Administrative Data Sheet Student Information:: Testing Public Schools

Testing Public Schools
03030 Avenue Street

Testing, TE 010101
District Contact Person/Phone #: Karla C Richards / 1234567890
Administrative Data Sheet
Student Information:
Student Name: Michel Alejandro Blanco Student ID#: 023040 ; SASID: 0954500230
DOE015 School ID Number: 1010 School Name: Humberstown High School
Date of Birth: 01/25/2001 Place of Birth: San Juan
Age: 16 Current Grade: 12
Primary Language: Spanish Language of Instruction:
Gender: M
Address: 26 William Rd Home Phone: 123-456-7890
Testing, TE 01033
If 16 or older: Acting on Own Behalf Court Appointed Guardian Shared Decision Making Delegated Decision-
Making
Parent/Guardian Information
Student Resides With: Parent/Guardian
Name: Maria Benavides Home Phone: 123-456-7890
Address: 26 William Rd Work Phone:
Testing, TE 01033 Other Phone: (123)456-7890
Email: mariabenavides02121@gmail.com
Primary Language of Parent/Guardian: Spanish
Meeting Information
Date of Meeting: 11/25/2021 Type of Meeting: Annual Review
Next Scheduled Annual Review Meeting: 11/25/2022 Next Scheduled 3 Year Reevaluation Meeting: 01/09/2023
Assigned School Information

School Name: Humberstown High Phone: 1234567890
Address: School 120 Fortmed St
Humberstown, TE 01010
Contact Person: Karla C Richards Phone: 1234567890

Role: Coordinator of Special Education
Cost Share Placement: Yes No Fully Funded If yes, specify agency:

After a meeting, attach to an IEP, an IEP Amendment or an Extended Evaluation Form.
ADM 1 - Test City DOE/Administrative Data Sheet Page 1

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Testing, TE 010101
Individualized Education Program (IEP)
IEP Dates: from 11/25/2021 to 11/25/2022
Student Name: Michel Alejandro Blanco Student ID: 023040

Student Date of Birth: 01/25/2001 Student Grade/Level: 12
Parent and/or Student Concerns

What concern(s) does the parent and/or student want to see addressed in this IEP to enhance the student's education?
Michel's mother, Ms. Benavides, attended the Annual Review meeting via Zoom due to Covid-19. She would like to listen to the
teachers and ask questions as they arise.
Student Strengths and Key Evaluation Results Summary

What are the student's educational strengths, interest areas, significant personal attributes and personal accomplishments?
What is the student's type of disability(ies), general education performance
including MCAS/district test results, achievement towards goals and lack of expected progress, if any?
Student Strengths: Michel is an energetic, affectionate and sociable 16 year old student enrolled in the TRANSITION program at
Humberstown High School. The Transition program designed to support students utilizing the principles of post-secondary skill
development. Michel has attended Humberstown High School since his freshman year and has developed strong relationships with
peers and staff throughout the building. Michel enjoys initiating and interacting with friends. He often seeks out opportunities to
socialize throughout his day.
Michel has been happy to be at school since returning from remote. He has been full of energy. He is continuing to work on math,
reading and writing. Counting and sorting money, taking inventory of things in the classroom and participating with the snack shack
in the classroom. He is using a communication device to express his wants and needs. Previously he did not want to do this. He has
been working on a lot of vocational activities. He has completed a lot of sweeping, dishes, wiping tables and counters. Outside of the
classroom, he has been participating in food prep in Cafe Montego, delivery services and collecting dishes. There is an afternoon coffee
cart that he helps with. He enjoys making the coffee. If the staff are soft spoken, Michel will stall before complying with the request
that has been made. He has been doing very well when out in the community with his class.
Michel will scratch his hands when stressed. Previously he would be given an ipad or phone to calm him down. He has broken both of
those and they need to be fixed so right now he doesn't have those tools to help him calm down, therefore, he has been picking at
his hands more. This was seen a lot more at school pre covid. It is unclear why there are such differences at home and school for his
behavior. Ms. Benavides has noticed that there have been other challenges with using the bathroom and touching himself
appropriately and she raised her voice with him which is believed to have triggered hand picking. Ms. Benavides is concerned that
Michel is getting bigger and she is trying to help him make better decisions and ask for things in an appropriate manner. Michel is not
yet able to make those better choices and Ms. Benavides is concerned that Michel will do something in public to another person if
he is not able to wait or ask appropriately. These are things that are worked on in school and will continue to be worked on moving
forward. It has been observed in school that there has been a lot of improvement regarding personal space when approaching others. He
used to walk right up to someone and sniff them, but now he will approach and tap them on the shoulder to gain their attention. It is
hoped that the suggestion of wrap around services can be explored again now that Michel is back in school. The BCBA will reach out
about beginning those discussions again.
Michel is a hard working student and is able to work on academic tasks for up to 30 minutes with minimal adult support. Michel likes
to use the iPad during leisure time and is able to navigate and use different apps on his own. He is a visual learner who responds well to
consistent routines and visual supports, such as picture checklists and "First, Then" boards. He does well working for access to preferred
items and activities.
The speech language therapist reports that Michel uses his ipad and is less proficient than he was two years ago and his skills need to be
built back up. He is able to change all of the language into Russian. Similar behaviors are seen at home. Michel can follow instructions
and follow simple rote WH questions. They will work on following directions for jobs he is not interested in. One of the concerns Ms.
Benavides has is that Michel does not write any novel sentences. He is only copying things that he has seen before. If anything
happened to him, he is not able to write anything down. This has also been observed in the classroom. Ms. Benavides would like
Michel to work on writing in English or Spanish so that he is able to communicate if anything happens. There was a nurse who came
to observe Michel
IEP - Test City DOE/Individualized Education Program Page 2

