INDIVIDUALIZED EDUCATION PLAN (IEP)

LEARNER/PARENT INFORMATION DIFFICULTIES MEETING INFORMATION

DATE OF MEETING________________
Learner: ____________________________________ Sex: ______ ___ Difficulty in Seeing DATE OF LAST IEP_________________
Birth date:_________________ Grade/Level:_________ PURPOSE OF MEETING
LRN:_________________________ ___ Difficulty in Hearing ___ Interim
Current School:___________________________________________ ___ Initial
Address of School_________________________________________ ___ Difficulty in Communicating ___ Annual
Mother Tongue Spoken_____________________________________ ___ IEP Following 3-yr
Address_________________________________________________ ___ Difficulty in Walking/Climbing Reevaluation
Learner’s Phone (if there is)__________________________________ ___ Revision to IEP Date
Parent/Guardian/Caregiver__________________________________ ___ Difficulty in Concentrating/Paying Attention ___ Exit/Graduation
Work & Workplace_________________________________________ ___ IEP Revision Without a Meeting:
Landline/Mobile/Cell Phone No._______________________________ ___ Difficulty in Remembering/Understanding At the request of ___Parent
Email___________________________________________________ ___ School
Mother Tongue Spoken_____________________________________ ___ Others (please specify)______________________ IEP Review Date________________
Interpreter or Other Accommodation Needed____________________ COMMENTS:
___________________________________
___________________________________

IEP TEAM
Parent/Guardian/Caregiver__________________________________________ School Psychologist_______________________________________________
*Learner________________________________________________________ Guidance Counselor/Designate______________________________________
Principal/School Head_____________________________________________ School Nurse_____________________________________________________
Other (name and role)___________________________________________ Therapist/Pathologist/Specialist______________________________________
Special Education Teacher__________________________________________ Speech/Language_________________________________________________
**Regular Education/ Receiving Teacher_______________________________ Interpreter_______________________________________________________
Other (name and role)__________________________________________ Other (name and role)______________________________________________

*Learner must be invited when transition is discussed.

**The IEP team must include at least one regular education teacher of the learner (if the learner is or may be participating in the regular education environment)
PROCEDURAL SAFEGUARDS
___ I have received a statement of procedural afeguards under the individuals with Disability Education Act (IDEA) and these rights have been explained to me in my primary
language

Signature over Printed Name of Parent/Guardian/Caregiver:______________________________________________

AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, LEARNER MUST BE INFORMED OF THE RIGHTS UNDER THE LAW AND ADVISED THAT THESE RIGHTS WILL
BE ENJOYED AT AGE 18.
__ Not Applicable (learner will not be 18 within a year) The learner has been informed of his rights under the law and advised of transfer of rights at age 18
Distribution: __Learner’s Folder __Parent/Guardian/Caregiver __Special Education Teacher __Adviser (Regular Education/Receiving Teacher)
 LEARNER:___________________________________________________________________ DATE:_____________________________________
PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Consider result of the initial evaluation or most recent reevaluatin, and the academic, developmental and functional needs of the student, which may include the following
areas: academic achievement, language/communication skills, social/emotional/behavioral skills, cognitive skills, heath, motor skills, adaptive skills, pre-vocational skills
and other skills as appropriate.

ASSSEMENT CONDUCTED ASSESSMENT RESULTS

STRENGTHS, CONCERNS, INTERESTS, AND PREFERENCES

STATEMENT OF THE LEARNER’S STRENGTH

STATEMENT OF THE LEARNER’S EDUCATIONAL CONCERNS

STATEMENT OF LEARNER’S PREFERENCES AND INTERESTS (required if transition services will be discussed)

CONSIDERATION OF SPECIAL FACTORS

1. Does the learner’s behavior impede the student’s learning or learning of others? ____No action needed ___Yes, addressed in IEP
If yes, team must consider the use of positive behavioral interventions, support and other strategies, to address behavior.

2. Is the learner blind or visually impaired? ____No action needed ___Yes, addressed in IEP
If yes, team must evaluate reading and writing needs and provide for instructional in Braille unless determined no appropriate for the learner.
 3. Is the learner deaf or hard of hearing? ____No action needed ___Yes, addressed in IEP
If yes, team must consider communication needs.

4. Does the learner require assistive technology devices and services? ____No action needed ___Yes, addressed in IEP
If yes, team must determine nature and extent of devices and services.

IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS AND SHORT-TERM OBJECTIVES
ACADEMIC ACHIEVEMENT PROGRESS REPORT
1. Satisfactory Progress being made
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) (continue)
2. Unsatisfactory progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date Date

SHORT-TERM GOAL OBJECTIVES

1.

2.

3.

