage (first, middle and last)
improving his comprehension and
retelling skills from 0/3 trials to 2/3
trials as measured by systematic
observation.
3. SOCIAL/BEHAVIOR When
given a 2 step routing group
instruction student will follow the
direction without additional
prompting from 1/5 opportunities to
3/5 opportunities per day as measured
by teacher created data collection
system (tally notes/graphic
organizer).
Gse of graphic
organizer to record
Student7s reponses to
questions about the
events in the story.
Systematic
observation$notes.
Trac2ing sheet
attached.
Student is ma2ing
progress retelling
and identifying the
beginning and
ending events of
recently read short
stories, but struggled
to retell the middle
event. Student
provided response to
Dwhat is the main
character doing5
Student successfully
completed a * step
direction *$/
attempts 3per day4.
Student7s
achievement is
impacted by his
present
attention$interest in
an ob=ect$activity.
Form 6c - IEP (without Transition) Page 8 +ugust *))# (Rev. 10/2013)
Benc"mark& or S"ort52erm O(6ect#e&
1ommunication < 1hec2 in &&$;)$&' student will refocus his attention to the spea2er &$/ opportunities. 1hec2 in *$*#$&/,
student will refocus his attention to the spea2er *$/ opportunities. 1hec2 in /$;)$&/, student will refocus his attention to the
spea2er ;$/ opportunities.
0eading < 1hec2 in &&$;)$&' student will read and answer ; comprehension questions &$; trials. 1hec2 in *$*#$&/, student will
read and answer ; comprehension questions *$; trials. 1hec2 in /$;)$&/, read and answer ; comprehension questions ;$; trials.
Social$(ehavior : 1hec2 in &&$;)$&' student follow directions from a * step routine *$/ opportunities. 1hec2 in *.*#.&/ student
follow directions from a * step routine ;$/ opportunities. 1hec2 in /$;)$&/ student follow directions from a * step routine '$/
opportunities.
Copy additional pages as necessary
Form 6c - IEP (without Transition) Page 9 +ugust *))# (Rev. 10/2013)
PURPOSE: The purpose of the report of student progress is to inform the parents and the student of the student7s progress toward meeting the measurable annual goal3s4 and to specify
how and when parents will be informed.
REPOR2 O3 S2U0E.2 PROGRESS:
POINTS TO CONSIDER%
Parents should be provided periodic reports on the student7s progress 3such as through the
use of quarterly or other periodic reports, concurrent with the issuance of report cards4.
State how the student7s progress toward meeting the annual goal3s4 will be measured (if not alread" addressed on measurable annual #oal pa#e(s))
Progre&& ,ll (e mea&ured t"roug" teac"er o(&er#aton& and 'ormal and n'ormal a&&e&&ment&4
State how the parents will be periodically informed of the student7s progress toward meeting the annual goal3s4
Parent& ,ll rece#e a mnmum o' t,o "and,rtten pra&e report&/,eek +&ent "ome ,t" t"e &tudent-4
B5mont"l) progre&& report& +"ard cop) and emal-, t,o per mont" and 7uarterl) progre&& report&4
P1R2/C/P12/O. /. S212E 1.0 0/S2R/C2$/0E 1SSESS!E.2S O3 S2U0E.2 1C8/E9E!E.2
State 1&&e&&ment : The student will participate in the following state assessment3s4 during this IEP year
POINTS TO CONSIDER%
The IEP team ma2es the
determination of what type of
assessment the student will ta2e
and what administrative
modifications and individual
accommodations are necessary.
+ccommodations provided on
state and districtwide
assessments should be those
that are provided as part of the
regular instructional program.
Parents and students should be
informed that any assessment
other than the regular state
assessment 3with or without
accommodations4 leads to a
1ertificate of Individual
+chievement 31I+4, rather than
a 1ertificate of +cademic
+chievement 31++4.
Cor further information
regarding the state assessment
system, allowable
accommodations, and
graduation requirements, please
refer to ESPI7s website
Readng !at" $rtng Scence
Regular State Assessment
Regular State Assessment with Accommodations
Alternate Assessment (WAAS Portfolio - requires benchmarks/objs.)
Other:
0&trct,de 1&&e&&ment : The student will participate in the following districtwide assessment3s4 this school year
The student will participate in the @easurement of +cademic Progress 3@+P4 assessment three times over the course of
the school year.
