Individualized Education Plan

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student: Abby Baierl Student: Ben Wilson
INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age
Student’s Name: Ben Wilson (pseudonym)

IEP Team Meeting Date (mm/dd/yy): 4/16/2020
IEP Implementation Date (Projected Date when Services and Programs Will Begin): 4/17/2020
Anticipated Duration of Services and Programs: 4/16/2021
Date of Birth: 02/8/2014
Age: 6
Grade: 1st
Anticipated Year of Graduation: 2031
Local Education Agency (LEA): Principle, Mr. Tim More
County of Residence: Allegheny County
Name and Address of Parent/Guardian/Surrogate: Phone (Home): 715-555-5555
John and Lucy Wilson Phone (Work): 715-555-8888
1235 North Ave.
Imperial, PA 15126
Other Information:
The LEA and parent have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:
Date of Revision(s) Participants/Roles IEP Section(s) Amended
Page 1 of 25 April 2014

IEP TEAM/SIGNATURES
The Individualized Education Program team makes the decisions about the student’s program and placement. The student’s parent(s), the student’s special
education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not
agreement. You can edit the roles for the sake of the project.
Role Printed Name Signature

Parent/Guardian/Surrogate John Wilson John Wilson
Parent/Guardian/Surrogate Lucy Wilson Lucy Wilson
Student* Ben Wilson Ben Wilson
Regular Education Teacher** Mrs. Sue Call Mrs. Sue Call
Special Education Teacher Ms. Abby Baierl Ms. Abby Baierl
Local Ed Agency Rep Mr. Tim More Mr. Tim More
Occupational Therapist Ms. Courtney Lu Ms. Courtney Lu
Speech Therapist Mr. Kellen Kip Mr. Kellen Kip
Physical Therapist Mrs. Hannah Fisher Mrs. Hannah Fisher
* The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.
** If the student is, or may be, participating in the regular education environment
*** As determined by the LEA as needed for transition services and other community services
**** A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.
One individual listed above must be able to interpret the instructional implications of any evaluation results.
Written input received from the following members:
N/A
Transfer of Rights at Age of Majority
For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals
with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.

PROCEDURAL SAFEGUARDS NOTICE
I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights,
including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.
Signature of Parent/Guardian/Surrogate: John Wilson
MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical Assistance programs)
I understand that the school may charge the School-Based Access Program (“SBAP”)—or any program that replaces or supplements the SBAP—the cost of certain
special education and related services described in my child’s IEP. To make these charges to the SBAP, the school will release to the administrator of that
program the name, age, and address of my child, verification of Medicaid eligibility for my child, a copy of my child’s IEP, a description of the services
provided and the times and dates during which such services were provided to my child, and the identity of the provider of such services. I understand that
such information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have provided written
consent to disclose such information.
I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to
write, at any time. My refusal to consent or my withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my family,
any service or program to which my child is entitled under the Individuals with Disabilities Education Act (“IDEA”) or that is necessary to enable my child to
receive a free appropriate public education as described in my child’s IEP.
I understand that the school cannot—
Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a condition of receiving a f ree appropriate
public education for my child;
Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including co-payments and deductibles,
unless it agrees to pay such expenses on my or my family’s behalf;
Cause a decrease in available lifetime coverage or any other insured benefit;
Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that are required for my child
outside the time that he or she is in school;
Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.

I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS “YES” MUST BE ADDRESSED IN THE IEP.
If you check yes, you need to address it in the rest of the IEP in the present level of performance section.
Is the student blind or visually impaired?
Yes The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an
evaluation of the student’s reading and writing skills, needs, and appropriate reading and writing media (including an
evaluation of the student’s future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of
Braille is not appropriate for the student.
X No
Is the student deaf or hard of hearing?

Yes The IEP must include a communication plan to address the following: language and communication needs; opportunities for
direct communications with peers and professional personnel in the student’s language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the student’s language and communication mode;
and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The
Communication Plan must be completed and is available at www.pattan.net
X No
Does the student have communication needs?

X Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)
No
Does the student need assistive technology devices and/or services?

X Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)
No
Does the student have limited English proficiency?

