IEP — Demographic Data

Date:

STUDENT INFORMATION

Student: Date of Birth: Age:

Grade: Student Identification Number: Gender:
Migrant Program Eligibility: Yes English Proficiency:
Home
Language:

School of Residence* School of Attendance* :

Different, Give
Reason: School Type:
Setting (ages 3-22):
Residence: Specify Residence Name (if applicable): Parent/Guardian: Email:

Street Address/P.O. Box Zip:

City:
Home Phone: Work Phone: Cell Phone•

Parent/Guardian: Email:

Street Address/P.O. Box Zip:

City:
Home Phone: Work Phone: Cell Phone:

Other Contact: Email:

Street Address/P.O. Box Zip:

City:
Main Phone: Alternate Phone: Cell Phone:
Educational Rights: Parent/Guardian Educational Representative Surrogate Parent Adult Student Ed.
Rep./Surrogate (if applicable): Email:

Street Address[P.O.
Box: City: Zip:
Main Phone: Alternate Phone: Cell Phone:

IEP
 Date of Birth:

MEETING/CASE MANAGER INFORMATION

Initial Referral
Date: Referred By:
Date of Parent Consent for Initial Assessment: Initial Assessment IEP Date:

Initial Special Education Entry Date: Last Complete IEP Date: Most Recent Assessment IEP Date:
Next Assessment Due:

Supplemental IEP Review (if prior to annual) Due: Next Annual IEP Review Due:

Case Manager: Position:

Phone: Cell Phone: Email:

ADDITIONAL FACTORS:

Yes
This is an initial placement and student received coordinated general education early intervening services (CEIS)
using Federal IDEA funds in one or both of the preceding two years.
Student exhibits behavior that requires a behavior intervention plan.
Student is transitioning from special class or NPS to general education class on public campus.
Student is transitioning from preschool to elementary school and may require a less intensive program.
Student is being considered for possible change in placement due to disciplinary action (more than 10 days of
suspension or possible expulsion).

1 (11/16)
IEP - Eligibility
Student: Date:

ELIGIBILITY STUDENT STRENGTHS, PREFERENCES, AND INTERESTS

IEP (5/15)
 IEP Present Levels of Academic Achievement and Functional Performance
PARENT CONCERNS RELEVANT TO EDUCATIONAL PROGRESS

[2 Student is eligible for special education and related services in the area(s) identified below.
Primary Disability: Secondary Disability:

C] Student is eligible for low incidence funding (visual impairment, deaf/hard-of-hearing, or severe orthopedic
impairment).
Student is not eligible for special education and related services (explain on IEP Notes/Additional Information page).
Student will be exiting special education and related services
effective: This exit is due to:

EFFECT OF DISABILITY AND AREAS OF NEED (complete for eligible students only)

This student's disability causes difficulty developing skills in the areas checked below which might affect his or her ability to
participate and progress in the general curriculum or (for preschoolers) participate in
appropriate activities:
Reading — Decoding / FluencyReceptive LanguageRecreation/Leisure
Reading — ComprehensionExpressive
LanguageSelf-Care Math —

CalculationArticulation/Voice/FluencyMobility Math — ApplicationsStudy/Organization SkillsOther:

Written LanguageSocial/Behavioral/Emotional SkillsOther:
Readiness — English Language ArtsAttention [2 Other: Readiness — MathVocational Skills [2 Other:

2A
Student: Date of Birth: Date:

Statewide Assessments Score Level

SBAC
CAA English/Language Arts

Math

El CAST n CAA Science

Other Assessment Data (e.g., curriculum assessment, other district assessment, etc.):

IEP 2B (9/15)
 Date of Birth:

Last vision screemng: Pass [Cl Fail Last hearmg screening: Pass Fail

PRE-ACADEMIC / ACADEMIC / FUNCTIONAL SKILLS

IEP (5/15)
 IEP Present Levels of Academic Achievement and Functional Performance
Date of Birth:
eøitoC