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and shared some of the same concerns as Ms. Benavides in terms of how he treats the ipad and putting too much food in his mouth at
one time.
Michel is mute and only communicates with his device.
The occupational therapy reports that Michel is using movement tools, hand fidgets in order to keep his hands busy and keep his hand
picking down. He is usually calm at school but it is understood that it is different at home. There has also been some overstuffing of
food in his mouth at school that has been observed and someone needs to sit with him and slow him down.
Michel completed his MCAS Alt portfolio in 2016.
Key Evaluation Results Summary: IEP goal progress school year 2021-2022: Goal #1: Self Regulation Across 2 person(s) and
2 setting(s), Michel initiated requests for needed or desired items or actions in 90% of opportunities for 2 consecutive week(s) with
5 items or actions. Across 2 person(s) and 2 setting(s), Michel maintained appropriate social distance when interacting with another
person in 82% of opportunities for 3 consecutive session(s). Across 2 person(s) and 2 setting(s), Michel produced personal identification
information when asked "What is your name?" in 100% of opportunities for 3 consecutive session(s).
Goal #2: Transition Across 2 person(s) and 1 setting(s), Michel independently completed a vocational activity, fading job coach proxim-
ity, in 96% of opportunities for 3 consecutive session(s) with 5 vocational tasks. Across 2 person(s) and 2 setting(s), Michel completed
the steps of a vertical picture schedule for vocational activities in 80% of opportunities for 5 consecutive session(s).
Goal #5: Math When given an item with price listed as dollar and cents, Michel stated and used the next highest dollar amount in 8
out of 10 opportunities as measured by data collection of discrete trials. There has been slight regression with money skills, number
identification, writing numbers following a verbal cue, and adding and subtracting numbers, however, Michel is demonstrating impr-
ovement and increased independence of these skills in the context of in-person instruction. Michel independently solved addition and
subtraction problems without regrouping in 7 out of 10 opportunities as measured by data collection of discrete trials. There has been
observable regression with money skills and number identification, however, Michel is demonstrating gradual recollection of these
skills in the context of in-person instruction. After selecting the needed items from the store, Michel made a purchase by giving the
clerk the necessary amount of money in cash using the next highest dollar (providing cash for payment by rounding up to the nearest
dollar) for 4 out of 5 purchases as measured by data collection of task analysis.
Goal #6: Reading/Writing Across 2 person(s) and 1 setting(s), Michel composed a "subject-is-verb" sentence to describe a picture
by typing or using his AAC device in 90% of opportunities. Across 2 person(s) and 2 setting(s), Michel answered and asked social
questions in 75% of opportunities. Across 2 person(s) and 2 setting(s), Michel used his AAC device or indicated a symbol/picture
icon to answer WH questions about simple scenarios (story, picture, social activity) in 92% of opportunities. Across 2 person(s) and 2
setting(s), Michel indicated named printed words and matched the words to objects or pictures in 87% of opportunities.
ABA Goal progress In this reporting period Michel has worked on his self regulation goals. To work towards these goals Michel
does well following the routine and schedule. He is able to wait for preferred items/activities without getting upset for up to a 5 minute
duration when given a visual support such as a "First/Then" board. He will communicate what he wants by pointing and/or gesturing.
He is working on using assistive technology (AAC) to communicate his wants and needs when prompted. Currently he will use his AAC
to make requests in 2 out of 5 opportunities when provided with verbal and gestural cues. He will ask for help or attention by touching
or tapping staff and signing "help" in 3 out of 5 opportunities
Speech and Language therapy progress: 1) When Michel is highly familiar with the question being asked he is able to answer rote wh-
questions. 2) Michel continues to require modeling and support in order to expand his utterances to be more than 1-2 words. 3) Michel
will answer simple questions about how he is feeling during structured group activities. He will not accurately report outside of these
structured opportunities. 4) Michel is able to make requests for his basic wants. He is less accurate about asking for the things that he
needs.
Occupational Therapy: Michel has made a smooth transition since returning back to in-person learning this September 2021. It is
noted that Michel has demonstrated measurable progress in regards to maximizing his independence with daily living and pre-vocation
skills with minimal prompting, redirection and occasional assistance. Michel does use sensory tools in order to successfully increase his
participation in the classroom tasks. He has been enjoying listening to music, movement, using hand fidgets, and also looking at pictures.
These tools are his sensory preferences and help to maintain an optimal level of calmness and attention. Michel is able to choose his
sensory preferences using visual supports in order to increase independence in self-regulation and participation in classroom activities.
Michel is participating in self-help and pre-vocational skills in the classroom when given modeling, visual supports and sensory tools. It

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is recommended that Michel continue to receive OT on a CONSULT-ONLY basis for 30 minutes once a month. It is a pleasure working
with Michel.
Previous IEP: The special education teacher reports that she has been working with Michel for the past 3 years, this year as his homeroom
teacher. She reports that Michel tries very hard. He always wants to interact with his friends and is kind with everyone. The academic
assessments were completed and one of them was not very helpful. It tested how Michel would perform compared with a typical 16
year old. His disability limited his performance on this assessment and his scores were very low. An observation was completed and an
inventory of his skills were used to assess his abilities. A lot more was learned about Michel in the other assessments that were given.
Michel is really good at memorizing things and learning that way. He knows all of his numbers to 100 and memorize patterns. He is
able to do a lot of things for himself. He can wash his hands and takes care of himself in that way. Michel struggles when he tries to
learn new skills when it is not 1:1 and when controlling his impulses. The impulsiveness limits his ability to complete tasks completely
independently. Having someone there with Michel to assist him and make sure he is doing things appropriately, such as not taking salad
dressing for spaghetti, is necessary.
The Speech and Language Pathologist reports that she previously worked with Michel at another school. She reports that his skills have
grown a lot since then. Michel uses an iPad very well and is able to assist the provider when she needs it. When he is paying attention
he is able to follow everything that is happening in the classroom. He can follow directions and answer simple directions. He has a good
sense of humor and understand simple jokes. For example, when another student dropped something he was able to laugh at it. He has
a social understanding of what is happening around him. He has a good understanding of the people in his environment who are both
positive and negative for him to work with. This is important as he grows older to know who is a safer person for him to be around.
Ms. Benavides does not see this at home and shared that Michel is not able to distinguish between people outside of school and there
have been situations where people have become upset with Michel. It is believed that since Michel knows the people at school he is
more comfortable with them. Michel reportedly feels safe here and does not feel the same when they travel to places within the
community. The provider will continue working with Michel on self advocating for himself and be able to tell Ms. Benavides what
happened in his day with accuracy. He is able to use his iPad to help him come up with new language that has not been taught to him
previously in order to represent his thoughts. The assessments consisted of skill sets and a lot of progress was shown. He was able to
complete some tasks on these assessments that he was not able to complete for previous assessments.
The school psychologist reports that she completed the cognitive testing. She was a new person for Michel but he went willingly to test
with her. He was assessed against typical age peers. The assessment was testing reasoning, with and without language, and processing.
Michel did very well with the Block Design assessment and scored in the High Average range. Ms. Benavides reports that Michel
has always been good with puzzles and he completes them quickly. Overall he still requires substantial support to make progress in
school and it is believed that he is correctly placed. He needs substantial support with interacting with others, the community, etc. He is
describes as a social student who enjoys interacting with others. He will greet the school police with a fist bump. He is able to work
for a half an hour.
The occupational therapist reports that he came willingly with her. They tested some in the classroom and office space. His visual
perceptual skills are much higher than his fine motor skills such as writing. His writing is very large. When given constraints to write
small her he can do that but when working independently he will write as big as the space he is given His sister reports that when he
is asked to write smaller he becomes stressed and refuse to write. The OT reports that he is able to control the pencil when given an
assessment where he was asked to keep the pencil within a confined space. He was able to see the end of the assessment which may
have assisted him. It does take a lot of effort for him to keep it so precise which may be where the stress comes from. Ms. Benavides
reports that Michel will become frustrated when things are not done in the same way that he is used to, for example when she was
making sandwiches differently. Assistive devices are beneficial for Michel such as working with the iPad. Ms. Benavides shared that
since Michel does not practice with paper and pencil as much anymore, his writing has become worse and he becomes more stressed
when asked to write. The special education teacher feels that his writing is associated with his sensory needs and that he likes the
feeling of writing big and pressing hard on the paper. The Occupational Therapist shared that as Michel ages they will focus his output
and teacher him skills that he needs and not focus on his handwriting in particular. The family shared that he is able to write things that
he wants clearly such as food or Youtube videos. The Occupational therapist reports that he works much better when his hands are
busy.
The Applied Behavior Analysis assessment included an observation and an assessment tool completed by the teacher. Michel was rated
in several categories such as fluent, emerging or developing. Michel has some great skills and the assessments showed similar findings
to other assessments providers. He engages with peers. There are a lot of things that he likes to do that he finds reinforcing. If he is
distracted it is difficult to get him back on track. He has great pre-requisite discrimination skills. He can match using the iPads and can
distinguish between students in the classroom as to who he should be close to. Because he can do that with known people, the focus can
turn to working on that skills with unknown people. He has a lot of good skills that need to be expanded. He is able to gain the attention

