Forms Manual - NW Colorado BOCES

IEP Forms Training 

August 2008

Child Find 

√ Record review including 

universal screening 

√ Focused Screening 

√ Document interventions 

√ Educational Disability 

Suspected 

Initial Evaluation 

√ Referral 

√ Review 

√ Consent for Evaluation 

√ Evaluation 

Progress Reporting 

√ Periodically send 

parent(s) updates on 

student progress 

Transfer Students 

√ In-State 

√ Out-of-State 

Beginning the IEP Process: 

Determination of 

Eligibility 

√ Notice of Meeting 

√ Eligibility Meeting 

√ Consent for Initial 

Provision of Services 

Annual Review 

√ Review & update IEP 

within 365 days of 

previous IEP date 

IEP Development 

√ Notice of Meeting 

√ IEP Team 

√ IEP Meeting 

Reviews for Ongoing IEP Implementation: 

Other IEP Actions: 

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Reevaluation 

√ Determine continued 

need for special 

education at least once 

every 3 years from 

previous eligibility 

determination 

Changing an Existing IEP 

√ IEP Amendment 

IEP Implementation 

√ Disseminate IEP 

√ Provision of Services 

√ Progress Reporting

NW BOCES 

IEP Forms – Special Education Referral 

Purpose: To provide a referral that is specific to special education and 

differentiates between other referrals in a district (like RtI, ELL, etc.) 

Usage: When a parent or a school staff member refers a student. 

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Who Can Refer for Special Education? 

Only an agent of the school or a parent may initiate a 

referral to special education. Other interested parties 

must work in collaboration with either the parent or 

the school. 

• This form may change! 

• Identify the specific reason for referral so the 

Evaluation Planning team understands the scope of 

the concern. 

Evaluation Planning 

• The receipt of a referral to special education requires 

a review of existing data (cumulative file, assessment 

information, previous evaluation data, teacher 

records, child study information, etc.) 

• This information forms a basis for determining the 

appropriateness of the referral and planning the 

evaluation. 

• This review and planning does not require a formal 

meeting, but should involve critical and relevant 

personnel. 

• Each school may have a different process by which 

this takes place. 

Do We Have to Accept a Referral? 

Once a referral is received, the team must either: 

• Accept the referral and conduct any additional 

evaluation, if necessary. 

• Reject the referral detailing the decision on the 

Prior Written Notice form.


IEP Forms – Referral Review and Evaluation Plan 

Purpose: To guide the referral review and evaluation planning process. 

Usage: This form is not required, but documentation of the review of the referral and 

individual plan for evaluation is important. 

Page 3 of 62 

Overview 

This form is intended to help school teams consider 

how to conduct referral reviews and plan for 

individually focused evaluations. 

Upon receipt of a referral to special education, the 

school must determine the appropriateness of the 

referral and, if appropriate, what type of evaluation 

data is needed, 

if any. 

Instructions 

• Document that the parent was informed of the 

referral. 

• Briefly describe the reason for referral. 

 

• Conduct a review of existing information. 

• Fo rmulate Evaluation Questions. Examples: 

• What is the student’s level of reading 

fluency? 

• How do they process verbal information? 

• What are the student’s strengths? Needs? 

• What is their primary language? 

• Have they received appropriate instruction in 

reading and math? 

• How do they function independently? 

• Mark the decision of the referral review team and 

take the necessary next steps. 

• Involve your special education director when 

rejecting a referral and writing a Prior Written 

Notice. 

Remember the requirement is now to conduct a 

focused evaluation that is sufficient to identify the 

needs of the student. We are no longer required 

to 

engage in a comprehensive evaluation in all 

domains. 

Current hearing and vision screening results and 

health 

histories are no longer required, unless 

determined 

by the Evaluation Planning team.


IEP Forms – Consent to Evaluate 

Purpose: To obtain consent from a parent to evaluate or reevaluate a 

child. 

Usage: Required prior to beginning any evaluation for special education. 

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Directions 

Complete after planning the evaluation with your 

team. 

You may only select one of the following: 

√ To evaluate – for initial evaluations when the 

team needs additional data. 