Yes The IEP team must address the student’s language needs and how those needs relate to the IEP.
X No

Does the student exhibit behaviors that impede his/her learning or that of others?
Yes The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that
utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels
section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction
sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A
Positive Behavior Support Plan and a Functional Behavioral Assessment form are available at www.pattan.net
X No
Other (specify):
II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

This is the largest section of the IEP.use the headings to answer this section. The domains of the birgance go in here.
Include the following information related to the student:
• Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based
assessments, transition assessments, progress toward current goals)
• Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
• Present levels related to current postsecondary transition goals if the student’s age is 14 or younger if determined appropriate by the IEP team
(e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)
• Parental concerns for enhancing the education of the student
• How the student’s disability affects involvement and progress in the general education curriculum
• Strengths
• Academic, developmental, and functional needs related to student’s disability
Present Levels of Academic Achievement (Ben currently is only progress monitored in class without any type of assessment)
Reading: Ben is able to identify and recognize all 26 letters of the alphabet. He has basic understanding of print concepts, as Ben can
hold a book the correct way, identify the title page, recognize that pictures carry meaning, and turn the pages. Ben has basic core
vocabulary in order to answer simple reading comprehension questions like, “What color is the shirt?” Ben can identify and spell his
name, colors, the days of the week and the months of the year. He is working to write more independently, specifically his name, but is
currently capable of tracing the letters of the alphabet.
Math: Ben is able is identify numbers 1-30 when the number is spoken to him and when he is shown a flashcard. He can recognize
shapes and identify them according to their basic properties. Ben demonstrates strong knowledge of sorting objects based on their
color, shape, and size into categories. He also understands one to one correspondence with objects and their names, colors of objects,
and pictures of objects/shapes and their names. Ben struggles with mathematical computations including basic addition and subtraction
of single digit numbers.
Present Levels of Functional Performance

Behavior: Ben is a very affectionate and kind individual. He listens to teachers and paraeducators well in the classroom when given one
step instructions or directions to follow. He also responds well to transitional warnings and the use of timer during and after activities.
He occasionally has difficulty staying on task for more than 15 minutes and often needs to be redirected to his work. He will often have
free time in the classroom without asking for permission from the teacher or paraeducator, which is something that teachers want to
focus on with Ben to improve time on task. Ben sometimes has difficulty accepting “no” when he requests a desired object or video,
currently he becomes upset or mad when he does not receive what wants. Ben is highly motivated by his iPad and anything related to
Peppa Pig, two things frequently used for reinforcement in the classroom.
Communication: Ben currently is using Language Acquisition through Motor Planning (LAMP), a communication device, through an iPad
to speak because he is nonverbal. He is well versed in using the system and has an advanced amount of vocabulary on his device. He
uses his device to communicate during one-on-one instruction where he occasionally needs to be prompted to select a response. Ben
communicates through actions and sound verbalizations. He is skilled at communicating his basic wants and needs along with
responding to simple questions. Ben consistently recognizes and responds to his name when said by a peer or teacher.
Social Skills: Ben very friendly around those he is comfortable and familiar with. He is more introverted and keeps to himself, but has
recently shown more interest in parallel play with his peers especially during music time. He enjoys going to the sensory room with a
familiar peer and gravitates towards people who make him feel safe. Ben will greet familiar peers with a wave or by using his
communication device to say hello but only when prompted. Teachers, specialists, and parents, would like to see an increase of
verbalizations through his device without prompts to improve social interactions.
Gross and Fine Motor Skills: Ben can put together board puzzles matching shape and picture. He can stack cups and blocks in a small
tower with assistance and prompting. Ben can use a pair of modified scissors to cut paper, but not in a straight line. He has motor skills
to hold a large pencil, crayons, and a white board marker for completing activities. Ben is able to run and hop, but has difficulty
skipping and galloping. He enjoys playing the drums quietly during music time, but does not have a sense of beat or rhythm yet. He also
is capable of climbing up and down a ladder on the jungle gym. He can further swing from a bar with assistance from a teacher.
Adaptive Skills: Ben is independent in navigating the school and classroom environment without physical assistance. He is confident in
opening doors and his locker. He is confident in using a spoon and a straw along with feeding himself finger foods. He is working to
improve functional skills such as hand washing and toileting. Ben likes to have order around him. He usually keeps his space organized
and neat when it comes to doing his work, especially with letters and numbers.
Present Levels Related to Current Postsecondary Transition Goals

Transition services are not required at this time.
Parental Concerns for Enhancing Education of the Student