1ccommodaton& : 8ist any individual accommodations in the administration of the state or districtwide
assessments that are necessary for the student to participate 8isted accommodations not applicable to state or
districtwide assessments.
Individual small group testing
EAtended time for testing
@ultiple$frequent brea2s during testing
@aterial bro2en into manageable parts
0ead materials$test to the student
+dult proAimity
0ead directions as needed
Form 6c - IEP (without Transition) Page 10 +ugust *))# (Rev. 10/2013)
($$$.k12.$a.us/assessment).

If the student 3a4 will not participate in the regular state assessment 3with or without accommodations4 or 3b4 is unable
to participate in a regular districtwide assessment, eAplain why the student cannot participate in the regular assessment
and why the selected assessment option is appropriate Statewide testing is not completed for the student7s grade level.
Form 6c - IEP (without Transition) Page 11 +ugust *))# (Rev. 10/2013)
PURPOSE: The purpose of this page is to document the modifications and$or accommodations that the student requires, based on the student7s assessed needs, in order to advance
appropriately toward attaining the identified annual goals, to be involved and ma2e progress in the general education curriculum, and to be educated with non:disabled peers to the
maAimum eAtent appropriate.
1CCO!!O012/O.S, !O0/3/C12/O.S, 1.0 1SS/S2/9E 2EC8.O%OG;
Su(6ect
(codes belo$)
1ccommodaton&/!od'caton& .eeded
Su(6ect
(codes belo$)
1ccommodaton&/!od'caton& .eeded
POINTS TO
CONSIDE
R%
The IEP team
ma2es the
determination of
what
modifications and
individual
accommodations
are necessary for
the student.
1opies of this
page should be
provided to the
general education
teacher3s4 or other
staff who will be
responsible for
ma2ing these
accommodations.
+ccommodations
provided on state
and districtwide
assessments 3as
noted on the
previous page4
should be those
that are provided
as part of the
regular
instructional
program.
Pre&entaton Settng
Gse large print$(raille$recorded boo2s a4 Provide individualized$small group instruction
+lter format of materials (hi#hli#ht, t"pe, spacin#, color%code etc.) a 0ead class materials orally
8ow:vision devices (ma#nifiers, &losed &ircuit '(, etc.) Provide study outlines$guides$graphic organizers
Sign 8anguage < +S8 or SEE a @odify$repeat$model directions
a Shortened assignments Ta2e test in separate location
Preview test procedures a Preferential seating
8imited multiple choice Ether
a 0ephrase test questions and$or directions Re&pon&e
Provide test$quiz study guide Gtilize oral responses to assignments$tests
Provide eAtra credit options TeAt:to:Speech ()ur*$eil, +,--, 'e!t .elp, etc.)
Simplify test wording +llow dictation to a scribe
a 0ead class materials orally a +llow use of a calculator
+ssign peer tutor$note ta2er +llow use of tape recorder
Ether a Spelling and grammar devices
2mng/Sc"edulng Speech:to:teAt software
Prior notice of tests$quizzes 9ands:on assignments
EAtra time to complete assignments Ether
@odify student7s schedule 3describe belo$4 Ot"er
a Provide des2top list of tas2s
a Provide homewor2 lists
a (ehavior plan$contract
a EAtra time on tests$quizzes a Provide daily assignment list
a +llow brea2s (durin# $ork, bet$een tasks, durin# testin#, etc.) @odified grading
Ether Ether
1&&&t#e 2ec"nolog)
!escribe
!escribe
!escribe
a. +ll sub=ects
b. 0eading
c. English
d. Spelling
e. @ath
f. Science
g. Social Studies
h. 9istory
i. 9ealth
=. Economics
2. Physical Education
l. @usic$+rt
m. Hocational
n. 8unch$0ecess
o. 8ibrary
p. EAtracurricular +ctivities
q. Ether
r. Ether
Form 6c - IEP (without Transition) Page 12 +ugust *))# (Rev. 10/2013)
PURPOSE: The information on this page is a summary of the student7s program$services, including when services will begin, where they will be provided, who will be responsible for
providing them, and when they will end.