LANGUAGE/COMMUNICATION SKILLS PROGRESS REPORT

1. Satisfactory Progress being made
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) (continue)
2. Unsatisfactory progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date Date

SHORT-TERM GOAL OBJECTIVES

1.

2.
3.

SOCIAL/EMOTIONAL/BEHAVIORAAL SKILLS PROGRESS REPORT

1. Satisfactory Progress being made
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) (continue)
2. Unsatisfactory progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date Date

SHORT-TERM GOAL OBJECTIVES

1.

2.

3.

COGNITIVE ABILITIES PROGRESS REPORT

1. Satisfactory Progress being made
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) (continue)
2. Unsatisfactory progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date Date

SHORT-TERM GOAL OBJECTIVES

1.

2.

3.
HEALTH/MOTOR SKILLS/ADAPTIVE SKILLS PROGRESS REPORT
1. Satisfactory Progress being made
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) (continue)
2. Unsatisfactory progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date Date

SHORT-TERM GOAL OBJECTIVES

1.

2.

3.

PRE-VOCATIONAL SKILLS PROGRESS REPORT

1. Satisfactory Progress being made
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) (continue)
2. Unsatisfactory progress being made
(need to review/revise)
3. Goal met (note date)
Date Date Date Date

SHORT-TERM GOAL OBJECTIVES

1.

2.

3.
 METHOD FOR REPORTING PROGRESS
METHOD FOR REPORTING THE STUDENT’S POGRESS TOWAR MEETING ANNUAL GOALS PROJECTED FREQUENCY OF REPORTS
(Check all methods that will be used)
___ IEP Goals Per Domain ___ Report Card ___ Quarterly ___ Semester
___ Specialized Progress Report ___ Parent Conference
___ Other (please specify): _________________________________________________________ ___ Trimester ___ Other

SPECIAL EDUCATION SERVICES

SPECIALLY DESIGNED INSTRUCTION BEGINNING AND ENDING FREQUENCY OF LOCATION OF
DATES SERVICES SERVICES

SUPPLEMENTARY AIDS AND SERVICES

Including aids, services and other supports provided in regular education classes or other education-related settings to enable participation with non-disabled learner
MODIFICATION, ACCOMMODATION OR SUPPORT FOR LEARNER OR BEGINNING AND ENDING FREQUENCY OF LOCATION OF
PERSONNEL (Describe below or select from supplemental “Modification, DATES SERVICES SERVICES
Accommodations and Supports”)

RELATED SERVICES
RELATED SERVICES SERVICES TYPE AND/OR BEGINNING AND ENDING FREQUENCY OF LOCATION OF SERVICES
DESCRIPTION DATES SERVICES
___ Speech/language Therapy
___ Physical Therapy
___ Occupational Therapy
___ Transportation
___ Counselling
___ Psychological Services
___ Orientation and Mobility
___ School/Health/Medical Services
___ Recreation Therapy
___ Parent Counselling and training
___ Audiology/ Interpreting Services
___ Social Worker
___ Other (specify)
 EXTENDED SCHOOL YEAR SERVICES
Does the learner require extended School year services?
___No ___Yes If YES, IEP goals and short-term objectives and/or related services to be implemented in ESY must be identified.
If need for ESY is to be determined at a later date, indicate date by which IEP decision will be made:

PLACEMENT
PLACEMENT CONSIDERATIONS PERCENTAGE OF TIME IN REGULAR EDUCATION
ENVIRONMENT
___Selected ___ Rejected Regular class w/ supplementary aides and services
___Selected ___ Rejected Regular class and SPED class (i.e. resources) combination
___Selected ___ Rejected Self-contained program
___Selected ___ Rejected Special School
___Selected ___ Rejected Community
___Selected ___ Rejected Hospital
___Selected ___ Rejected Home
___Selected ___ Rejected Other
JUSTIFICATION FOR PLACEMENT INVOLVING REMOVAL FROM REGULAR EDUCATION ENVIRONMENTS
Explain why IEP goals and objectives cannot be implemented in regular education environments, including the reasons why the team rejected a less restrictive placement.
Include an explanation of any harmful effects on the learning of this or other learner which affected the placement selection.

IEP IMPLEMENTATION

___ As a parent, I agree with the components of this IEP, I understand that its provisions will be implemented as soon as possible after the IEP goes into effect.

___ As the parent, I disagree will or part of this IEP, I understand that the School must provide me with written notice of any intent to implement this IEP. If I wish to prevent the
implementation of this IEP, I must submit a written request for a due process hearing to the school principal.

_______________________________________________
Parent’s Signature

_________________________________ ________________________________ _________________________________

Special Education Teacher Regular/Receiving Teacher (if LSEN is in inclusion) Principal/School Head

_________________________________ ________________________________ _________________________________

Learner (if applicable) Guidance Counselor/SPED Coordinator Psychologist/Other Specialist