Professional Documents
Culture Documents
Iepform
Iepform
STATE OF NEVADA
INFORMATION
STUDENT/PARENT INFORMATION ELIGIBILITY CATEGORY MEETING INFORMATION
Student Rita Sex Female Autism Spectrum Disorder DATE OF MEETING n/a
Birthdate n/a Grade 3rd Student ID # 19687943 DATE OF LAST IEP MEETING n/a
Deaf/Blind
Student Primary Language English PURPOSE OF MEETING
Developmental Delay
Student English Proficiency Code (optional) Interim IEP
Emotional Disturbance
Address 123 Meadows Dr Initial IEP
Health Impairment
Student Phone 555-677-5985 Hearing Impairment/Deaf
Annual IEP
IEP Following 3-Yr Reevaluation
Intellectual Disability
Parent/Guardian/Surrogate Ms.G Revision To IEP Dated n/a
Multiple Impairment
Parent Phone (Home) 555-678-0909 (Work) 555-678-9898 Exit/Graduation
Orthopedic Impairment
Optional: Cell 555-909-5748 Email Ms.G@gmail.com IEP Revision Without A Meeting:
Specific Learning Disability
Primary Language Spoken at Home English At the request of : Parent or School District
Speech/Language Impairment
LEP Status n/a Other n/a
Federal Placement Code n/a Traumatic Brain Injury
IEP SERVICES WILL BEGIN n/a
Federal Student Ethnicity Code n/a Visual Impairment/Blind
ANTICIPATED
Interpreter or Other Accommodations Needed n/a ELIGIBILITY DATE n/a DURATION OF SERVICES n/a
Emergency Contact/Phone Number 555-678-2344 ANTICIPATED IEP REVIEW DATE n/a
3-YR REEVALUATION n/a
Current School n/a Zoned School n/a COMMENTS n/a
IEP PARTICIPATION
Parent/Guardian/Surrogate* Ms.G Speech/Language Therapist/Pathologist/Specialist n/a
Student** Rita School Nurse n/a
LEA Representative* n/a Interpreter n/a
Special Education Teacher* n/a Other (name and role) n/a
Regular Education Teacher*** Mr.Martinez Other (name and role) n/a
School Psychologist n/a Other (name and role) n/a
*Required participant.
** Student must be invited when transition is discussed (beginning at age 14 or younger if appropriate).
***The IEP team must include at least one regular education teacher of the student (if the student is, or may be, participating in the regular education environment).
PROCEDURAL SAFEGUARDS
✔ I have received a statement of procedural safeguards under the Individuals with Disabilities Education Act (IDEA) and these rights have been explained to me in my primary language.
AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, STUDENTS MUST BE INFORMED OF THEIR RIGHTS UNDER IDEA AND ADVISED THAT THESE RIGHTS WILL TRANSFER TO THEM AT AGE 18.
✔ Not applicable. Student will not be 18 within one year, and the student's next annual IEP meeting will occur no later than the student's 17th birthday.
The student has been informed of his/her rights under IDEA and advised of the transfer of these rights at age 18.
academic achievement, language/communication skills, social/emotional/behavior skills, cognitive abilities, health, motor skills, adaptive skills, pre-vocational skills, vocational skills, and other skills as
appropriate. For students who are 16 or older, or will turn 16 when this IEP is in effect, also consider the results of age appropriate transition assessments related to training/education, employment,
ASSESSMENTS CONDUCTED ASSESSMENT RESULTS EFFECT ON STUDENT'S INVOLVEMENT AND PROGRESS IN GENERAL EDUCATION
CURRICULUM OR, FOR EARLY CHILDHOOD STUDENTS, INVOLVEMENT IN
DEVELOPMENTAL ACTIVITIES
Mathematics She scored really low. She is 1.5-2 Her most serious mathematical difficulties were in the areas
years below her present grade. of numerical reasoning and word problems. She also did
poorly in addition, subtraction and multiplication. Her scores
were low in fractions and division, but she has not had
instruction in these areas in the classroom. I can understand
how she did bad with fractions and division because she
hasn’t been taught them yet.
Reading She did alright for her reading test. Rita scored satisfactorily in tests of word recognition, but her
performance dropped considerably when reading
comprehension was required. When she was observed during
the reading, she seemed to lose her place and had difficulty
concentrating on the material. Her word identification, phonics
skills and reading vocabulary are adequate.
Handwriting She does really bad with this. She’s She needs major help with her handwriting because the
left-handed which makes things really teacher can’t even read her work.
difficult for her. This couldn’t be tested
because of how poor her handwriting
is.
Spelling She showed poor visual memory for She needs help with simple words that she should know how
irregularly spelled words. She scored to spell.
at a second grade level which is lower
than the grade she is in.
STATEMENT OF STUDENT'S PREFERENCES AND INTERESTS (required if transition services will be discussed, beginning at age 14 or younger if appropriate)
She likes music class, eating and doesn’t like the gym or math. She likes watching tv and eating as well.