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of peers and staff and have his needs met during the observation with by tapping them, using the iPad, or bringing items to them. He was
able to ask permission when wanting some hand lotion. Ms. Benavides reports that he has brought things to her for assistance since he
was a young child. Working on generalizing those skills will help him when transitioning to an adult program and the people do not
know him well. Ms. Benavides has been fearful of thinking of the future for Michel leaving the school. She knows he is growing into a
man but it is difficult to think of him in that way because of incidents that have happened previously. It is believed that he has a lot of
the skills necessary to be successful in an adult program when the time comes. He needs to be able to follow directions such as stop,
and working in a small group of students. This will change what an adult program will look like for him if he is able to do those things.
Michel wants to be part of the group and involved in things and that is a difficult skill to teach so it is beneficial that he already has it.
The Functional Behavioral Assessment was completed based on two behaviors that get in the way of Michel accessing the school
programming. Self injury(picking and biting himself) and taking items from others were the chosen behaviors. There was a struggle to
decide how they would collect data on his distractibility so the other two areas were chosen. It is believed with consistency and focus on
organizing it will decrease the distractibility. The FBA showed that Michel knows which students he is able to take things from without
a negative interaction and which students he avoided because they will react to him. This is resulting in Michel being separated from
some of his friends which is not ideal since Michel is so social. The observations of these behaviors were ongoing for approximately
20 days. For self injury, the reason the behavior was occurring was determined to be deal to access of something that he wanted whether
it be his own or someone else. Denied access also entailed being told no or having an item removed and given to someone else. Another
reason for the self injurious behavior can be the feeling that Michel gets when he does it that would not be a desirable feeling for others if
they completed the same behavior. Because it feels good to Michel, teaching him other behaviors to replace the self injurious behaviors
is more difficult. When the behavior was taking items from others, the reason was more clear that he wanted access to that item for his
own use. Replacement behaviors have been determined and will be provided for Michel.
Michel will request preferred items or activities and, when distressed, will use his iPad to ask for things he needs (backpack, milk, etc).
Michel requires reminders to provide space when interacting with peers and staff. When presented as a discrete trial, Michel is able to
present personal information with 50% accuracy independently. It is expected that Michel will continue to make progress in the coming
term.
Michel participates in vocational skills training four days a week. He completes vocational activities in four out of four opportunities
while working on tasks such as recycling, greenhouse tasks, deliveries, washing tables and doing task boxes. He is working with staff
as he participates and often needs a re-direct back to task (in three out of four opportunities). He appears to enjoy these tasks but often
gets distracted and will be prompted to resume his work. During vocational task work, visual schedules are used and Michel is shown
the visual before beginning his task and as a prompt back to the task if he becomes distracted. In three out of four opportunities, Michel
will look at and point to the visual as it is reviewed by staff.
He has followed all directions and is willing to follow class activities most of the time. He is consistently showing improvement in the
ability to follow multi step exercise routines. With continued attendance and more active participation, he will be on track to achieving
the Adapted Phys Ed. goals.
Michel is seen in groups with his peers for speech and language therapy. He is a willing and relatively compliant participant in most
activities. 1) Michel is able to answer simple wh- questions when he is attending to task. He requires significant cueing to stay on task.
2) Michel relies heavily on gestures in order to direct others and comment. When prompted to do so, he is able to use his device in order
to be more symbolic with his communication. Michel is a pleasure to work with and continued progress is expected.
When presented with a price up to $3.99, Michel is able to identify the next highest dollar with a verbal and visual prompt. When
provided a worksheet of addition and subtraction math facts and a calculator, Michel is able to complete the worksheet independently
and accurately. When making a purchase at a store, Michel is able to identify the item he would like to purchase, walk to the register, and
take his items independently. Michel requires a prompt to wait appropriately and to provide payment. Michel often becomes frustrated
with limitations to his purchases (wanting to buy more things than he is able to afford) and is working on decreasing the prompting from
staff. It is expected that Michel will continue to make progress towards achieving this goal in the following term.
Michel is able to independently compose a "subject-is-verb" sentence to describe a picture by typing or using his AAC device in 60%
of opportunities. Michel is able to independently answer personal information questions using his AAC device in 70% of opportunities.
Michel is able to use his AAC device or indicate a symbol/picture icon to answer WH questions about simple scenarios in 75% of
opportunities. Michel is able to indicate named printed words from the unit theme and match the words to objects or pictures in 85% of
opportunities.
Given his age and the results of the assessments, Michel's educational plan should focus on functional academics, independent living

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skills, and pre-vocational skills. He should also continue to improve his self-regulation skills. Instruction should continue in a highly
structured, substantially separate program that incorporates systematic teaching approaches and opportunities to practice skills in real-life
situations. Instruction throughout his day should be based on the principles of Applied Behavior Analysis. Michel requires visual supp-
orts, practice and repetition, behavior contracts, and coping strategies to be successful. Opportunities for choice making and supported
social interaction should be provided to encourage Michel to expand on his verbal communication skills.
Michel continues to make progress in the functional skill area of pre-vocational skills with daily practice and repetition. Michel
responds well to sensory diet tools including hand tools which help to maintain an optimal level of calmness.
MA Category of Disability
Primary Disability: Autism
Vision Statement: What is the vision for this student?

Consider the next 1 to 5 year period when developing this statement. Beginning no later than age 14,
the statement should be based on the student's preferences and interest,
and should include desired outcomes in adult living, post-secondary and working environments.
It is reported that Michel is interested in technology and does well with this so Ms. Benavides would like to see him do something in
this area.

Individualized Education Program (IEP) IEP Dates: from 11/25/2021 to 11/25/2022
Student Name: Michel Alejandro Blanco DOB: 01/25/2001; Student ID#: 023040
Present Levels of Educational Performance

A: General Curriculum
General Curriculum Areas affected by Michel's Disability(ies):
English Language Arts-
History and Social Sciences-
Mathematics-
Science and Technology-
Other Curriculum Areas Specify:
How does the disability(ies) affect progress in the curriculum area(s)?
Michel's disability(ies) affect progress in the general curriculum as follows: Michel's diagnosis of Autism Spectrum Disorder, com-
munication/language, motor, and self-regulation deficits affect progress in all curriculum areas. Progress is affected with comprehension
of text, retention of information, recalling/retelling stories, following oral directions, concentration, answering "wh" questions, engaging
in appropriate peer relationships, missing social cues, answering when called upon, decoding, comprehension of vocabulary, completing
timed tasks, understanding written directions, reading and understanding math word problems, completing grade level writing, planning
and organizing work, volunteering information, recalling/remembering math facts, performing written assignments, asking for/accepting
assistance, editing written work, drawing conclusions/inferring, listening to stories, identifying letters/numbers, poor class participation,
using correct mechanics in writing, following classroom and school rules, spelling, taking turns, counting, sharing time.
What type(s) of accommodation, if any, is necessary for the student to make effective progress?
The following accommodations are necessary for Michel to make effective progress in the general curriculum.
· Accommodations suggested: Individual testing Modified content Human reader Visual cues Increased wait time Calculator
Visuals or gestures Sheet of basic math facts 1:1 instruction on new skills Small group ABA based instruction Modified content
Extended time to complete task Frequent breaks
What type(s) of specially designed instruction, if any, is necessary for the student to make effective progress?
Check the necessary instructional modification(s) and describe how such modification(s) will be made.
Content:
Curriculum is modified by decreasing the amount and level of material. Additionally, Individualized instruction in a small group with
instruction of new skills in a 1:1 setting ABA based instruction Behavior management-Visuals, Reinforcers, First/Then boards Practice
and Repetition, Data collection based on discrete trials, work samples, and observation
Methodology/Delivery of Instruction:
Michel must be instructed in a small, highly structured group utilizing a slow pace, multi sensory techniques, visual cues, tactile cues,
a behavioral component, and opportunities for 1:1 assistance.
Performance Criteria:
Progress toward goals and benchmarks, data checklists, behavioral plan, observations/notes, Alternate Portfolio Assessment
IEP 2 - Test City DOE/Individualized Education Program Page 7