Ben’s parents would like to continue to work on toileting in order to have Ben potty trained. They would also like to see Ben increase
his vocabulary and begin to associate this vocabulary with what is drawn in picture books.
How the Student’s Disability Affects Involvement and Progress in the General Education Curriculum
Ben spends the majority of his day in the life skills, special education classroom because of the needs his disability requires. When in
the special or general education classroom, he is accompanied by a paraeducator or a teacher to assist him one-on-one or in a small
group. Ben does not work from his grade level curriculum, but rather a curriculum that is at his ability level. He does not receive
assessments in his classroom, rather he is closely progress monitored when working on assignments. All of Ben’s learning opportunities
and activities are presented with a hands-on approach through the use of manipulates, puzzles, games, and visuals. He works alongside
peers without disabilites during specials, homeroom, class parties, and assemblies.
Strengths
1. Ben is an affection, loving, and kind individual. He possesses a welcoming presence to those around him.
2. Ben’s organizational skills during learning activities are admirable. This allows him to access materials effectively and
efficiently while learning.
3. Ben possesses several strengths with fundamental literacy skills including responding to comprehension questions, tracing
letters, identifying all the letters of the alphabet, and having basic print concept skills.
Academic, Developmental, and Functional Needs Related to Student’s Disability

Academic: Based off of data collected and obtained, Ben needs to continue working on his mathematical computation skills beginning
with one-digit addition. Further, Ben is fluid in letter tracing skills and therefore needs to improve his independence in writing. He
should begin to write independently through learning something familiar like his name.
Developmental: Based off of data collected and obtained, Ben is currently demonstrating deficits in communication. One area he needs
to improve in is asking for permission from an adult. He frequently leaves his work unattended and begins to have free time during his
work time.
Functional: Based off of data collected and obtained, Ben is demonstrating basic functional skills, but lacks the ability to independently
wash his hands. Because his parents have seen an increase interest in toilet and desire for Ben to be potty trained, the skill of hand
washing should be learned.
III. TRANSITION SERVICES – This is required for students age 14 or younger if determined appropriate by the IEP team. If the student does not attend the
IEP meeting, the school must take other steps to ensure that the student’s preferences and interests are considered. Transition services are a coordinated
set of activities for a student with a disability that is designed to be within a results oriented process, that is focused on improving the academic and
functional achievement of the student with a disability to facilitate the student’s movement from school to post school activities, including postsecondary
education, vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent
living, or community participation that is based on the individual student’s needs taking into account the student’s strengths, preferences, and interests.
POST SCHOOL GOALS – Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education
and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal.
Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.
For students in Career and Technology Centers, CIP Code:

N/A
Postsecondary Education and Training Goal:

Measurable Annual Goal
N/A Yes/No
(Document in Section V)
Courses of Study:
Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible
Employment Goal:
N/A Yes/No
Courses of Study:


Independent Living Goal, if appropriate:

N/A Yes/No
Courses of Study:

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Instructions for IEP Teams:
Please select the appropriate assessment option. Information on available testing accommodations may be found in the Accommodations Guidelines
available on www.education.state.pa.us.
State Assessments
Not Assessed
X No statewide assessment is administered at this student’s grade level.
No English proficiency assessment administered because the student is not an English Language Learner.
PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5
and 8; and ELA*)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Math
Science
Reading
Writing
ELA*
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11th grade)
Without With
Algebra 1
Literature
Biology
Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam module.)
Without With
Algebra 1
Literature
Biology
Validated Local Assessment (Available when selected as option by LEA)

Without With
Algebra 1
Literature
Biology
PASA (Administered in grades 3-8, 11 for Reading and Math; Grades 4, 8, 11 for Science)
Student will participate in the PASA.
Explain why the student cannot participate in the PSSA or the Keystone Exam for Reading/Literature, Math/Algebra 1,
Science/Biology, and Composition (The Composition exam will be available for the 2016-17 school year):
Explain why the PASA is appropriate:
Choose how the student’s performance on the PASA will be documented.

