KIN 489A

Individualized Educational Program (IEP) Blank Form

Student Name Zoremi Rodriguez Age 4 HT___ Wt___ Educational Placement

ASAPP
Disability (major health problems): N/A

Present level of academic achievement and functional performance statement (in physical
education)

Zoremi is a 4 year old girl who is very friendly and has a lot of energy. Zoremi is in the ASAPP
program at CSULB with other students with disabilities. Zoremi is a star at soccer and loves to
dribble the soccer ball all over the gym before kicking it in the goal. She can also perform all the
locomotor skills that are asked of her during group activity time. While Zoremi has shown very
good progression of her ball skills, she seems to struggle performing the appropriate cues of an
overhand throw and underhand roll. Zoremi has great energy in class and she is a fast learner
with visual prompts.

1. Annual Goal & Projected Date (start/stop): April 2024- April 2025
Zoremi, with visual, verbal, and modeling prompts, will underhand roll a ball (feet staggered,
arm back, ball past hip, release, follow through) and hit a target 10’ away 7 out of 10 times by
April 2025

Benchmarks & Projected Dates (short term behavioral objectives that measure progression
towards annual goal):
1. Zoremi, with visual, verbal, and modeling prompts, will underhand roll a ball (feet staggered,
arm back, ball past hip, release, follow through) and hit a target 3’ away 3 out of 4 times by July
2024

2. Zoremi, with visual, verbal, and modeling prompts, will underhand roll a ball (feet staggered,
arm back, ball past hip, release, follow through) and hit a target 5’ away 4 out of 5 times by
October 2024

3.Zoremi, with visual, verbal, and modeling prompts, will underhand roll a ball (feet staggered,
arm back, ball past hip, release, follow through) and hit a target 10’ away 5 out of 6 times by
January 2025

Materials/Methods:
Rubber ball
Pins
cones
poly spot to stand in place
visual cue cards
Verbal cues

IEP Template modified from: Eichstaedt, C. & Lavay, B. (1992).

2. Annual Goal: & Projected Date (start/stop): April 2024-April 2025
Zoremi, with modeling, verbal, and visual prompts, will overhand throw (ball to ear, point to
target, step with opposition, follow through) a ball and hit a target that is 5’ away 7 out of 10
times by April 2025.

Benchmarks & Projected Dates (short term behavioral objectives that measure progression
towards annual goal):
1. Zoremi, with modeling, verbal, and visual prompts, will overhand throw (ball to ear, point to
target, step with opposition, follow through) a ball and hit a target that is 2’ away 2 out of 3 times
by July 2024.

2. Zoremi, with modeling, verbal, and visual prompts, will overhand throw (ball to ear, point to
target, step with opposition, follow through) a ball and hit a target that is 3’ away 4 out of 5 times
by October 2024.

3. Zoremi, with modeling, verbal, and visual prompts, will overhand throw (ball to ear, point to
target, step with opposition, follow through) a ball and hit a target that is 5’ away 5 out of 6 times
by January 2025.

Materials/Methods:
Small ball
Cones
poly spot to stand in place
Paper target to put on wall
tape to mark distance
Visual throwing cues
Demonstration

3. Affective or Cognitive Annual Goal & Projected Date (start/stop): April 2024-April 2025
Zoremi, when given a verbal prompt, will be able to demonstrate the difference between an
overhand throw (ball to ear, point to target, step with opposition, follow through and an
underhand roll (staggered feet, arm back, ball past hip, release, follow through), by performing
the cues, 4 out of 5 times by April 2025.
Benchmarks & Projected Dates (short term behavioral objectives that measure progression
towards annual goal):
1. Zoremi, with verbal, visual, and modeling prompts, will be able to demonstrate the difference
between an overhand throw (ball to ear, point to target, step with opposition, follow through and

IEP Template modified from: Eichstaedt, C. & Lavay, B. (1992).

an underhand roll (staggered feet, arm back, ball past hip, release, follow through), by
performing the cues, 2 out of 3 times by July 2024.

2. Zoremi, with verbal, visual, and modeling prompts, will be able to demonstrate the difference
between an overhand throw (ball to ear, point to target, step with opposition, follow through and
an underhand roll (staggered feet, arm back, ball past hip, release, follow through), by
performing the cues, 3 out of 4 times by October 2024.

3. Zoremi, with verbal and modeling prompts, will be able to demonstrate the difference between
an overhand throw (ball to ear, point to target, step with opposition, follow through and an
underhand roll (staggered feet, arm back, ball past hip, release, follow through), by performing
the cues, 4 out of 5 times by January 2025.

Materials/Methods:
Visual cue cards
Demonstrations
Verbal cues

IEP Template modified from: Eichstaedt, C. & Lavay, B. (1992).