SUMMAR) OF SERVICES MATRI*
Ser#ce
/ntaton
0ate
3re7uenc)
(i.e. minutes per $eek)
%ocaton o'
Ser#ce
(settin#)
0uraton
Sta'' Re&pon&(le 'or
0el#erng Ser#ce
PO/.2S 2O
CO.S/0E
R:
If the position
responsible for
delivering the
specially designed
instruction is
anyone other than
a certificated
special education
teacher or related
service provider,
then the
certificated
special education
teacher$related
service provider
must design and
supervise the
instruction, and
monitor and
evaluate the
student7s progress.
Cor definitions of
special education,
related services,
and
supplementary
aids and services,
refer to >+1 ;I*:
&%*+:)&)*)
through :)&*)).
Specal Educaton (speciall" desi#ned instruction)/
SE1I+8$(E9+HIE0
#$&/$*)&'
;) @inutes $ ;
Times >ee2ly
Spec Ed 1lassroom
#$&/$&' <
#$&/$&/
Spec Ed Teacher
0E+!I"- #$&/$*)&'
;) @inutes $ &
Times>ee2ly
Spec Ed 1lassroom
#$&/$&' <
#$&/$&/
Spec Ed Teacher
@+T9 #$&/$*)&'
%% @inutes $ /
Times >ee2ly
Spec Ed 1lassroom
#$&/$&' <
#$&/$&/
Spec Ed Teacher
0E+!I"- #$&/$*)&'
,% @inutes $ /
Times>ee2ly Spec Ed 1lassroom
#$&/$&' <
#$&/$&/
Spec Ed Teacher
>0ITTE" 8+"-G+-E #$&/$*)&'
,% @inutes $ /
Times>ee2ly
Spec Ed 1lassroom
#$&/$&' <
#$&/$&/
Spec Ed Teacher
SE1I+8 (E9+HIE0 #$&/$*)&'
#) @inutes $ /
Times>ee2ly
Spec Ed 1lassroom
#$&/$&' <
#$&/$&/
Spec Ed Teacher
1E@@G"I1+TIE" #$&/$*)&'
;) @inutes $ ,
Times @onthly Spec Ed 1lassroom
#$&/$&' <
#$&/$&/
S8P
Related Ser#ce& (i.e. speech, motor, counselin#, vision/hearin#, transportation, interpretin# services, orientation/mobilit", parent trainin#, etc.)/
Eccupational Therapy #$&/$*)&'
;) @inutes $ &
Times
>ee2ly
Spec Ed 1lassroom
#$&/$&' <
#$&/$&/
ET
Physical Therapy #$&/$*)&'
;) @inutes $ *
Times @onthly Spec Ed 1lassroom
#$&/$&' <
#$&/$&/
PT
Supplementar) 1d& and Ser#ce& (allo$s student to be educated $ith non%disabled peers to the ma!imum e!tent in #eneral education or other
educational settin#)/
Form 6c - IEP (without Transition) Page 13 +ugust *))# (Rev. 10/2013)
SE1I+8$(E9+HIE0
;) @inutes $ ;
Times
>ee2ly
-eneral Education
1lassroom
#$&/$&' <
#$&/$&/
Spec Ed Teacher
0E+!I"-
;) @inutes $ &
Times
>ee2ly
-eneral Education
1lassroom
#$&/$&' <
#$&/$&/
Spec Ed Teacher
Program !od'caton& or Support& 'or Sc"ool Per&onnel (i.e. staff development/trainin#, technical assistance, etc.)/
Form 6c - IEP (without Transition) Page 14 +ugust *))# (Rev. 10/2013)
Supplementary
+ids and
Services high
staff to student
ratio
Supports for School
Personnel 3 training,
professional,
development etc4
1lassroom staff will be
trained in best practices
for wor2ing with children
with special needs
includingJ applied
behavior analysis,
strategies for wor2ing on
challenging behavior,
sensory integration
strategies and strategies
for increasing
communication.
#$&'$&'
&,/) min$ wee2
special education and
general
Education classroom
#$&'$&' <
#$&'$&/
Special Ed and -en Ed
Teachers
Form 6c - IEP (without Transition) Page 15 +ugust *))# (Rev. 10/2013)
Total minutes per week student spends in school: 1650 minutes per week
Total minutes per week student is served in a special education setting: 1530 minutes per week
Total minutes per week student is served in a general education setting: 120 minutes per week
Total minutes of SDI and Related Services: 1650 minutes per week
Percent of time in general education setting: 7.27% in General Education Setting
Form 6c - IEP (without Transition) Page 16 +ugust *))# (Rev. 10/2013)
PURPOSE: The purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum, participate in eAtracurricular and
nonacademic activities and be educated and participate with other special education students and non:disabled students.