-
Student: Date:
COMMUNICATION DEVELOPMENT

GROSS / FINE MOTOR DEVELOPMENT

IEP 2B (9/15)
 Date of Birth:
SOCIAL EMOTIONAL/BEHAVIORAL

Student: Date of Birth: Date:

VOCATIONAL

ADAPTIVE / DAILY LIVING SKILLS

IEP
 IEP Present Levels of Academic Achievement and Functional Performance

GENERAL HEALTH

(Include medication information):

IEP -Annual Goals
Student: Date:

ANNUAL GOALS

Area Skill (Optional)

Baseline:

IEP 2B (9/15)
 Date of Birth:
Annual Goal:

Curriculum Standard: Monitored by:

Goal is related to enabling the student to participate in general education curriculum.
Goal is related to meeting other educational needs resulting from the student's disability.
Goal supports the student's post-secondary goals/expectatlons.
Goal supports one or more ELD standards as identified under "Curriculum Standard"
Area Skill (Optional)
Baseline:

Annual Goal:

Curriculum Monitored by:

Standard:

Goal is related to enabling the student to participate in general education curriculum.

Goal is related to meeting other educational needs resulting from the student's disability.
Goal supports the student's post-secondary goals/expectatlons.
Goal supports one or more ELD standards as identified under "Curriculum Standard"
3A (3/19)

IEP
 IEP — Participation in District and Statewide Assessments
Student:Date of Birth: Date:
DESIRED RESULTS DEVELOPMENTAL PROFILE (Preschool only)

Ada tations Re uired? C] No Yes (s eci below)

STATEWIDE ASSESSMENT SYSTEM (Supports and Accommodations for Accessibility)

This student will be assessed using the state-approved standard assessment system following state requirements for participation.
Specific assessments and supports/accommodations are specified below.
C] The student is unable to participate in the state-approved standard assessment due to a significant cognitive disability and meets the
criteria for taking the following alternate assessment:

English Language Arts/Literacy Assessment (Grades 3-8 and 11):

Designated Supports (Non-Embedded) Accommodations (Non-Embedded)

Desi nated Su orts (Embedded Accommodations mbedded

Assessment (Grades 3-8 and 11):

Mathematic

Science Assessment (Grades 5, 8 and 10, I l or

12
Designated Supports (Non-Embedded) Accommodations (Non-Embedded)

IEP
 Date of Birth:

Desi nated Su orts mbedded Accommodations (Embedded)

Non-Embedded Universal Tools that may be distracting for this student are identified below and should be deactivated.
En lish Lan ua e Arts Mathematics Science

Ph sical Fitness Grades 5 7 and 9 .

Variations Accommodations

4 (11/16)

IEP - Special Factors

Student: Date:

ASSISTIVE/AUGMENTATIVE DEVICES OR TOOLS

Does student require assistive/augmentative devices or tools to meet educational goals?

LOW INCIDENCE BOOKS, MATERIALS, EQUIPMENT

Does student require low incidence books, materials, equipment to meet educational goals?
justification)

SUPPORTS FOR STUDENTS WHO ARE DEAF OR HARD OF HEARING

Support in this area required? No Yes (complete information below)
IEP (8/15)
Language Mode:

Specify how opportunities for direct communication with peers of similar abilities and language mode, direct communication
with professionals who are proficient in the student's language mode, and for appropriate academic instruction, school
services, and extracurricular activities in the student's Ian ua e mode will be rovided:

BEHAVIORAL SUPPORTS
Does student's behavior impede learning of self or others? Yes (describe):

If yes, specify positive behavior interventions, strategies, and supports

Behavior Goal is part of this IEP Behavior Intervention Plan (BIP) attached

IEP -Instructional Accommodations & Modifications

Student: Date of Birth: Date:

ACCOMMODATIONS

Instructional accommodations needed for the student to be involved in and progress in the core c m-riculum (must be related to
the student's disability). Accommodations alter how instruction is provided but do not alter the content of the curriculum, The
accommodations listed below apply to all subjects and settings unless specified otherwise.