Present Levels of Educational Performance

B: Other Educational Needs
Check all that apply. General Considerations
-Adapted physical education
-Braille needs (blind/visually impaired)
-Extra curriculum activities
-Social/emotional needs
-Assistive tech devices/services
-Communication (all students)
-Language needs (LEP students)
-Travel training
-Behavior
-Communication (deaf/hard of hearing students)
-Nonacademic activities
-Skill development related to vocation or preparation experience
-Other
Age-Specific Considerations
-For children ages 3 to 5 - participation in appropriate activities
-For children ages 14+ (or younger if appropriate) - student's course of study
-For children ages 16+ (or younger if appropriate) to 22 - transition to post-school activities including community
experienced, employment objectives, other post school adult living and, if appropriate, daily living skills
How does the disability(ies) affect progress in the indicated area(s) of other educational needs?
Michel's disability(ies) affect progress in other educational areas as follows: Michel's diagnosis of Autism Spectrum Disorder, com-
munication/language, motor, and self-regulation deficits affect progress in all curriculum areas. Progress is affected with comprehension
of text, retention of information, recalling/retelling stories, following oral directions, concentration, answering "wh" questions, engaging
in appropriate peer relationships, missing social cues, answering when called upon, decoding, comprehension of vocabulary, completing
timed tasks, understanding written directions, reading and understanding math word problems, completing grade level writing, planning
and organizing work, volunteering information, recalling/remembering math facts, performing written assignments, asking for/accepting
assistance, editing written work, drawing conclusions/inferring, listening to stories, identifying letters/numbers, poor class participation,
using correct mechanics in writing, following classroom and school rules, spelling, taking turns, counting, sharing time.
What type(s) of accommodation, if any, is necessary for the student to make effective progress?
The following accommodations are necessary for Michel to make effective progress in other educational areas.
· Michel should be provided with examples and demonstrations. Directions should be simplified and given in small steps. He
needs extra time to process information and complete tasks. He needs practice and repetition to learn new skills and concepts.
Michel should be provided with breaks between assignments and cueing back to task. He requires a structured setting with
clear expectations and visual supports. He should be given the opportunity to generalize skills in various settings. Michel
needs a small group setting and preferential seating. He should be provided with assistive technology, including an AAC
device and picture/topic boards to enhance comprehension and communication. He should be provided with manipulatives
and a calculator to complete math tasks.
What type(s) of specially designed instruction, if any, is necessary for the student to make effective progress?
Check the necessary instructional modification(s) and describe how such modification(s) will be made.

Content
Instruction is modified to meet Michel's needs. Content should be modified to meet Michel at an ap-
propriate level. He works on functional academic and transition skills which are aligned with the MA
Curriculum frameworks at entry points. Michel is instructed using a total communication approach and
any assessments should consider his communication needs.
Methodology/Delivery of Instruction:
Michel must be instructed in a small, highly structured group utilizing a slow pace, multisensory tech-
nques, visual cues, tactile cues, a behavioral component, and opportunities for 1:1 assistance.
English Language Needs:
To address this student's English language needs the instructional strategies such as but not limited to -
strategies that make core content and English language instruction comprehensible: the use of visual aids,
modeling, demonstrations, graphic organizers, vocabulary previews, predictions, adapted texts, cooperat-
ive learning, peer tutoring, using multi-cultural content, tiered vocabulary instruction, 7 step-vocabulary,
partner reading, write around and cut and grow and clarification in native language.
Performance Criteria:
IEP objectives set, progress reports, data checklists, behavioral plan, observations/notes, Alternate Port-
folio Assessment

Current Performance Levels/Measurable Annual Goals
Goal # 1 Specific Goal Focus: Self Regulation Skills
Current Performance Level: What can the student currently do? Michel does well following the routine and schedule. He is
able to wait for preferred items/activities without getting upset for up to a 2 minute duration when given a visual support such as a
"First/Then" board. He will communicate what he wants by pointing and/or gesturing. He is working on using assistive technology
(AAC) to communicate his wants and needs when prompted. Currently he will use his AAC to make requests in 2 out of 5 opportunities
when provided with verbal and gestural cues. He will ask for help or attention by touching or tapping staff and signing "help" in 3 out of
5 opportunities.
Measurable Annual Goal: What challenging, yet attainable, goal can we expect the student to meet by the end of this IEP
period? How will we know that the student has reached this goal? Given specific instruction, Michel will increase his self-
regulation skills by communicating his wants/needs, maintaining appropriate social distance, and producing his personal information in
3 out of 5 opportunities as measured by pre/post assessments, teacher observation and feedback, and progress reports to be completed by
the end of the IEP period.
Target Mastery: Target Date:

Benchmark/Objectives: What will the student need to do to complete this goal?
· Across 2 person(s) and 2 setting(s), Michel will greet another person, while maintaining an appropriate social
distance, in 90% of opportunities for 3 consecutive session(s).
· Across 2 person(s) and 2 setting(s), Michel will initiate requests for needed or desired items in the context of util-
izing coping skills in 90% of opportunities for 2 consecutive week(s) with 5 items or actions.
Goal # 2 Specific Goal Focus: Transition Skills
Current Performance Level: What can the student currently do? When provided with a pre-vocational opportunity, Michel
completed the given job correctly with fading teacher support in 5 out of 5 opportunities as measured across the last 5 opportunities for
data.
Michel accessed a variety of vocational tasks by reviewing a visual schedule of the steps required. In the context of in person learning,
Michel has access to visual schedules through structured learning time. In the context of in person learning, Michel followed a picture
activity schedule to complete three domestic chores (i.e. folding towels, wash dishes, laundry, sweeping and wiping the table) with 100%
accuracy and 100% independence (without prompting from staff) as measured across 5 consecutive sessions for data collection. Michel
completed a variety of vocational tasks in a predetermined amount of time, given staff supervision and least to most prompting in 5 out
of 5 opportunities as measured across the last 5 opportunities for data collection. Michel successfully used a schedule-token system,
both as a motivator and to track participation in tasks, to earn points towards a preferred reinforcer in 5 out of 5 opportunities.
In the context of self help skills, Michel prepared 3 different cold food snacks (i.e. peanut butter and jelly sandwich, fruit cups, trail
mix) by following the steps of a picture sequence visual when presented with programmed opportunities with 100% accuracy and 90%
independence as measured across 5 opportunities for data collection.
period? How will we know that the student has reached this goal? Given a variety of school and community based experiences,
Michel will expand transition skills in the areas of vocational skills in 4 out of 5 opportunities as measured by pre/post assessments,
teacher observation and feedback, and progress reports to be completed by IEP end date.


