Name of the school

School Address
Phone Number, E-mail Address

INDIVIDUALIZED EDUCATION PROGRAM

Confidential

STUDENT INFORMATION:

Student Name: Sex:

Date of Birth : Age:

Place of Birth:
Students Dominant Language: Parents Dominant Language:

CONFERENCE AND REVIEW DATE:

Date of Conference: Review Date:

PARENT/GUARDIAN/SURROGATE INFORMATION:

Relationship to Student:
Nam
Addres
Home Other
Primary Language

RECOMMENDED PLACEMENT:

Present Eligibility Category of the Student:

Program Recommendation:

School Placement :

School Address:

Grade Level: Class section : Time/Schedule:

SPED Teacher: Regular School Teacher:

Progress Report:

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Name of Student: ____________________ Date of Birth : _____________

Service Delivery
What are the total service delivery needs of this student?
Include services, related services, program modifications and supports (including positive behavioral supports, school
personnel and/or parent training/supports). Services should assist the student in reaching IEP goals, to be involved and
progress in the general curriculum, to participate in extracurricular/nonacademic activities and to allow the student to
participate with nondisabled students while working towards IEP goals.

A. RELATED SERVICES
Program or
Service Frequency Duration Date Initiated
Agency

B. SPECIAL ALERTS (Disability, Illness, Important Reminders)

C. ASSISTIVE TECHNOLOGY

Type of Service Type of Support

Itinerant Regular classroom instruction for most of the
U U

school day with special education services and AS Autistic Support

U U

programs provided by special education personnel

U

BVIS Blind or Visually Impaired Support

inside or outside of the regular class for part of the
U

school day. DHIS Deaf or Hearing Impaired Support

U
U

ES Emotional Support
U
U

Resource Regular classroom instruction for most of the

U U
LS Learning Support
U

school day with special education services and

U

LSS Life Skills Support

U

programs provided by special education personnel MDS Multi-Disabilities Support

U U

in a resource classroom for part of the school day. PS Physical Support

U U

SL Speech and Language

Part-Time Special education services and programs are
U

U U

provided outside of the regular classroom but in a

regular school for most of the school day, with
some instruction provided in the regular classroom
for part of the school day.

Full-Time Special education classes are provided for the

U U

entire school day, with opportunity for participation in

non-academic and extracurricular activities to the
maximum extend appropriate, which may be
located in or outside of a regular school.

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Name of Student: ____________________ Date of Birth: ____________________

LEVEL OF PERFORMANCE AT THE TIME OF ASSESSMENT

DATE
AREA ASSESSMENT TOOLS AND TECHNIQUES RESULTS ADMINIS
TERED

Page 3 of 10
Name of Student: ____________________ Date of Birth: ____________________

SUMMARY OF ASSESSMENT

STRENGTHS WEAKNESSES

.
LONG RANGE EDUCATIONAL PLAN

Annual Goals
Present Level of Performance
Problem Behavior

Academic
Area: Reading

Area: Spelling and Writing

Area: Mathematics

Area: Paragraph Writing

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Name of Student: __________________________ Date of Birth: ___________________________

Short-term Instructional Evaluation Method and

Methods and Materials Date of Mastery
Objectives Criteria

Participants in the IEP Planning Conference

Name Relationship to Student or Signature

Profession/Service

DATE OF IEP: _____________________

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Name of Student: _______________ Date of Birth: _____________________

Response Section
School Assurance

I certify that the goals in this IEP are those recommended by the Team and that the
indicated services will be provided.

Signature Principal/School Representative

Date

Parent Options / Responses

It is important that the school knows your decision as soon as possible. Please
indicate your response by checking at least one (1) box and returning a signed copy
to the (Name of your school). Thank you.
I accept the IEP as developed. I reject the IEP as developed.
I reject the following portions of the IEP with the understanding that any portion(s) that I do not
reject will be considered accepted and implemented immediately. Rejected portions are as
follows:

I request a meeting to discuss the rejected IEP or rejected portion(s).

Signature of Parent, Guardian, Educational Surrogate Parent, Student 18 and Over*

Date
*Required signature once a student reaches 18 unless there is a court appointed guardian.

Parent Comment: I would like to make the following comment(s) but realize any comment(s) made
that suggest changes to the proposed IEP will not be implemented unless the IEP is amended.
 Page 6 of 10

Name of Student: _______________ Date of Birth: _____________________

Progress Report on IEP Dated: from

INFORMATION FROM CURRENT IEP

Goal Specific Goal
Current Performance Level: What can the student currently do?

Measurable Annual Goal: What challenging, yet attainable, goal can we expect the student to meet by the end
on this IEP period? How will we know that the student has reached this goal?

Benchmarks/Objectives: What will the student need to do to complete this goal?

PROGRESS REPORT
Progress Report Progress of
Date: Report #
Progress Reports are required to be sent to parents at least as often as parents are informed of their nondisabled
childrens progress. Each progress report must describe the students progress toward meeting each annual goal.
 Page 7 of 10

COMPLETE IF PARENT NOT PRESENT AT MEETING

Describe attempts to gain parental participation and initial:

INITIAL
METHOD DATE
Letter

Phone Call

Home Visit

Other (Specify)

Parent input given by:

_____________________________
Write name and designation

CHECK HERE
METHOD DATE
Phone call during meeting

Home Visit

Other (Specify)

Parent input given by:

_____________________________
Write name and designation
 Name of the8 of
Page school
10
Address of the School
Telephone Number , E-mail Address

To: ____________________

Re: ___________________ Date of Birth : ___________________

Subject: MEETING INVITATION

Notice Date: ________________

You are invited to a meeting to discuss the above-named student. Your participation is
essential. The purpose and details of the meeting are printed below. Other invited
participants are listed on the enclosed attendance form.

It is your legal right to be present and to participate. Also, the school values your input
and hopes you will make every effort to attend this meeting.

If the suggested meeting time is inconvenient, we will set a more convenient time. Please
call the listed contact person to request another meeting time. If you cannot attend, it is
our responsibility to obtain your participation, if at all possible, in another way.

You may invite other individuals to attend who have knowledge or special expertise
regarding this student. We request that you inform us in advance of the meeting if you
plan to invite other individual(s) to join us. Again, please call the listed contact person with
this information.

We look forward to working cooperatively with you on behalf of this student.

Meeting Purpose: Eligibility Determination, IEP Development, Placement

Determination, Transition Planning, Others, Please specify _______________

Meeting Date/Time/Location:

Contact Person:

Contact Information:

Page 9 of 10
 Name of the School
Address of the School
Telephone Number, E-mail Address

Attendance Sheet
Special Education Team Meeting

Date :
Student DOB ID#: Error! Not a valid
Name: of Meeting: Check all boxes that apply. :
Purpose bookmark self-reference.

Eligibility Determination IEP Development Placement

Initial Evaluation Initial

Reevaluation Annual Review

Other:

Print Names of Initial

Team Members Print Roles of if in
Team Members attendance

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