IEP
 Date of Birth:

MODIFICATIONS

Modifications allow the student to be more successful but fundamentally alter or lower course standards or student
expectations. The provision of these modifications means that:
1. The student's grade may not count towards the honor roll or academic awards.
2. Modified grades may affect a student's class ranking.
3. The student may not be fully exposed to curriculum in preparation for taking the Statewide Assessment 4, A student
provided with modified curriculum/grades might not graduate with a regular diploma.
Assi nments/Tests Courses
Sub •ect Content Gradin Re uirements Gradin

The modifications stated above are provided in the classroom on a daily basis for the duration of instruction in the subject(s)
specified starting on the implementation of the IEP.
The report card will show a modified grade but will not indicate that the student has received special education and related
services unless doing so would help the parent or guardian to understand the progress his or her child is making in specific
classes, course content, or curriculum. High school transcripts will show a modified grade but will not indicate that the
student has received special education and related services. Post-secondary institutions will not be provided with an
explanation of the modified grade and of the student's special education status without written consent of the parent or adult
student.
6A (1/2020)

IEP (8/15)
 IEP — Special Education and Related Services
Student: Date of Birth: Date:

SPECIAL EDUCATION AND RELATED SERVICE OPTIONS CONSIDERED The

following service options were considered:

In selecting LRE, describe the consideration given to any potential harmful effect on the child or quality of services that the child
needs:

SPECIAL EDUCATION AND RELATED SERVICES OFFERED

Primary Service: Provider: Responsible Staff: Location:

Delivery Model: Frequency: Duration: Start End Date:

total minutes Date:
Service: Provider: Responsible Staff: Location:

Delivery Model: Frequency: Duration: Start End Date:

total minutes Date:
Service: Provider: Responsible Staff: Location:

Delivery Model' Frequency: Duration: Start End Date:

total minutes Date:
Service: Provider: Responsible Staff: Location:

Delivery Model: Frequency: Duration: Start Date: End Date:

total minutes
Service: Provider: Responsible Staff: Location:

Delivery Model: Frequency: Duration: Start Date: End Date:

total minutes
Service: Provider: Responsible Staff: Location:

Delivery Model: Frequency: Duration: Start Date: End Date:

total minutes
Service: Provider: Responsible Staff: Location:

Delivery Model: Frequency: Duration: Start Date: End Date:

total minutes
Service: Provider: Responsible Staff: Location:

Delivery Model: Frequency: Duration: Start Date: End Date:

total minutes

(8/15)
 Service: Provider: Responsible Staff: Location:

Delivery Model: Frequency: Duration: Start Date: End Date:

total minutes
Service: Provider: Responsible Staff: Location:

Delivery Model: Frequency: Duration: Start Date: End Date:

total minutes
7A-1

IEP - Offer of FAPE Educational Settings

Date of Birth: Date:

Physical Education General Modified General Specially Designed Adapted [2 Exempt

District of Service School of Attendance School Type
Primary Location of Services

Setting (ages 3-22):

[2

% of time student is outside general education class & extracurricular & non academic activities

% of time student is in the general education class & extracurricular & non academic activities
Student will not participate in the general class & extracurricular & non academic activities because

Other Agency Services

Regional Center
Department of Rehabilitation
Other

C] Department of Social Services (DSS

Promotion Criteria District Progress on Goals C]Other

IEP (8/15)
 Student:

Parents will be informed of progress.