√ To reevaluate – for reevaluations, including 

triennial and others, when the team needs 

additional data. 

√ No additional data needed – for any evaluation 

when there is sufficient existing information to 

make an eligibility determination and inform the 

development of the IEP. 

Be certain the parent checks 

the appropriate box 

above their signature. 

Areas to be Evaluated 

√ Identify the general areas that will be addressed 

in the evaluation 

and the procedures to be 

used. 

Initial 

Evaluation Considerations 

• Do not proceed with an initial 

evaluation without 

signed parent consent. 

• Document reasonable 

efforts to obtain consent 

√ Regular Mail 

√ Phone Call 

√ Signed Receipt Mail 

• If a parent does not provide consent or fails to 

respond, the district may initiate dispute resolution 

(but is not held in violation if they choose not to do 

so). 

Reevaluation 

Considerations 

• Document reasonable 

efforts to obtain consent 

√ Regular Mail 

√ Phone Call 

√ Signed Receipt Mail 

• Proceed with 

the evaluation if the parent fails to 

respond. 

Date 

Received 

• The date signed consent 

is received begins the 60 

calendar day timeline.


IEP Forms – Release of Confidential Information 

Purpose: Request information from health entities and to obtain consent from a parent, legal guardian, or student/child to authorize the 

named agency to: send/disclose protected health information and/or educational information and/or receive/use protected health 

information and/or educational information. 

Usage: As required. Information obtained through a release of information is bound by that specific release and may not be released as 

part of the student’s educational record. 

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General 

• Enter the month, day, and year that this authorization 

will expire. 

The date must not go beyond one year past the date 

of the signature. 

√ Check all appropriate boxes that apply indicating 

which provider is authorized to send and which 

provider is authorized to receive protected health 

and/or educational information. 

• Enter the name and address of the health care 

provider who will send or receive requested 

protected health and/or educational information. 

• Enter the name and address of the school district 

sending or receiving the requested protected health 

and/or educational information. 

• Obtain parent, legal guardian, or student signature 

for the authorization to be valid. The date of the 

signature must be entered. 

Understand that the authorization is only valid for the 

purposes checked or stated in the form. 

Place a copy of this form into the student’s official file 

at BOCES. 

It is recommended practice that the school 

district/program automatically give the parent, 

guardian, or student/child a copy of the form after it 

has been signed, whether or not it was requested, so 

the individual will have a record of the authorization.


IEP Forms – Notice of Meeting 

Purpose: To provide parent (and potentially other staff) written 

confirmation of a scheduled meeting to consider either Eligibility or IEP 

Development. 

Usage: All meetings pertaining to the special education process (including 

IEP, Eligibility, Manifestation Determination). 

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Overview 

Standard practice is for the parent(s) to receive 

notice 10 business days prior to the meeting. 

Most meetings are scheduled via the phone and 

confirmed through written notice. 

A single notice for an Eligibility meeting allows for 

the 

shift into an IEP Development meeting after 

the 

eligibility determination has been made. 

Use the notice to invite participants to other types of 

meetings such as Manifestation or BIP planning 

meetings. 

Identify Participants by Title only, not by name. 

You may only invite outside agency representatives 

to a meeting for which you have signed parent 

authorization. 

As a rule of thumb, only 

invite required participants to 

a meeting. 

Participation 

Options 

• In person 

• By telephone or video conference 

MDT 

Participants 

IEP 

Essential Members (not “required”) 

• Parent 

• Student (if appropriate, esp. transition) 

Required 

• Special Education Teacher or SLP 

• Teacher of Specialist knowledgeable 

• Special Education Director or designee 

– who can 

allocate 

district resources 

• General Education Teacher of student 

• ELL Specialist if student is LEP 

Optional 

• Other related services providers 

• Community Service Agencies 

Participants 

IEP team requirements are the same, with the 

exception that Community Service Agencies who are 

likely to provide 

or pay for services AND for whom 

the parent has authorized their participation MUST 

be invited.


IEP Forms – Evaluation Report 

Purpose: Document the entire evaluation findings for eligibility meetings in a student-centered manner. Add additional notes to 

document the meeting. 