%E1S2 RES2R/C2/9E E.9/RO.!E.2:
Students ages 3 to 5 Choose one:
POINTS TO CONSIDER:
1hildren should be
educated with non:
disabled peers to the
maAimum eAtent
appropriate.
The IEP Team, including
the parent3s4, is
responsible for
determining the
educational placement of
the child.
Kob placements and
community:based
instruction are considered
to be general education
settings, unless only
disabled individuals are
present 3such as in a
sheltered wor2shop4.
Cor additional information
on 80E for students ages ;
to / and ages , and above,
refer to the 80E
1alculator.
A Regular Early Childhood (REC) program
means a program outside the childs home
that includes at least 50% children without
disabilities.
If the child attends a REC program, check the
appropriate box from the first four choices. If
the child does not attend a REC program,
check the appropriate box from the five
remaining options.
In a REC program:
REC Program 10 hours per week &:
Special education services with non-
disabled peers
Special education services elsewhere
REC Program <10 hours per week &:
Special education services with non-
disabled peers
Special education services elsewhere
Not in a REC program:
Separate class
In separate day school (public
or private)
Residential facility (public or
private)
Home
Service provider location
Students ages 6 and above Choose one:
A. 1650
= Total minutes per week of building
instructional time available for this student
(excluding lunch)
In general ed. setting 80 to 100% of the time
In general ed. setting 40 to 79% of the time
In general ed. setting 0 to 39% of the time
In separate day school (public or private)
Residential facility (public or private)
Correctional facility
Homebound/hospital
Home-school/parentally-placed private school
B. 1530
= Total of those minutes in A. above in which
this student is in a special education setting
(excluding lunch)
7.27%
= Percent of time spent in a general education
setting (A minus B divided by A)
+n eAplanation of the eAtent, if any, to which
the student will not participate with
nondisabled students in the general education
class, and in nonacademic and eAtracurricular
activities, including a description of any
adaptations needed for participation in
physical education
Form 6c - IEP (without Transition) Page 17 +ugust *))# (Rev. 10/2013)
P1R2/C/P1.2S /. /EP !EE2/.G (0i#natures are used to document participation in the meetin# and do not constitute a#reement
or disa#reement)/
Parent Student$@other

POINTS TO CONSIDER%
IEP team membership is described
in >+1 ;I*:&%*+:);)I/.
School district must give prior
written notice when proposing or
refusing to initiate or change the
identification, evaluation,
educational placement, or
provision of C+PE.
+ required team member may be
eAcused from attending an IEP
meeting with the agreement$
consent of the parent3s4 and the
district, depending upon whether
that member7s area is being
discussed or modified at the
meeting. See >+1 ;I*:&%*+:
);)I/ 3/4 for additional related
requirements.
The IEP must include the district7s
procedures for notifying parents
regarding the use of restraint or
isolation. !istricts must also
provide parents with a copy of the
district7s policy on the use of
isolation and restraint.
1arent/2uardian -ame/'itle
1arent/2uardian -ame/'itle
0tudent -ame/'itle
S.0utledge$Spec Ed Teacher
0pecial 3ducation 'eacher -ame/'itle
+riana >estbroo2$-en Ed Teacher
2eneral 3ducation 'eacher -ame/'itle
8. 0otherneberger$
istrict Representative -ame/'itle
Ether individuals who should be informed of his$her responsibilities in implementing the IEP 3bus driver, librarian, etc.4
"eighborhood School EAplanation
appropriate program is not available at neighborhood school
Ether 1onsiderations
&. Transportation 0egular L Special
a. 1entral Staff 1onsulted L 6es "o
b. Transportation !etails
Form 6c - IEP (without Transition) Page 18 +ugust *))# (Rev. 10/2013)
!oor to door transportation
(us driver to updated of above special considerations.
The district has procedures for notifying parents regarding the use of restraint or isolation. + copy of those procedures is attached to this IEP.
*Note: Before providing initial special education services to a student, the district must obtain informed written parental consent.
(See model form 3)
Form 6c - IEP (without Transition) Page 19 +ugust *))# (Rev. 10/2013)