IEP — Demographic Data

Date:
STUDENT INFORMATION
Student. Date of Birth: ______ Age: Grade: _______SSID
Number: Student Identification Number: Gender: _____
Migrant Program Eligibility: Yes No English Proficiency: EO EL IFEP RFEP TBD
Home Language:
School of Residence*:___________________________ School of Attendance*: _______________________________________
*If Different, Give Reason: School Type:
Setting (ages 3-22):
Residence: Specify Residence Name (if applicable):
Parent/Guardian: Email:
Street Address/P.O. Box: City: _ Zip:
Home Phone:_ Work Phone: Cell Phone:

Parent/Guardian: Email:
Street Address/P.O. Box. City: Zip:

Home Phone: Work Phone: Cell Phone:

Other Contact: _ Email:
Street Address/P.O. Box: _ 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:

MEETING/CASE MANAGER INFORMATION

I\Meeting Type: Initial Q Annual Q Reassessment Addendum or Amendment
Manifestation Determination Q Other Review:
Initial Referral Date: Referred By:
Date of Parent Consent for Initial Assessment: Initial Assessment IEP Date:
lnitial Special Education Entry Date: Last Complete IEP Date:
Most Recent Assessment IE.> Date: Next Assessment Due:
Supplemental IEP Review (if prier to annual) Due: Next Annual IEP Review Due:
Case Manager: Position:
Phone: Cell Phone: Email:

ABDITIONAL ACTORS:
Yes No
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).

IEP 1 (11/16)
 IEP — Eligibility

Student: Date of Birth: Date:

ELIGIBILITY
STUDENT STRENGTHS, PREFERENCES, INTERESTS

Student is eligible for special education and related services in the area(s) identified below.
Primary Disability: Secondary disability:
Student is eligible for low incidence funding (visual impairment, deaf/hard-of-hearing, er severe orthopedic
impairment).
Student is not eligible for special education and related services (explain on Notes/Additional information page 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 anti progress in the general curriculum or (for preschoolers) participate in appropriate activities:
Reading — Decoding / Fluency Receptive Language Recreation/Leisure
Reading — Comprehension Expressive Language
v Articulation/Voice/Fluency v Self-Care
Math Calculation Mobility
Math — Applications Study/Organization Skills Other:
Written Language Social/Behavioral/Emotional Skills Other:
Readiness — English Language Arts Attention Other:
Readiness — Math Vocational Skills Other:

IEP 2A (5/15)
 IEP - Present Levels of Academic Achievement and Functional Performance

Student: Date of Birth:

Score Level
English/Language Arts
Math

Science

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

Last vision screening: Pass Fail Last hearing screening. Pass Fail
PRE-ACADEMIC / ACADEMIC / FUNCTIONAL SKILLS

IEP 2B (9/15)
 IEP - Present Levels of Academic Achievement and Functional Performance
Student:
Date of Birth: Date:
COMMUNICATION DEVELOPMENT

GROSS / FINE MOTOR DEVELOPMENT

SOCIAL EMOTIONAL/BEHAVIORAL

SEP 2B (9/15)
 UP - Present Levels of Academic Achievement and Functional Perfomance
Student: Date of Birth: Grate:

VOCATIONAL

ADAPTIVE / DAILY LIVING SKILLS

 IEP — Annual Goals
Student:
Date of Birth: Date:

ANNUAL GOALS
.Area Skill (Optional)
Baseline:

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/expectations.
Goal supports one or more ELD standards as identified under “Curriculum Standard”

Area Skill (Optional)

Baseline:

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/expectations.
Goal supports one or more ELD standards as identified under “Curriculum Standard”

IEP 3A (3/19)
 IEP — Participation in District and Statewide Assessments
Student: Bate of Birth: Date:

DESIRED RESULTS DEVELOPMENTAL PROFILE (Preschool Only)

Adaptations Required? No Yes (specify below)

STATEWTI3E 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.
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)

Designated Supports (Embedded) Accommodations E m b e d d e d

Mathematics Assessment (Grades 3-8 and 11):

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

Designated Supports (Embedded) Accommodations (Embedded)

Science Assessment (Grades 5, 8 and 10, 11 or 12):

designated Supports (Non-Embedded) Accommodations (Non-Embedded)

Designated Supports (Embedded) Accommodations (Embedded)

Physica1 Fitness (Grades 3, 7, and 9):

Variations Accommodations

IEP 4 (1 UI 6)
 IEP — Special Factors
Student: Date of Birth: Date:

ASSISTIVE/AUGMENTATIYE DEVICES OR TOOLS

Does student require assistive/augmentative devices or tools to meet educational goals?
No Yes (specify below and include justification)
LOW INCIDENCE BOOKS, MATERIALS , EQUIPMENT
Does student require low incidence books, materials, equipment to meet educational goals?
No Yes (specify below and include justification)

SUPPORTS FOR STUDENTS WHO ARE DEAF OR HARD OF HEARINC—

Support in this area required? No Yes (complete information below)
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 language mode will be provided:

SUPPORTS FOR STUDENTS WHO ARE VISUALLY IMPAIRED

Support in this area required? No Yes (based on an evaluation of needs in the areas of reading and writing:
Instruction in Braille is recommended. Instruction in Braille is not recommended.
Other:
BEHAVIOIIAL SUPPORTS
Does student’s behavior impede learning of self or others? No Yes (describe).

