DEPARTMENT OF EDUCATION

Region III
Schools Division of Nueva Ecija Overview: This IEP has been designed in accordance with the World Health Organization International Classification of Functioning
__________________________ Disability and Health. In accordance with this approach, Disability is defined as an impairment in interaction with a wide range of
__________________________ environmental barriers. In this IEP, teachers are asked to identify the learner’s impairment in combination with their school
environment. The learning barriers should be documented alongside accommodations designed to remove the participation barriers
and improve educational success.
SECTION A: PERSONAL INFORMATION
LEARNER/PARENT INFORMATION: DIFFICULTIES: MEETING INFORMATION
DATE OF MEETING _____________
Learner: ____________________ Sex : _________ ___ Difficulty in Seeing DATE OF LAST IEP ______________
Birth date: _________ Grade/Level: ______ LRN: ____________ PURPOSE OF MEETING :
Current School: ___________________________ ___ Difficulty in Hearing ___ Interim IEP
___ Initial IEP
Address of School: __________________________________
___ Annual IEP
Mother Tongue Spoken: ___________________________ ___ Difficulty in Communicating
___ IEP Following 3-Yr
Address _____________________________________ Reevaluation
Learner’s Phone (if there is)_______________________________ ___ Difficulty in Mobility / Walking ___ Revision to IEP Date_________
Parent/Guardian/Caregiver: ______________________________ ___ Exit/Graduation_____________
Work & Workplace: _________________ ___ Difficulty in Displaying Interpersonal Behavior ___ IEP Revision Without a Meeting:
At the request of ___Parent
Landline/Mobile/Cell Phone No. ___________Email___________
____ Difficulty in Performing Adaptive Skills ___School
Mother Tongue Spoken: __________________ IEP Review Date ________________
Interpreter or Other Accommodations Needed: ______________ ____ Difficulty in Basic Skills and Applying Knowledge COMMENTS:

___ Difficulty in Remembering/ Understanding ______________________________

___ Others (please specify) _______________

___ Medical Diagnosis (if yes, please specify)
___________________________

IEP TEAM MEMBERS IN ATTENDANCE

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)
 Signature over Printed Name of Parent/Guardian/Caregiver:________________________________________
AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, LEARNER MUST BE INFORMED OF THEIR RIGHTS UNDER THE LAW AND ADVISED THAT THESE RIGHTS WILL
BE ENJOYED AT AGE 18.
___ Not Applicable (learner will not be 18 within one year ____The learner has been informed of his/her rights under law and advised of the transfer of rights at age 18

Distribution: __Learner’s Folder __Parent/Guardian/Caregiver __Special Education teacher __Adviser (Regular Education/Receiving Teacher)

LEARNER:__________________________________________________________________________________ DATE:_________________________

I. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Results of Initial or most recent evaluation and results of school and division assessments:

Description of academic, developmental and/or functional strengths

Description of academic, developmental and/or functional needs:

Parental concerns regarding their child’s education:

Impact of the disability on involvement and progress in the general education curriculum:

STRENGTHS, CONCERNS, INTERESTS AND PREFERENCES

STATEMENT OF THE LEARNER’ STRENGTH
Regine can learn the lessons presented to her with moderate assistance.

STATEMENT OF PARENTS’ EDUCATIONAL CONCERNS

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

Regine likes playing and drawing.

II. CONSIDERATION OF SPECIAL FACTORS
 SECTION B: DIFFICULTIES, BARRIERS AND ENABLING SUPPORTS

DIFFICULTY ENVIRONMENTAL BARRIERS ENVIRONMENTAL FACILITATORS ACCOMODATIONS

(enter all areas of difficulty) (describe each factor restricting (describe each factor enabling (list items, staff resources and
participation) participation in response to barriers) infrastructure changes required to
enable participation)
SECTION C: LEARNER GOALS

To support Identification of learner goals, also confirm:

• What opportunities are available at the school to support learner goals?
• What are the student interest areas?
• What disability-specific skills does the learner need to develop to support their participation / attainment of goals?
Goals – (e.g. skills to improve participation in education or daily living skills? Goals should be SMART

INTEREST GOAL INTERVENTIONS TIMELINE INDIVIDUALS REMARKS PROGRESS /

RESPONSIBLE NEXT STEPS
 METHOD FOR REPORTING PROGRESS
METHOD FOR REPORTING THE STUDENT’S PROGRESS TOWARD MEETING PROJECTED FREQUENCY OF REPORTS
ANNUAL GOALS (Check all methods that will be used)
___IEP Goals Per Domain ____Report Card ____Quarterly ____Semester
___Specialized Progress Report ____Parent Conferences
___Other (please specify):___________________________________________________ ____ Trimester ____Other

SPECIAL EDUCATION SERVICES

SPECIALLY DESIGNED INSTRUCTION BEGINNING AND FREQUENCY OF LOCATION OF

ENDING DATES SERVICES SERVICES

SUPPLEMENTARY AIDS AND SERVICES

Includes aids, services and other supports provided in regular education classes or other education-related settings to enable participation with
non-disabled learner
MODIFICATION, ACCOMODATION OR SUPPORT FOR LEARNER BEGINNING AND FREQUENCY OF LOCATION OF
OR PERSONNEL (Describe below or select from supplemental ENDING DATES SERVICES SERVICES
“Modifications, Accommodations and supports”
 RELATED SERVICES
RELATED SERVICES SERVICES TYPE BEGINNING AND FREQUENCY OF LOCATION OF SERVICES
AND/OR ENDING DATES SERVICES
DESCRIPTION
___Speech/Language Therapy
___Physical Therapy
___Occupational Therapy
___Transportation
___Counseling
___Psychological Services
___Orientation and Mobility
___School Health/Medical Services
___Recreation Therapy
___Parent Counseling & Training
___ Audiology /Interpreting Services
___Social Work Services
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. resource) 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 the 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