Videotape (preferred method)
Written narrative notes (requires prior approval in accordance with PDE

guidance)

ACCESS for ELLs (Administered in grades K-12)

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to
Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking
Alternate ACCESS for ELLs (Administered in grades 1-12)

Student will participate in the Alternate ACCESS for ELLs.
Explain why the student cannot participate in the ACCESS for ELLs:
Explain why the Alternate ACCESS for ELLs is appropriate:
Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to

Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking
Local Assessments
X Local assessment is not administered at this student’s grade level; OR
Student will participate in local assessments without accommodations; OR
Student will participate in local assessments with the following accommodations; OR

The student will take a local alternate assessment.
Explain why the student cannot participate in the local regular assessment:
Explain why the local alternate assessment is appropriate:

V. GOALS AND OBJECTIVES – Include, as appropriate, academic and functional goals. Use as many copies of this page as needed to plan appropriately.
Specially designed instruction may be listed with each goal/objective or listed in Section VI.
Short term learning outcomes are required for students who are gifted. The short-term learning outcomes related to the student’s gifted program may be
listed under Goals or Short-Term Objectives.
MEASURABLE ANNUAL GOAL Describe HOW the

Describe WHEN periodic
Include: Condition, Name, Behavior, and Criteria student’s progress toward
reports on progress will be Report of Progress
(Refer to Annotated IEP for description of these meeting this goal will be
provided to parents
components) measured
When presented with one-step single digit Ben’s progress will be Quarterly report cards will
addition problems, Ben will independently solve measured using work be sent home to show Ben’s
the problems with 90% accuracy 8 out of 10 trials. samples and progress will progress.
be tracked during trials
with running records
based on teacher
observation.
When told to write his name, Ben will Ben’s progress will be Quarterly report cards will
independently write his name with 80% accuracy measured by his accuracy be sent home to show Ben’s
for 5 consecutive trials. using a scale of 1-5 based progress.
on location of name
written on the paper,
accuracy of letter
formation, and neatness
of letters written linearly.
When done with his work, Ben will use his Ben’s progress will be Quarterly report cards will
communication device to ask if he can have a measured through be sent home to show Ben’s
break, with only one prompt, with 100% accuracy anecdotal records and progress.
when given the opportunity, for 10 consecutive direct observation based
trails. on the frequency and
accuracy of use of his
communication with and
without prompts.
When finished using the restroom, Ben will wash Ben’s progress will be Quarterly report cards will
his hands independently with 90% accuracy for 5 measured using a scoring be sent home to show Ben’s
consecutive days. rubric based on the task progress.
analysis that the skill will
be learned through. The
teacher should note the
time and the date of each

trial and the accuracy at
which the task was
completed.
SHORT TERM OBJECTIVES – Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
Short term objectives / Benchmarks
N/A

VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS – Include, as appropriate, for nonacademic
and extracurricular services and activities.
A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)

• SDI may be listed with each goal or as part of the table below.
• Include supplementary aids and services as appropriate.
• For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or modifications to the general
education curriculum, as appropriate for a student with a disability.
Modifications and SDI Location Frequency Projected Beginning Date Anticipated Duration
Goal 1
The teacher will provide
Ben with a place mat to
place digits on to depict his
Special Education
thinking. 3 times/week 4/17/2020 4/16/2021
Classroom
+ =
Goal 1
The teacher will model and
provide Ben with math Special Education
3 times/week 4/17/2020 4/16/2021
counters when practicing Classroom
addition with one-digit
numbers.
Goal 2
The teacher will highlight
Special Education All assignments with a
the line where Ben is to 4/17/2020 4/16/2021
Classroom name line.
write his name on the
paper.
Goal 2
The teacher should use
dotted lines for letters and
slowly fade to Special Education All assignments with a
4/17/2020 4/16/2021
starting/ending points for Classroom name line.
letters until the skill is
performed independently
and accurately.
Goal 3 4 times a day after
Special Education
The teacher will model and activities have been 4/17/2020 4/16/2021
Classroom
think aloud how to use the completed
communication device to
ask “Can I have a break?”
after Ben has completed his
work.
Goal 3
The teacher will use
proactive teaching to
remind Ben how he should
ask if he can have a break Special Education 4 times a day before an
4/17/2020 4/16/2021
once he has completed his Classroom activity has begun
task. The teacher will
remind him verbally before
the start of the activity.
Goal 4
The teacher will post
Special Education
visuals for Ben for each Each time hand washing
Classroom, School 4/17/2020 4/16/2021
step of the task as he learns occurs.
Bathroom
to wash his hands in order
for him to follow along.
Goal 4
The teacher will use direct
instruction through
prompting Ben, beginning Special Education Once every day in the
4/17/2020 4/16/2021
with hand over hand Classroom special education classroom
guidance and fading to a
less intrusive prompt.
B. RELATED SERVICES – List the services that the student needs in order to benefit from his/her special education program.
Service Location Frequency Projected Beginning Date Anticipated Duration