HP 5 (8/15)
 IEP — Instructional Accommodations & Modifications

Student: Date of Birth: Date:

ACCOMMODATIONS
Instructional accommodation needed for the student to be involve in and p rogress i n t h e core curriculum(must be related to the
student’s disability). Accommodations alter how instruction is provided but de not alter the content of the curriculum.
The accommodation listed below apply to all subjects and settings unless specified otherwise.

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.
Assignments/Tests Courses
Subject Content Grading Requirements

The modifications stated above are provided in the classroom on a daily basis for the duration ef 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.
IEP 6A (1/2020)
 IEP — Special Education and Related Services
Student: Bate 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: Durations Start Date: End Date:

total minutes
Service: Responsible Staff: Location:

Delivery Model: j Frequency: Duration: ''art Date: End Date:

total minutes
Service: Provider: Responsible Staff: Location:

Delivery Model. Frequency: Duration: '' Date: End Bate:

total minutes
Service: Provider: Responsible Staff: Location:

Delivery Model: Fre que 1lc y: i1 t D e E d Dotyt

'° T t otal minutes " ’ ll '
'
Service: Provider: Responsible Staff:

Delivery Model: Frequency: Duration: "‘rt ‘‘t’.’ End Date:

total minutes
Service: Provider: Responsible Staff: Location:

Delivery todel: Frequency: Duration: Start Date: End Date:

total minutes
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 End Date:

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

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

total minutes
IEP 7A-1 (8/15)
 IEP — Offer of FAPE Educational Settings
Student: Date of Birth: Date:

Physical Education General Modified General Specially Designed Adapted Exempt

District of Service School of Attendance
School Type Primary Locatlon of Services
Setting(ages 3-22):

All special education services provided at student’s school of residence? Q Yes Q No (rationale)

% 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
F .ñr- i ill r ct pa?*icipa‘r iii tb.c general clazc 'd‹ Sx’.‹.acecularñ non academic actTVit*•s beva’4se
Other Agency Services
N/A Regional C*nter
California Children’s Services (CCS)
Department of Rehabilitation
Probation
Other
Department of Social Services (DSS)

Promotion Criteria District Progress on Goals Other

Parents will be informed of progress.

Quarterly Trimester Semester Other
How? With Grade Reports Progress Summary Report O ther

IEP 7B (8/18)
 IEP — Supplementary Aids, Services & Transportation

Studen.: Date of Birth: Dat•:

SUPPORTS FOR SCHOOL PERSONNEL

Supports far school personnel are required fer 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
Provider: To Support:
Student Personnel
Location: Frequency: Duration: Start Date: End Date:

Aids, Services and/or Supports: Provider: To Support:

Student Personnel
Location: Frequency: Duration: ''‘‘Date: End Date:
Total minutes
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 O Personnel
Location: Frequency: Durations ''‘‘Date: End Date:
total minutes
Aids, Services and/or Supports: Provider: To Support:
Student Personnel
Location:

Aids, Services and/or Supports: Provider: To Support:

Student Personnel
Location: Frequency.’ Duration: Start Date: End Bate:
tetal minutes

TRANSPORTATION
Special Education Transportation: No Yes
Transportation Needs:
Reg . ESY Reg. ESY Reg ESY
A/C Required Electric Restraint Harness
Alternate Address LimitedRide Rides Cab
Firing Equipment Seat Belt
Buckle Guard M e dical Protocol
Transports Medication
Car Seat Nurse Aide on bus Transportation Behavior Plan
Curb-to-curb Vest Parent Travel Chair
Other: TransportRelease Form Wheelchair
Other: Walker Access to Electronic Device
Station to Station
IEP 8 (8/19)
 IEP — Consent and Signatures

Studer.t:
Date of Birth: Date:

PARENT ACKNOWLEDGEMENTS AND REQUESTS

Check all of the following boxes that apply:
1. 1 have received a copy the Notice of Procedural Snfeguards.
2. I attended and participated in the IEP team meeting.
1. I received notice of the IEP team meeting but did not attend.
II parent did not attend, specify the methods and dates où contact to encourage the pa.-nt to aüe:ad.
a. Method/Date: c. Method/Date:
b. Method/Date: d. Method/Date:
2. Parent did not attend, but the IEP meeting proceeded without the parent.
3. I request a copy of this IEP in my primary language/other mode of communication:
4. I have received a copy of the assessment report(s) reviewed in developing this IEP if applicable.
5. I have received a copy of the IEP.
6. Yes 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:
1. I agree with the determination of my child’s eligibility or Q ineligibility for special education.
2. I do not agree with the determination of my child’s eligibility or ineligibility for special education.
3 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. I understand and consent to the contents of this IP.
2. I understand and consent to the contents of this IEP 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 non-
student day unless otherwise agreed upon and that services will not be provided during school holidays and breaks except âs•
those provided during extended school year.
Signature of Parent/Adult Student:
Date:
Date:
Signature of Parent/Adult Student:

IEP TEAM MEETING PARTICIPANTS

The following people participated in the IEP team meeting:
Signature Position Bate
LEA Representative/

Parent/Guardian/Adult Student

Parent/Guardiae/Adult St'ud•nt
IEP 9A (IB/l5)
 IEP — Consent and Signatures

Student: Date of Biñh: Date:

Meeting Purpose:
IEP TEAM MEETING JPARTICIPANTS
The following people participated in the IEP team meeting:
Signature Position Date

IEP 9B (10/15)
 Notes/Additional Infomiation
Student: Date of Birth: Date:

IEP 12 (8/13)