· Across 2 person(s) and 1 setting(s), Michel will independently complete a vocational activity, fading job coach
proximity, in 80% of the opportunities for 3 consecutive session(s) with 5 vocational tasks.
· Across 2 person(s) and 1 setting(s), Michel will independently complete a job related activity, fading job coach
proximity, in 80% of the opportunities for 3 consecutive session(s) with 5 vocational tasks.
· Across 2 person(s) and 2 setting(s), Michel will determine interests and practical variables related to employment in
80% of the opportunities for 3 consecutive session(s), up to 3 job related tasks.
Goal # 3 Specific Goal Focus: Motor Skills
Current Performance Level: What can the student currently do? Michel is participating in a group PE program with the other
students in his class with APE supports. He is participating in modified sports activities and motor development exercises. His focus
remains on participation, understanding and coordinating learned skills as they relate to age appropriate games.
period? How will we know that the student has reached this goal? By the end of the IEP, Michel will be able to perform an
increased variety of age appropriate gross motor activities 80% of the time.

· When working in a group setting, Michel will participate in a multi set exercise routine consistently 80% of the
time.
· When working in a group setting, Michel will maintain proper posture while participating in exercise movements
consistently 80% of the time.
Goal # 4 Specific Goal Focus: Speech/Language
Current Performance Level: What can the student currently do? When Michel is highly familiar with the question being asked,
he can answer rote wh- questions. Michel continues to require modeling and support to expand his utterances to be more than 1-2 words.
Michel will answer simple questions about how he is feeling during structured group activities. He will not accurately report outside
of these structured opportunities. Michel can make requests for his basic wants. He is less accurate about asking for the things that he
needs.
period? How will we know that the student has reached this goal? By the end of the IEP period ,given decreasing cues and support
Michel will improve his receptive and expressive language skills past baseline in 4 out of 5 structured opportunities.

· By the end of the IEP period, given decreasing cues and support, Michel will expand his utterances to include 3-4
symbols in 4 out of 5 opportunities.
· By the end of the IEP period, given decreasing cues and support, Michel will produce novel utterances in response
to questions about personal experiences in 3 out of 5 opportunities.
· By the end of the IEP period, given decreasing cues and support, Michel will follow directions to accomplish vo-
cational and ADL tasks in 4 out of 5 opportunities.
· By the end of the IEP period, given decreasing cues and support, Michel will express to staff when he is in
physical or emotional discomfort 3 out of 5 structured opportunities.
Goal # 5 Specific Goal Focus: Math Skills
Current Performance Level: What can the student currently do? Given visual and verbal prompts, Michel identified coins
and bills in 5 out of 5 opportunities as measured across 5 discrete trial sessions. Michel identifies bills ($1, $5, $10, $20) and coins
penny, nickel, dime, quarter) with 100% accuracy and 100% independence as measured across the last 5 consecutive sessions for data.
When brought to a store in the community, Michel made a purchase at a store, following the steps in a task analysis, with increased

independence for out of 5 out of 5 purchases as measured by data collection. When making a purchase at a store, Michel is able to
identify the item he would like to purchase, walk to the register, remove payment from her wallet, hand payment to the cashier, receive
the receipt and take the items independently. Michel benefits from an occasional prompt to provide payment. Presented with a simulated
shopping routine, Michel identified the correct US Bill to use in the context of a purchasing routine, up to $5 dollars, using the round
up method with guided prompts from an adult in 3 out of the last 5 opportunities for data. Michel requires a visual prompt to identify
the next highest dollar when presented with the price of an item.
Measurable Annual Goal: What challenging, yet attainable, goal can we expect the student to meet by the end of this
IEP period? How will we know that the student has reached this goal? By IEP end date, Michel will increase his ability to
access functional math skills in the classroom and community (making a purchase at a store, counting with one to one correspondence,
identifying named numbers, identify dollar bills and coins), for 9 out of 10 opportunities as measured by data collection of discrete trials
and task analyses.

· By IEP end date, when brought to a store in the community, Michel will make a purchase at a store, following the
steps in a task analysis, with increasing independence for 9 out of 10 purchases as measured by pre/post asses-
sments, teacher observation and feedback, and progress reports to be completed by IEP end date.
· By IEP end date, when given an item with price listed as dollar and cents, Michel will state and use the next hig-
hest dollar amount in 8 out of 10 opportunities as measured by data collection of discrete trials.
· By IEP end date, when given an item with price listed as dollar and cents, Michel will determine if he has enough
money to make a purchase in 8 out of 10 opportunities as measured by data collection of discrete trials.
Goal # 6 Specific Goal Focus: Daily Living Skills
Current Performance Level: What can the student currently do? Michel is currently able to complete many activities in self-care
(toothbrushing, toileting, dressing) without prompting from staff. Occasionally, Michel benefits from staff supporting him by providing
verbal reminders and the selection of his own personal hygiene products. Michel continues to work on requesting to use the bathroom
frequently throughout the day and benefits from reminders and frequent check-ins. Michel is continuing to reduce prompt dependency
and increase his ability to care for himself. Over the course of the year, Michel participated with hygiene and self care lessons relating
to COVID-19 safety guidelines, showering, dental hygiene, bathroom etiquette, hand washing, first aid, etc. Michel identified the need
for a medical procedure or attention (i.e. needing to see the nurse, requesting band-aid for a cut, ice pack for headache, etc).
Michel demonstrated interests with preferred activities and initiated the request to engage with the preferred activity by communicating
with staff, using his communication device or gaining the attention of the staff. Michel has increased his interest with self-directed
activities and has increased independence while engaged with the activity.
period? How will we know that the student has reached this goal? Given a variety of school and community based experiences,
Michel will expand his transition skills in the areas of vocational skills in 4 out of 5 opportunities as measured by pre/post assessments,

· By IEP end date, given specific instruction and following visual task prompts, Michel will engage in activities of
self-care with increasing independence and decreasing prompts in 4 out of 5 programmed opportunities as measured
by pre/post assessments, teacher observation and feedback, and progress reports to be completed by IEP end date.
· Across 2 person(s) and 2 setting(s), Michel will determine interests and engage with self-directed activities in 4
out of 5 opportunities for 3 consecutive session(s), up to 3 self-directed tasks, as measured by pre/post assessments,
Goal # 7 Specific Goal Focus: Travel Training
Current Performance Level: What can the student currently do? Given demonstration and opportunity for practice and rep-
etition during community based experiences, Michel independently remained on the sidewalks, when traveling in 3 out of the last 5

opportunities. Michel benefits from verbal reminders to stop at street corners and wait for the group as he may continue walking to get
to the target location. Michel attended community outings each week with peers and teachers to various locations. Since returning to in
person learning, Michel has demonstrated significant improvement with participating in community activities with teachers and peers.
Via direct observation, Michel monitored and maintained a close proximity to the travel group in 3 out of the last 5 opportunities. Mi-
chael benefited from staff providing him no more than 1 verbal cue to stop at the crosswalk and look both ways before crossing the street.
Michel benefits from an adult walking within arm's length. In addition, over the course of the year, Michel targeted this goal through
video simulation, educational videos relating to staying with a group while traveling in the community and responding to questions from
the teacher to assess for understanding.
In the context of using a T-pass in the community, Michel presented his T pass upon entering the vehicle following a verbal cue from
the staff. Prior to the school closures, Michel was demonstrating progress with this objective.
period? How will we know that the student has reached this goal? Given a variety of community based experiences, Michel
will expand community skills in 4 out of 5 opportunities as measured by pre/post assessments, teacher observation and feedback, and
progress reports to be completed by IEP end date.