2 times/week for 30
Occupational Therapy Wilson Elementary School 4/17/2020 4/16/2021
minutes
2 times/week for 30
Physical Therapy Wilson Elementary School 4/17/2020 4/16/2021
minutes
3 times/week for 30
Speech Therapy Wilson Elementary School 4/17/2020 4/16/2021
minutes
Assistive Technology Device Home, School, Community 7 days a week 4/17/2020 4/16/2021
C. SUPPORTS FOR SCHOOL PERSONNEL – List the staff to receive the supports and the supports needed to implement the student’s IEP.
School Personnel to Projected Beginning

Support Location Frequency Anticipated Duration
Receive Support Date
General and Special OT Consultation
Classroom 20 minutes/month 4/17/2020 4/16/2021
Education Teachers
General and Special PT Consultation
Education Teachers
General and Special Speech Consultation
Education Teachers
General and Special Collaboration
Classroom 2x week for 1 hour 4/17/2020 4/16/2021
Education Teachers Meeting

D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS IDENTIFIED AS A STUDENT WITH A DISABILITY – Support services are
required to assist a gifted student to benefit from gifted education (e.g., psychological services, parent counseling and education, counseling services,
transportation to and from gifted programs to classrooms in buildings operated by the school district).
Support Service N/A

Support Service
Support Service
E. EXTENDED SCHOOL YEAR (ESY) – The IEP team has considered and discussed ESY services, and determined that:
X Student IS eligible for ESY based on the following information or data reviewed by the IEP team:
Ben is eligible for extended school year due to the severity of his disability. He requires continued and further support with his
academic skills, communication and speech skills, physical development, and basic, functional living skills.
OR
As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:
The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the student’s ESY Program are:
The goals listed in Ben’s IEP will be continue to be worked towards during ESY. Ben will work to improve
communication skills, academic skills and functional skills over summer break. He will continue will
continue OT, PT, and Speech for two times per week alongside instruction in the life skills classroom.
If the IEP team has determined ESY is appropriate, complete the following:
ESY Service to be Provided Location Frequency Projected Beginning Date Anticipated Duration
Summer School Wilson Elementary School Monday-Thursday 6/15/2020 8/1/2020
Occupational Therapy Wilson Elementary School 2x/week for 30 minutes 6/15/2020 8/1/2020
Physical Therapy Wilson Elementary School 2x/week for 30 minutes 6/15/2020 8/1/2020
Speech Therapy Wilson Elementary School 2x/week for 30 minutes 6/15/2020 8/1/2020
VII. EDUCATIONAL PLACEMENT
A. QUESTIONS FOR IEP TEAM – The following questions must be reviewed and discussed by the IEP team prior to providing the explanations regarding
participation with students without disabilities.
It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public
or private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal
of students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education
in general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily.
• What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary
aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general
education class.
• What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?
• What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the
class, even with supplementary aids and services?
• To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:
Ben will participate with students without disabilities for approximately one hour each day during home
room, class assemblies, and music time. Ben need intense interventions from the life skills, special
education classroom, which limits the time he is able to spend in the general education classroom.
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Ben will not participate in the general education curriculum due to the needs of his disability and the
specific accommodations and modifications required for learning.

Student’s Name:
B. Type of Support
1. Amount of special education supports
Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day
Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than
80% of the school day
X Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day
2. Type of special education supports
Autistic Support
Blind-Visually Impaired Support
Deaf and Hard of Hearing Support
Emotional Support
Learning Support
X Life Skills Support
Multiple Disabilities Support
Physical Support
Speech and Language Support

Student’s Name:
C. Location of student’s program
Name of School District where the IEP will be implemented: West Allegheny School District
Name of School Building where the IEP will be implemented: Wilson Elementary School
Is this school the student’s neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
X Yes
No. If the answer is “no,” select the reason why not.

