Professional Documents
Culture Documents
Iepform Nevada
Iepform Nevada
STATE OF NEVADA
INFORMATION
STUDENT/PARENT INFORMATION ELIGIBILITY CATEGORY MEETING INFORMATION
Student Chloenette Baker Sex Female Autism Spectrum Disorder DATE OF MEETING 04/14/2017
DATE OF LAST IEP MEETING 04/14/2016
Birthdate 8/15/200 Grade Student ID # Deaf/Blind
Student Primary Language English and Indonesian PURPOSE OF MEETING
Developmental Delay
Student English Proficiency Code (optional) Interim IEP
Emotional Disturbance
Address 111 Ocean Park Orange CA 92677 Initial IEP
Health Impairment
Student Phone Annual IEP
Hearing Impairment/Deaf
✔ IEP Following 3-Yr Reevaluation
Intellectual Disability
Parent/Guardian/Surrogate Alice and Andy Baker Revision To IEP Dated
Multiple Impairment
Parent Phone (Home) 714-000-0000 (Work) 714-000-0000 Exit/Graduation
Orthopedic Impairment
Optional: Cell 714-000-0000 Email abaker@gmail.com
IEP Revision Without A Meeting:
Specific Learning Disability
Primary Language Spoken at Home English and Indonesian At the request of : Parent or School District
Speech/Language Impairment
LEP Status N/A Other
Federal Placement Code 52 Traumatic Brain Injury
IEP SERVICES WILL BEGIN 04/15/2017
Federal Student Ethnicity Code 7 Visual Impairment/Blind
ANTICIPATED
Interpreter or Other Accommodations Needed ELIGIBILITY DATE 04/14/2017 DURATION OF SERVICES Until the age of 21.
Emergency Contact/Phone Number 714-000-0000 ANTICIPATED IEP REVIEW DATE 04/14/2018
3-YR REEVALUATION 04/14/2020
Current School Sunnydale Elementary Zoned School Sunnydale Elemntary COMMENTS
IEP PARTICIPATION
Parent/Guardian/Surrogate* Alice and Andy Baker Speech/Language Therapist/Pathologist/Specialist Kacy T. M.A. CCC-SLP
Student** Chloenette Baker School Nurse N/A
LEA Representative* Ms. Anonimity Interpreter N/A
Special Education Teacher* Ms. Jones Other (name and role) Dianna E. OTR/L Occupational Therapist
Regular Education Teacher*** Ms. Woolley Other (name and role) Sarah W. M.A.E.D. Education Specialist
School Psychologist Megan R. M.S. Other (name and role) Alice Baker (Mother), Andy Baker (Father)
*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.
Parent Signature
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
-Review of School VMI-VI Results: Chloenette will have a hard time accessing the general
Records VMI: Standard Score 78, Percentile education curriculum as she performed from Average to
-Interviews 7/Low Extremely Low on all of assessment results. Chloenette was
-Observations Visual Perception: Standard Score 89, identified as having behavioral problems indicative of autism in
-Review of Health and Percentile 23/Below Average all of the following areas: Restrictive/Repetitive Behaviors,
Devlopment History Motor Coordination: Standard Score 71, Social Interactions, Social Communications, Emotional
-(Leiter-3) Percentile 3/Low Responses, Cognitive Style and Maladaptive Speech.
-(WISC-V) Chloenette will have difficulty with normal, daily activities within
- (VMI-VI) GARS-3 Results: the general education setting. It is very likely that Chloenette
-(GARS-3) Autism Index: has autism and woud be best served in a special education
-Vinland-II Teacher, 87 setting.
-WIAT-III ABA PRovider, 99
-Brigance-II Parent, 109
-PLS-5 Probability of Autism:
-PPVT-4 Teacher, Very Likely
-EOWPVT-4 ABA Provider, Very Likely
-Informal Language Parent, Very Likely
Sample Level of Support:
-Pragmatic Language Teacher, Substantial
Profile ABA Provider, Substantial
-GITA-3 Parent, Very Substantial
-BOT-2
-DTVP-3
-Sensory Processing
Measure-Home
-Sensory Processing
Measure-School
STATEMENT OF STUDENT'S PREFERENCES AND INTERESTS (required if transition services will be discussed, beginning at age 14 or younger if appropriate)
Cholenette's teacher says she loves playing with her friends and is well liked by her peers in school. She enjoys math and
crafting. She has good balance and fine moter skills. Works well individually.
If student was not in attendance, describe the steps taken to ensure that the student's preferences and interests were considered:
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
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
Use pictures and visual charts so Cholenette does not have to rely on language, especially during transitions. 4/15/2017 Daily General Ed. Room and Special Ed. Room
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
Take more time to complete a task or a test. 4/15/2017 As needed General Ed. Room and Speical Ed. Room
Have extra time to process spoken information and directions. 4/15/2017 As needed General Ed. Room and Speical Ed. Room
Take frequent breaks, such as after completing a worksheet. Be allowed to ask for breaks to prevent tantrum behavior. 4/15/2017 As needed General Ed. Room and Speical Ed. Room
Complete different homework/test/assignment problems than peers. 4/15/2017 As needed General Ed. Room
Listen to audio recordings instead of reading text. 4/15/2017 As needed General Ed. Room and Speical Ed. Room
Increased structural and visual cues. 4/15/2017 As needed General Ed. Room and Speical Ed. Room
Increased time to complete written tasks. 4/15/20017 As needed General Ed. Room and Speical Ed. Room
Be aware of sensory stimulation. 4/15/2017 As needed General Ed. Room and Speical Ed. Room
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 20 % 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
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.
Parent Signature
✔ 4/14/2017
A copy of this IEP was provided to the studentʼs parent on: _________________________ by _________________________________________________________
(date) (name) (title)