· Given a variety of school and community-based lessons and opportunities, Michel will increase the recognition of
signs in the community and understanding of their purpose by demonstrating an appropriate response in 4 out of
5 opportunities as measured by pre/post assessments, teacher observation and feedback, and progress reports to be
completed by IEP end date.
· Given a variety of school and community-based lessons and opportunities, Michel will increase the recognition of
travel signs in the context of public transportation and navigation of the community in 4 out of 5 opportunities as
measured by pre/post assessments, teacher observation and feedback, and progress reports to be completed by IEP
end date.
Progress Reports are required to be sent to parents at least as often as parents are informed of their nondisabled
children's progress. Each progress report must describe the student's progress toward meeting each annual goal.

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.
School District Cycle: The Humberstown High School is on a 5-day cycle.

A. Consultation (Indirect Services to School Personnel and Parents)
Focus on Type of Service Type of Personnel Frequency and Start End
Goal # Duration per Cycle Date Date
1 Applied Behavior BCBA 1 Session of 60 min- 11/25/2021 11/25/2022
ute(s) per month
1, 2 Occupational Therapy Occupational Ther- 1 Session of 30 min- 11/25/2021 11/25/2022
apist ute(s) per month
4 Speech and Language Services SLP 1 Session of 30 min- 11/25/2021 11/25/2022
ute(s) per month
B. Special Education and Related Services in General Education Classroom(Direct Services)

No services in this grid
C. Special Education and Related Services in Other Locations (Direct Services)

1 Self Regulation Skills Special Ed Teacher 5 Session (s) of 76 min- 07/12/2022 08/12/2022
ute(s) each per week
2, 6, 7 Transition Skills Special Ed Teacher 5 Session (s) of 76 min- 07/11/2022 08/12/2022

1 Self Regulation Skills Special Ed Teacher 5 Session (s) of 60 min- 11/25/2021 11/25/2022
2, 6, 7 Transition Skills Special Ed Teacher 5 Session (s) of 160 11/25/2021 11/25/2022

minute(s) each per
week
5 Math Skills Special Ed Teacher 5 Session (s) of 60 min- 11/25/2021 11/25/2022
5 Math Skills Special Ed Teacher 5 Session (s) of 76 min- 07/11/2022 08/12/2022

3 Adapted Physical Education Adaptive Physical 1 Session of 30 min- 07/11/2022 08/12/2022

Education Teacher ute(s) per week
1 Applied Behavior ABA Specialist 5 Session (s) of 60 min- 07/11/2022 08/12/2022


ute(s) per week
1 Applied Behavior ABA Specialist 5 Session (s) of 60 min- 11/25/2021 11/25/2022
3 Adapted Physical Education Adaptive Physical 2 Session (s) of 45 min- 11/25/2021 11/25/2022
Education Teacher ute(s) each per week

ute(s) per week

Nonparticipation Justification
Is the student removed from the general education classroom at any time? (refer to IEP 5 service delivery, section C.)
Yes No If yes, why is removal considered critical to the student's program?
Michel's diagnosis of Autism Spectrum Disorder and communication/language, motor,and behavioral deficits impact upon his daily
skills acquisition and performance, requiring specialized instruction with modification of all content area materials and assignments,
provided within a highly structured, small group environment. Michel receives speech and language therapy, occupational therapy,
adaptive physical education, assistive technology and Applied Behavior Analysis (ABA) services.
IDEA 2004 Regulation 20 U.S.C. educat-

ional environment occurs only when the nature or severity of the disability of a child is such that education in regular
classes with the use of supplementary aids and services cannot be achieved satisfactorily.' (Emphasis added.)
Schedule Modification
Shorter: Does this student require a shorter school day or shorter school year?
No Yes - Shorter Day Shorter year If yes, answer the questions below
Longer: Does this student require a longer school day or longer school year to prevent substantial loss of previously learned skills
and/or substantial difficulty in relearning skills?
No Yes - Longer Day Longer year If yes, answer the questions below
How will the student's schedule be modified? Why is this schedule modification being recommended? If a longer day or year is recom-
mended, how will the school district coordinate services across program components?
Michel will attend school for a standard school day.
Because of Michel's special needs, he is enrolled in the Extended School Year program. An explanation is given below.
Michel requires ESY services to prevent substantial loss of previously learned skills and may experience substantial difficulty relearning
said skills
Transportation Services
Does the student require transportation as a result of the disability(ies)?
No Regular transportation will be provided in the same manner as it would be provided for students without
disabilities. If the child is placed away from the local school, transportation will be provided.
Yes Special Transportation will be provided in the following manner:

on a regular transportation vehicle with the following modifications and/or specialized equipment and
precautions:
on a special transportation vehicle with the following modifications and/or specialized equipment and
precautions:
Door to Door: Monitor: 1:1 Monitor
IEP 6 - Test City DOE/Individualized Education Program Page16

State or District-Wide Assessment
Fill out the table below. Consider any state or districtwide assessment to be administered during the time span
covered by this IEP. For each content area, identify the student's assessment participation status by putting an X in
the corresponding box for column 1, 2, or 3.
1. Assessment Participat- 2. Assessment Participat- 3. Assessment Participat-

ion: Student participates in ion: Student participates in ion: Student participates in
on-demand testing under on-demand testing with acc- alternate assessment in this
routine conditions in this ommodations in this content content area. (see below)
content area. area. (see below)
Content Areas
English Language Arts
History and Social Sciences
Mathematics
Science and Technology
Reading
Accommodations for State or District-Wide Assessments:

Additional Information
Include the following transition information: the anticipated graduation date; a statement of interagency respons-
ibilities or needed linkages; the discussion of transfer of rights at least one year before age of majority; and a rec-
ommendation for Chapter 688 Referral.
Document efforts to obtain participation if a parent and if student did not attend meeting or provide input.
Record other relevant IEP information not previously stated.
For students with an Autism Spectrum disability please check to verify that each of the needs below has
been considered and addressed (as needed) by the IEP Team:
Verbal and nonverbal communication needs
Need to develop social interaction skills and proficiencies
Needs resulting from unusual responses to sensory experiences
Needs resulting from resistance to change or transitions
Needs resulting from engagement in repetitive activities or stereotyped movements
Need for positive behavioral interventions, strategies, and supports to address behavioral difficulties
Need for assistive technology
Other needs resulting from the disability that impact progress in the general curriculum including social and emot-
ional development
Please note what was discussed regarding the ASD checklist at the team meeting:
All items on the ASD checklist were reviewed at the Team meeting.
Transition Verification
Student Anticipated Graduation Date 08/17/2025
1) The student's vision statement was updated to reflect their post-secondary goals.
2) The post-secondary goals, in the vision statement, are measurable and based on an age- appropriate
transition assessment.
3) The student's measurable annual skill-based IEP goal(s) relate to the student's transition service
needs.
4) Was a State Agency Contacted? Yes
a. If Yes, what agency? DDS
5) Transfer of Rights at Age of Majority was discussed.
As per the Test City Bullying Prevention and Intervention Law, M.G.L., c. 71, 370, the Team
discussed the student's disability as it relates to social interactions and determined that the student:
is vulnerable to bullying, harassment, or teasing either as a target or an aggressor. This determination was consid-
ered with the development of this IEP.
is not vulnerable to bullying, harassment, or teasing either as a target or an aggressor. However, if, at any point in
the future, such concerns arise, the IEP Team will reconvene to discuss and to address skills needed to avoid and
respond to bullying in the IEP. The whole school bullying prevention curriculum is provided to all students.
Michel will remain in school until he ages out at 22.