Special education supports and services required in the student’s IEP cannot be provided in the neighborhood school
Other. Please explain:

Student’s Name:
VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one Educational Environment)
To calculate the percentage of time inside the regular classroom, divide the number of hours the student spends inside the regular classroom by the total number of hours in the school day (including
lunch, recess, study periods). The result is then multiplied by 100.
SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers – Indicate the Percentage of time INSIDE the regular classroom for this student:
Time spent outside the regular classroom receiving services unrelated to the student’s disability (e.g., time receiving ESL services) should be considered time inside the regular classroom.
Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time
spent inside the regular classroom.
Calculation for this Student:
Column 1 Column 2 Calculation Indicate Percentage Percentage Category

Total hours the student Total hours in a typical (Hours inside regular Section A: The percentage of
school day classroom ÷ hours in
spends in the regular time student spends inside the
school day) x 100 = %
classroom per day regular classroom: Using the calculation result – select the appropriate percentage category
(including lunch, recess
& study periods) (Column 1 ÷ Column 2) x
100 = %
1 hour 8 hours (1/8) x 100 = 12.5% 12.5% of the day INSIDE the Regular Classroom 80% or More of the Day
INSIDE the Regular Classroom 79-40% of the Day
INSIDE the Regular Classroom Less Than 40% of the Day
SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day – select and indicate the Name of School or
Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP team must do the calculation
in Section A)
Approved Private School (Non Residential) _________________________ Other Public Facility (Non Residential) _________________________
Approved Private School (Residential) _________________________ Hospital/Homebound _________________________
Other Private Facility (Non Residential) _________________________ Correctional Facility _________________________
Other Private Facility (Residential) ________________________ Out of State Facility _________________________
Other Public Facility (Residential) ________________________ Instruction Conducted in the Home _________________________
EXAMPLES for Section A: How to Calculate PennData–Educational Environment Percentages

Column 1 Column 2 Calculation Indicate Percentage
Total hours the student spends in the Total hours in a typical school day (Hours inside regular classroom ÷ hours in school day) Section A: The percentage of time student
(including lunch, recess & study x 100 = % spends inside the regular classroom:
regular classroom per day
periods)
(Column 1 ÷ Column 2) x 100 = %
Example 1 5.5 6.5 (5.5  6.5) x 100 = 85% 85% of the day
(Inside 80% or More of Day)
Example 2 3 5 (3 5) x 100 = 60% 60% of the day
(Inside 79-40% of Day)
Example 3 1 5 (1 5) x 100 = 20% 20% of the day
(Inside less than 40% of Day)
For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on the website. If you do not have access
to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.

Student’s Name:
Task Analysis & Chaining Project

Review of Records
EDU 347
1. What items did you review (e.g., sample work, report card, progress reports, behavioral records, IEP, BIP, FBA, anecdotal notes, etc.)?
2. Record information on the student’s current level of performance as it related to their grades, goals, and current level of development.
M.M is performing below grade level and is primarily focused on pre-academic skills and strengthening his functional skills. Although
he has shown progress over the course of the school year, he is currently dependent on caretakers to get through the academic day.
3. Does the student receive any accommodations or modifications in the classroom or during assessments? M.M has access to a
classroom paraprofessional in both the regular education classroom as well as the special education classroom. He does not receive
assessments at this time. All assignments are delivered at M.M’s academic level and pace where he is most likely to see success.
Learning opportunities are presented in a hands on approach, either one on one or in a small group setting. He also has a
communication device that he uses throughout the day to provide a means of communication.
4. How much of the school day does the student spend in the general education environment per the IEP? M.M spends about 15% of his
day in the general education environment. This includes a morning check in, specials with his typical peers and any classroom parties
or assemblies.
5. Does the student have a completed FBA, BIP, or another behavior-specific plan? N/A
6. After reviewing the information, what was most helpful and interesting? What impact, guidance, or influence does it have on your
chaining project?

Student’s Name:
Task Analysis & Chaining Project
Teacher Interview
EDU 347
Student Pseudonym: M.M
Grade: 1
Age: 6
Environment: Urban Rural Suburban Other:
Parents/Guardians:
Siblings: none
Current Grades in School: Satisfactory on IEP goals with modifications
Present Level of Performance:
Reading: Letter identification, core vocabulary, simple reading comprehension questions (What color is the shirt?)
Spelling: Name, colors, days of the week, months of the year
Writing: Name tracing, letter tracing
Math: Number identification 1-30, counting 1:1 correspondence, shape identification, color sorting.
Any adaptations in place for taking assessments? M. M primarily uses a communication device (LAMP) to communicate and respond to prompts.
All assessments are based on observations and progress monitoring
Academic Strengths: M.M. can match and identify all letters of the alphabet, numbers 1-30, and all shapes. He has strong sorting skills and
sometimes enjoys looking at books of his choice. He can navigate his communication device to answer basic reading comprehension questions as
well as communicate his basic wants and needs.