If student was not in attendance, describe the steps taken to ensure that the student's preferences and interests were considered:
n/a
1. Does the student's behavior impede the student's learning or the learning of others? ✔ No. Yes.
If YES, IEP committee must provide positive behavioral strategies, supports and interventions, or other strategies, supports and interventions to address that
behavior.
Addressed in IEP.
2. Does the student require assistive technology devices and services? ✔ No. Yes.
If YES, IEP committee must determine nature and extent of devices and services.
Addressed in IEP.
If YES, IEP committee must consider the following (check box if IEP committee considered the item):
Language needs of the student as those needs relate to the student's IEP.
5. Does the student have communication needs that require IEP services? ✔ No. Yes.
Addressed in IEP.
The availability to the student of a sufficient number of age, cognitive, academic and language peers of similar abilities.
The availability to the student of adult models who are deaf or hearing impaired and who use the student’s primary communication mode.
The availability of special education teachers, interpreters and other special education personnel who are proficient in the student’s primary communication mode.
The provision of academic instruction, school services and direct access to all components of the educational process, including, without limitation, advanced
placement courses, career and technical education courses, recess, lunch, extracurricular activities and athletic activities.
The preferences of the parent or guardian of the student concerning the best feasible services, placement and content of the student’s IEP.
The appropriate assistive technology necessary to provide the student with an appropriate and equal opportunity for communication access.
7. Does the student have a Specific Learning Disability and Dyslexia? No. ✔ Yes.
If YES, the IEP committee must consider the following instructional approaches (check box if IEP committee considered the item):
Explicit, direct instruction that is systematic, sequential and cumulative and follows a logical plan of presenting the alphabetic principle that targets the specific needs of
the student.
Individualized instruction to meet the specific needs of the student in an appropriate setting that uses intensive, highly-concentrated instruction methods and materials
that maximize student engagement.
Meaning-based instruction directed at purposeful reading and writing, with an emphasis on comprehension and composition.
Multisensory instruction that incorporates the simultaneous use of two or more sensory pathways during teacher presentations and student practice.
TRANSITION
DIPLOMA OPTION SELECTED FOR GRADUATION (Diploma option must be declared at age 14 and reviewed annually.)
Standard or Advanced High School Diploma. Must complete all applicable credit Adjusted High School Diploma. Must complete IEP requirements.
requirements and participate in a College and Career Readiness Assessment.
Alternative High School Diploma. Must complete all applicable credit requirements and participate in the Nevada Alternate Assessment.
Training/Education
Employment
Other
Instruction
Related Services
Community Experiences
Acquisition of Daily Living Skills and Functional Vocational Evaluation (if appropriate)
IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS, AND BENCHMARKS OR SHORT-TERM OBJECTIVES
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress Being Made (continue)
Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates:
2. Unsatisfactory Progress Being Made
(need to review/revise)
Training/Education Employment Independent Living Skills Other
3. Goal Met (note date)
Check here if this goal will be addressed during Extended School Year Services (ESY) Date Date Date Date
n/a
MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress Being Made (continue)
Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates:
2. Unsatisfactory Progress Being Made
(need to review/revise)
Training/Education Employment Independent Living Skills Other
3. Goal Met (note date)
Check here if this goal will be addressed during Extended School Year Services (ESY) Date Date Date Date
n/a
DATE PAGE OF
METHOD FOR REPORTING PROGRESS
METHOD FOR REPORTING THE STUDENT'S PROGRESS TOWARD MEETING ANNUAL GOALS (check all PROJECTED FREQUENCY OF REPORTS
methods that will be used)
IEP Goals Pages District Report Card Quarterly Semester
Specialized Progress Report Parent Conferences Trimester Other n/a
Other n/a
Includes aids, services, and other supports provided in regular education classes, other education-related settings (including special education settings), and in
extracurricular and nonacademic settings to enable students with disabilities to be educated with nondisabled students to the maximum extent appropriate.
MODIFICATION, ACCOMMODATION, OR SUPPORT FOR STUDENT OR PERSONNEL BEGINNING AND FREQUENCY OF LOCATION OF
Provide specific description(s) below. ENDING DATES SERVICES SERVICES
n/a n/a n/a n/a
PLACEMENT
PLACEMENT CONSIDERATIONS PERCENTAGE OF TIME
IN REGULAR EDUCATION ENVIRONMENT
Selected Rejected Regular class with supplementary aids and services (no removal)
Selected Rejected Regular class and special education class (e.g., resource) combination The student will spend n/a % of his or her school day in
Selected Rejected Self-contained program the regular education environment.
Selected Rejected Special school
Selected Rejected Residential
Selected Rejected Hospital
Selected Rejected Home
Selected Rejected Other
*Regular education environments include academic classes (which might include field trips linked to the curriculum), nonacademic settings (such as recess), and extracurricular activities (for
example, sports, after-school clubs, band, etc.).
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 with all or part of this IEP. I understand that the school district 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 local school district superintendent.
Ms.G
Parent Signature