Michel participates in a variety of programs to help develop self advocacy skills including the Circles Cur-
riculum.
Ms. Benavides will pursue guardianship. She will be connected with Tasha Baizerman. Michel was seen by
Tasha again 10/12/21.
688 referral submitted 3/9/21

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 and Role of LEA Representative Date Principal Signature Date
Parent Options/Responses
It is important that the district 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 district.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 16 and Over* Date
* Required signature once a student reaches 16 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.

Placement Consent Form - PL1: 6-21 year olds

District: Testing Public Schools School: Humberstown High
Student: Michel Alexander Negron School
SASID: 0954500230 IEP Dates: 12/15/2021 to 12/14/2022
Team Recommended Educational Placements Corresponding Placement

The Team identified that IEP services are provided outside the gen- Full Inclusion Program
eral education classroom less than 21% of the time (80% inclusions).
The Team identified that IEP services are provided outside the gen- Partial Inclusion program
eral education classroom at least 21% of the time but not more than
60% of the time.
The Team identified that all IEP services are provided outside the Substantially Separate Classroom
general education classroom for more than 60% of the time.
The Team identified that all IEP services should be provided outside Separate Day School
the general ed. classroom and in a separate school that only serves Public or Private
students with disabilities.
The Team identified that IEP services require a 24-hour education Residential School
program.
The Team has identified a mix of IEP services that are not provided Other
in primarily school-based settings.
Other Authority Required Placements

These non-educational placements are not determined by the Team and therefore service delivery may be limited.
The Department of Youth Services has placed
the student in a facility for committed or detained
youth
The Department of Mental Health has placed
the student in a hospital psychiatric unit or resident-
ial treatment program.
The Department of Public Health has placed the
The placement has been made by a state agency to an institutional-
student in the Testing Rehabilitation Hospital for
ized setting for non-educational reasons.
Children.
Day or Residential
The student is incarcerated in the county house
of corrections or in a department of corrections
facility.
A doctor has determined that the student must be served in a home Home-based Program
setting.
A doctor has determined that the student must be served in a hosp- Hospital-based Program
ital setting.
Placement Consent Form

Specific Program Location(s) and Dates: Humberstown High School, ABA Based Classroom
(Substantially separate), 11/25/2021 - 11/25/2022
Parent Options/Responses
It is important that the district 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 district along with your response to the
IEP. Thank you.
I consent to the placement decision.
I refuse the placement decision.
I request a meeting to discuss the refused placement decision.
Signature of Parent, Guardian, Educational Surrogate Parent, Student 16 and Over* Date
PL1 (6-21) Revised 08/07

Educational Environment / Placement - PL2: 6-21 year olds

(For school district record keeping only)
District: Testing Public Schools School: Humberstown High School
Student: Michel Alexander Negron SASID: 0954500230 IEP Dates: 12/15/2021 to 12/14/2022
SPECIAL EDUCATION SUMMARY DATA

DOE034
Educational Environment for Students Age 6-21
40
6-21 Year Olds Receiving Special Education Services:

01- Not currently a special education student 6-21, but was previously a special education student during the cur-
rent school year
10- Full inclusion-special education services outside the general education classroom less than 21% of the time
(80% inclusions).
20- Partial Inclusion- special education services outside the general education classroom 21% to 60% of the time.
40- Substantially Separate Classroom - special education services outside the general education classroom more
than 60% of the time.
41- Public Separate Day School
50- Private Separate Day School
60- Residential School
70- Homebound/Hospital
90- Public Residential Institution Facilities (DMH and DPH=370XXXX schools; DYS=09200300; County House or
Dept. Corrections = 09200500)
PL2 (6-21) Revised 08/07

Primary Disability / Level of Need - PL3: 3-21 year olds

(For school district record keeping only)
District: Testing Public Schools School: Humberstown High School
Student: Michel Alexander Negron SASID: 0954500230 IEP Dates: 12/15/2021 to 12/14/2022
SPECIAL EDUCATION SUMMARY DATA FOR ALL AGES (3-21 YEAR OLDS)
DOE036 DOE038
Nature of Primary Disability Level of Need
11 04
01 - Intellectual 08 - Specific Learning Disabilities 01 - Low less than 2 hours
02 - Sensory:Hearing 09 - Sensory: Deaf-Blind of services per week
03 - Communication 10 - Multiple Disabilities 02 - Low -2-5 hours of
04 - Sensory: Vision 11 - Autism services per week
05 - Emotional 12 - Neurological 03 - Moderate
06 - Physical 13 - Developmental Delay 04 - High
07 - Health
Determining Level of Need for 3-5 year olds

How many total hours does the child receive DOE038
special education services each week? Level of Need
Less than 2 hours of special education services per week = 01 -Low less than 2 hours of services per
week
2-5 hours of special education services per week = 02 -Low -2-5 hours of services per week
6-14 hours of special education services per week = 03 -Moderate
15 or more hours of special education services per week = 04 -High
Determining Level of Need for 6-21 year olds

Primary Setting(s): Service Provider(s): Percent of Program Time
Receiving Special Education
Services:
Row 1 in general education general educators and paraprofess- under 25% of program
classroom ionals with consultation time
Row 2 in and out of general combination of general educators, between 25% and 75% of
education classroom paraprofessionals, special educa- program time
tors and related service providers
Row 3 out of general educat- special educators and related over 75% of program
ion classroom service providers time
Decision Criteria for 6-21 year olds

These criteria are provided for you convenience. If the result of applying these criteria does not satisfactorily reflect the
student's Level of Need, use professional judgment.
· If two or more boxes are checked in Row 1, indicate low .
· If two or more boxes are check in Row 2, indicate moderate .
· If two or more boxes are check in Row 3, indicate high .
· If one box is check in each row, indicate either moderate or high depending on the need of the student.
Please refer to the Test City Department of Education web site at http://www.doe.mass.edu/inforservices/data/ for definitions of Primary disability, Nature of Services, Sped
Placement, Cost-Share Placement, Level of Need, and Private Placement.
PL3 Revised 08/07

Test City Department of Education Transition Planning Form
03030 Avenue Street
Testing, TE 010101
TRANSITION PLANNING FORM (TPF)
Test City requires that beginning when the eligible student is 14 for the IEP developed that year, the school district must plan for
the student's need for transition services and the school district must document this discussion annually. This form is to be
maintained with the IEP and revisited each year.
Student: Michel Alejandro SASID: 0954500230 Age: 16