Student’s Name:
Academic Areas for Improvement: M.M needs to increase his time on task, calendar skills, pre-readiness skills and mathematical computations.
Behavioral Strengths: M.M is affectionate and enjoys being around familiar peers. He is able to be redirected when a reinforcement is present. M.M
responds to transitional warnings and the use of a timer. He is not aggressive.
Behavioral Areas for Improvement: M.M needs to improve on accepting “no” when he is requesting a desired object/video and remain in the
assigned area until his task is completed or he is granted permission.
Behavior Intervention Plan (BIP)? Yes No
If Yes, please describe:

N/A
Describe the level of independent functional skills. M.M is able to open doors on his own, navigate throughout the school without physical
assistance, open his locker, respond to his name, drink from a straw, use a spoon and feed himself finger foods.
Describe social skills and relationships with peers: M.M will greet familiar peers with a wave or by using his device to say “hello” (Prompted). He
typically keeps to himself but has recently shown more interest in parallel playing with other students during music time. He enjoys going to the
sensory room with a typical peer and will gravitate toward people who make him feel safe.
Describe organization and decision-making skills: M.M has limited organizational skills but is able to put things away with moderate assistance.
When he is given specific directions, he can follow one step directions to organize his belongings. M.M likes things to be in order, specifically letters
and numbers.
Describe things that he/she finds motivating and reinforcing: M.M loves to play on the ipad and is highly motivated by anything Peppa Pig.
Goals or aspirations the parents have for their child for this school year: M.M’s parents would like to see him become more independent and have
more success with potty training.
Additional Information:
+ Does the student qualify for ESY? Yes.
+What additional services does Ben require? OT, PT, and Speech Therapy
This was completed over email with Collaborating Teacher Jen Rogers. Spring 2020.

Individualized Education Plan

Uploaded by

Copyright:

Available Formats

You might also like

Individualized Education Plan

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Individualized Education Plan

Uploaded by

Copyright:

Available Formats

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student: Abby Baierl Student: Ben Wilson

INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

Student’s Name: Ben Wilson (pseudonym)

Date of Revision(s) Participants/Roles IEP Section(s) Amended

Page 1 of 25 April 2014

Role Printed Name Signature

Written input received from the following members:

Transfer of Rights at Age of Majority

Page 2 of 25 April 2014

PROCEDURAL SAFEGUARDS NOTICE

Signature of Parent/Guardian/Surrogate: John Wilson

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

I understand that the school cannot—

Cause a decrease in available lifetime coverage or any other insured benefit;

Page 3 of 25 April 2014

Is the student deaf or hard of hearing?

Does the student have communication needs?

Does the student need assistive technology devices and/or services?

Does the student have limited English proficiency?

Page 4 of 25 April 2014

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Present Levels of Functional Performance

Present Levels Related to Current Postsecondary Transition Goals

Parental Concerns for Enhancing Education of the Student

Academic, Developmental, and Functional Needs Related to Student’s Disability

For students in Career and Technology Centers, CIP Code:

Page 7 of 25 April 2014

Postsecondary Education and Training Goal:

Projected Anticipated Person(s)/Agency

Projected Anticipated Person(s)/Agency

Page 8 of 25 April 2014

Independent Living Goal, if appropriate:

Projected Anticipated Person(s)/Agency

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Page 9 of 25 April 2014

Validated Local Assessment (Available when selected as option by LEA)

Explain why the PASA is appropriate:

Choose how the student’s performance on the PASA will be documented.

Written narrative notes (requires prior approval in accordance with PDE

Page 10 of 25 April 2014

ACCESS for ELLs (Administered in grades K-12)

Alternate ACCESS for ELLs (Administered in grades 1-12)

Explain why the Alternate ACCESS for ELLs is appropriate:

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to

X Local assessment is not administered at this student’s grade level; OR

Student will participate in local assessments without accommodations; OR

Student will participate in local assessments with the following accommodations; OR

Page 11 of 25 April 2014

The student will take a local alternate assessment.

Explain why the local alternate assessment is appropriate:

Page 12 of 25 April 2014

MEASURABLE ANNUAL GOAL Describe HOW the

time and the date of each

Short term objectives / Benchmarks

Page 14 of 25 April 2014

A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)