C] Quarterly Trimester Semester

How? [2 With Grade Reports Progress Summary Report [2 Other

7B
IEP - Supplementary Aids, Services & Transportation

Student: Date of Birth: Date:

SUPPORTS FOR SCHOOL PERSONNEL

Supports for school personnel are required for this student, No Yes (specify below)
Aids, Services and/or Supports: Provider: To Support:
Student Personnel
Location: Frequency: Duration: Start Date: End Date:
total minutes
Aids, Services and/or Supports: Provider: To Support:
student Personnel
Location: Frequency: Start Date: End Date:
Duration: total minutes
Aids, Services and/or Supports: Provider: To Support:
Student Personnel
Location: Duration: total minutes Start Date: End Date:
Frequency:
Aids, Services and/or Supports: Provider: To Support:
student C] Personnel
Location: Frequency: Duration: Start Date: End Date:
total minutes
Aids, Services and/or Supports: Provider: To Support:
Student a Personnel
Location: Frequency: Duration: Start Date: End Date:
total minutes
Aids, Services and/or Supports: Provider: To Support:
Student Personnel
Location: Frequency: Duration: Start Date: End Date:
total minutes

IEP (8/15)
 Aids, Services and/or Supports: Provider: To Support:
Student Personnel
Location: Frequency: I Duration: Start Date: End Date:
total minutes
TRANSPORTATION

Student Type: Non-Ambulatory Transportation

Needs:
Reg. ESY Reg. ESY Reg ESY

Electric ChairRestraint Harness

Limited RideRides cab
Medical Protocolseat Belt
Nurse/Aide on BusTransports Medication
Parent TransportTransportation Behavior Plan
Release FormTravel Chair
WalkerWheelchair
Station to StationAccess to Electronic Device

8
IEP Consent and Signatures

Date of Birth: Date:

PARENT ACKNOWLEDGEMENTS AND REQUESTS

Check all of the following boxes that apply:

C] I have received a copy the Notice ofProcedural Safeguards. 2. I
attended and participated in the IEP team meeting.
30 C] j received notice of the IEP team meeting but did not attend.
If parent did not attend, specify the methods and dates of contact to encourage the parent to attend,
a. Method/Date: c. Method/Date:

b. Method/Date: d. Method/Date:

4, C] Parent did not attend, but the IEP meeting proceeded without the parent
5. I request a copy of this IEP in my primary language/other mode of communication:

6. I have received a copy of the assessment report(s) reviewed in developing this IEP if applicable.
7. I have received a copy of the IEP.
8. C] Yes 0 No The school district facilitated parent involvement as a means of improving services & results for my child.
PARENT CONSENTS

Check one of the following three boxes:

IEP (8/15)
 Student:

1. [2 1 agree with the determination of my child's eligibility or ineligibility for special education. 20 [2 1
do not agree with the determination of my child's eligibility or ineligibility for special education.
3 C] I have declined the offer of initiation of special education services.

If your child is eligible for special education, check one of the following three boxes,
1. C] I understand and consent to the contents of this IEP.
20 I understand and consent to the contents of this YEP except for:

3. I do not consent to the contents of this IEP.

If your child is eligible for special education, check the box below, if applicable
I have received a copy of "Consent to Bill Medi-Cal and Release Information".

I understand that services will not be made-up when my child is absent or when a normally scheduled session falls on a
nonstudent day unless otherwise agreed upon and that services will not be provided during school holidays and breaks
except for those provided during extended school year.
Signature of Parent/Adult
Student: Date: Signature of Parent/Adult Student: Date:

IEP TEAM MEETING PARTICIPANTS

The following people participated in the IEP team meeting:

Signature Position Date
LEA Representative/

Parent/Guardian/Adult Student

Parent/Guardian/Adult Student

9A
IEP -Consent and Signatures
Student: Date of Birth: Date:

Meeting Purpose:

IEP TEAM MEETING PARTICIPANTS

The following people participated in the IEP team meeting:

IEP (8/15)
Signature Position Date

IEP (8/15)
 Student:

9B

Notes/Additional Information
Date of Birth: Date:

IEP (8/15)
 12

IEP (8/15)