Blanco
Date form completed: 01/19/2022
Anticipated date of graduation: 08/17/2025 Current IEP dates from: 11/25/2021 to: 11/25/2022
Anticipated date of 688 referral, if applicable: 03/09/2021
POST-SECONDARY VISION
Write the student's POST-SECONDARY VISION in the box below. In collaboration with the family, consider the student's
preferences and interests, and the desired outcomes for post-secondary education/ training, employment, and adult living. This sect-
ion should correspond with the vision statement on IEP 1.
The TEAM would like to see Michel expand his vocational skills and independence by providing him with vocational explorat-
ion and community access opportunities. The TEAM would like Michel to increase his independence and safety skills in his
daily living activities and in the community, increase his functional academic skills, and increase his communication and self-
advocacy skills to prepare him for the future.
Michel's mother wants him to continue to live at home after he leaves school. She has completed an application for the after
school program TRACE. She would like to see him be more independent when he ages out at 22.
DISABILITY RELATED NEEDS
Write the skills (disability related) that require IEP goals and/or related services in the box below. Consider all skills (disability related)
necessary for the student to achieve his/her post-secondary vision.
Michel's mother and his IEP team believe Michel should focus on his ability to self-regulate (requesting appropriately,
maintaining appropriate social distance, waiting, and decreasing his self-injurious behaviors), transitional skills (follow schedules
and participate in vocational activities), and develop functional academic skills (money use and functional literacy) that will
support his ability to have greater independence upon completing high school.
Michel will continue to target his communication, motor and self regulation skills with the support of speech and language ther-
apy, ABA therapy, APE and occupational therapy.
Mandated Form 28M/9 Page 23

Test City Department of Education Transition Planning Form
03030 Avenue Street
Testing, TE 010101
Student: Michel Alejandro Blanco Date form completed: 01/19/2022
ACTION PLAN
The ACTION PLAN should outline how the student can develop self-determination skills and be prepared both academically and
functionally to transition to post-school activities in order to achieve his/her post-secondary vision. Indicate how Special Educat-
ion/General Education, family members, adult service providers or others in the community will help the student develop the necessary
skills. Disability related needs must also be stated on page 1.
Develop the ACTION PLAN needed to achieve the POST-SECONDARY VISION by outlining the skills the student
needs to develop and the courses, training, and activities in which the student will participate. Include information on who will
help the student implement specific steps listed below in the Action Plan.
· Instruction: Is there a course of study or specific courses needed that will help the student reach his/her post-
secondary vision? Consider the learning opportunities or skills that the student may need. This could include specific
general education courses and/or special education instruction, career and technical education, and/or preparation for post-
secondary outcomes such as vocational training or community college.
This year Michel continues to participate in functional academic classes geared toward necessary life skills in reading,
writing, math, and social-emotional skills. He will also participate in classroom based programs explicitly teaching in-
dependence, safety and self-advocacy skills.
· Employment: Are there employment opportunities and/or specific skills that will help the student reach
his/her post-secondary vision? Consider options such as part-time employment, supported job placement, service le-
arning projects, participation in work experience program, job shadowing, internships, practice in resume writing/ interv-
iewing skills, the use of a one-stop resource center and job specific skills in areas such as customer service, technology, etc.
Michel will increase soft and hard competitive work skills through a variety of opportunities both within the school
setting as well as the community. He will be provided with opportunities to practice accurately reporting his per-
sonal information as well as completing routine jobs around the school, such as cleaning in cafe and photocopying and
delivery.
· Community Experiences/ Post School Adult Living: Are there certain types of community and/or adult
living experiences that will help the student reach his/her post-secondary vision? Consider options such as
participation in community based experiences, learning how to independently access community resources, building social
relationships, managing money, understanding health care needs, utilizing transportation options and organizational skills
Michel will increase his community and safety skills through direct instruction in the classroom and through supervised
community trips with the program. He will work on making purchases, using public transportation, demonstrating ap-
propriate community skills by following social rules in the community based on specific environments, indicate and ob-
serve rules of personal safety, and increase skills in walking safely on community outings.
Mandated Form 28M/9 Page 24

Administrative Data Sheet Student Information:: Testing Public Schools

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Administrative Data Sheet Student Information:: Testing Public Schools

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Testing Public Schools

03030 Avenue Street

Assigned School Information

Contact Person: Karla C Richards Phone: 1234567890

Cost Share Placement: Yes No Fully Funded If yes, specify agency:

ADM 1 - Test City DOE/Administrative Data Sheet Page 1

Student Name: Michel Alejandro Blanco Student ID: 023040

Parent and/or Student Concerns

Student Strengths and Key Evaluation Results Summary

IEP - Test City DOE/Individualized Education Program Page 2

Michel is mute and only communicates with his device.

Michel completed his MCAS Alt portfolio in 2016.

IEP - Test City DOE/Individualized Education Program Page 3

IEP - Test City DOE/Individualized Education Program Page 4

IEP - Test City DOE/Individualized Education Program Page 5

Vision Statement: What is the vision for this student?

IEP - Test City DOE/Individualized Education Program Page 6

Present Levels of Educational Performance

How does the disability(ies) affect progress in the curriculum area(s)?

IEP 2 - Test City DOE/Individualized Education Program Page 7

Present Levels of Educational Performance

IEP 3 - Test City DOE/Individualized Education Program Page 8

IEP 3 - Test City DOE/Individualized Education Program Page 9

Current Performance Levels/Measurable Annual Goals

Goal # 1 Specific Goal Focus: Self Regulation Skills

Target Mastery: Target Date:

IEP 4 - Test City DOE/Individualized Education Program Page 10

Target Mastery: Target Date:

Target Mastery: Target Date:

Target Mastery: Target Date:

IEP 4 - Test City DOE/Individualized Education Program Page 11

Target Mastery: Target Date:

Target Mastery: Target Date:

IEP 4 - Test City DOE/Individualized Education Program Page 12

Target Mastery: Target Date:

IEP 4 - Test City DOE/Individualized Education Program Page 13

School District Cycle: The Humberstown High School is on a 5-day cycle.

B. Special Education and Related Services in General Education Classroom(Direct Services)

C. Special Education and Related Services in Other Locations (Direct Services)

2, 6, 7 Transition Skills Special Ed Teacher 5 Session (s) of 76 min- 07/11/2022 08/12/2022

2, 6, 7 Transition Skills Special Ed Teacher 5 Session (s) of 160 11/25/2021 11/25/2022

5 Math Skills Special Ed Teacher 5 Session (s) of 76 min- 07/11/2022 08/12/2022

3 Adapted Physical Education Adaptive Physical 1 Session of 30 min- 07/11/2022 08/12/2022

IEP 5 - Test City DOE/Individualized Education Program Page 14

4 Speech and Language Services SLP 1 Session of 15 min- 07/11/2022 08/12/2022

4 Speech and Language Services SLP 1 Session of 30 min- 11/25/2021 11/25/2022

IEP 5 - Test City DOE/Individualized Education Program Page 15

Yes No If yes, why is removal considered critical to the student's program?

IDEA 2004 Regulation 20 U.S.C. educat-

Michel will attend school for a standard school day.

Yes Special Transportation will be provided in the following manner:

IEP 6 - Test City DOE/Individualized Education Program Page16

State or District-Wide Assessment

1. Assessment Participat- 2. Assessment Participat- 3. Assessment Participat-

Accommodations for State or District-Wide Assessments:

IEP 7 - Test City DOE/Individualized Education Program Page 17

Record other relevant IEP information not previously stated.

Michel will remain in school until he ages out at 22.

IEP 8 - Test City DOE/Individualized Education Program Page 18

Signature and Role of LEA Representative Date Principal Signature Date

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

IEP 8 - Test City DOE/Individualized Education Program Page 19