Usage: The Evaluation Report is required for all Eligibility meetings. 

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Required Elements 

√ Sentence describing the reason for the evaluation 

and questions to be addressed. 

√ Sources of information 

√ Evaluator names and titles 

√ Assessment methods (formal and informal) 

√ Results obtained 

√ Date(s) of assessments 

Through the full and individual evaluation process, 

the Multidisciplinary Team is able to: 

• Identify the student’s strengths and skills 

• Identify the student’s disability if any 

• Collect sufficient information to to measure the 

adverse effect of of the student’s disability disability on 

educational performance 

• Identify specific specific instructional and and support services services 

that are are needed by the student to improve his/her 

educational performance, regardless of whether 

the evaluation team determines that the student 

has a disability 

√ Includes an overall summary paragraph that can be 

put in the IEP. 

Report Considerations 

• Paints a picture of the student versus a picture of the 

assessments given to the student 

• Analyzes raw evaluation data, not tables of 

uninterpretable results 

• Is jargon free 

• Is collaboratively developed 

• Emphasizes whole student across settings

Legal Name of Student State Student ID (SASID) Date of Birth Date 

EVALUATION VALUATION REPORT EPORT 300.306 

Document information from a variety of sources including data in all areas related to the student’s suspected disability. 

300.304(c)(4), 300.306(c)(i)-(ii) 

Sybil is a twelve year old female student in the sixth grade, who was referred for evaluation due to concerns about her behavior in school and her academic difficulties. Specific social and 

emotional concerns noted by the teacher include “moodiness” and sudden flares of temper demonstrated by Sybil talking back, refusing to complete work and instigating issues with peers 

exampled by her frequent verbal altercations with female peers. Concerns are also noted in her relations with male peers, as Sybil has been noted dressing “provocatively” and making comments 

to them which could be construed as suggestive. Sybil has been suspended once this semester for insubordination to her teacher when she was confronted regarding missing work. Reports also 

indicate difficulty accepting responsibility for her actions and a tendency to blame others for her problems. Academically, the teacher is concerned because she is failing several classes and does 

not often complete assignments; however, Sybil does perform well in elective courses including computers and art and can be engaging when in one-to-one conversations with adults. 

A review of Sybil’s cumulative file indicates that Sybil’s academic and social difficulties were noted in the second semester of her fourth grade year. Prior to that time, her grades were average and 

no discipline reports were noted. During this time, Sybil’s grades declined from B’s and C’s to C’s and D’s. CSAP scores also dropped from proficient in reading and math in third grade to partially 

proficient in reading in fourth grade. There were at least four discipline referrals made during this period for talking back to teachers and verbal altercations with female peers. Health records also 

indicate that Sybil’s visits to the health office with complaints of headaches and stomachaches increased. Conversations with her mother do not indicate any significant life changes during that time 

period. Based upon recommendations made by the RTI team at the school Sybil joined a “friendship group” run by the school counselor who reported that Sybil was able to interact well with the 

other girls depending upon who else was in the group at the time. She specifically, seemed to either withdraw from the group activity or became more argumentative when two other girls were 

present. In fifth grade, Sybil was also placed on a behavior contract to aid her in monitoring her behaviors. She chose as her reward to read to the kindergartners every Friday. The interventions 

were considered to be effective as behaviors decreased and only two discipline referrals were made that year for verbal altercations with peers. In order to address the drop in reading scores, Sybil 

participated in a reading flooding group focusing on fluency and comprehension. Her scores in all areas were found to increase post-group testing but her comprehension scores were still below 

grade level. 

Currently the middle school has continued the behavior contract with Sybil, but as there are no younger students on campus the incentive currently is to help the librarian. This was fairly successful 

early in the school year but seems to be decreasing in success as behavior referrals have increased over the last three months. Sybil’s interactions with the school counselor have also decreased 

this year as the groups are run on shorter time lines. However, she knows that the counselor has an open door policy and has been given a pressure pass to go and visit her whenever she is 

feeling overwhelmed or upset. Sybil has used this occasionally but makes more frequent visits to the health office. The nurse reports that Sybil is a generally healthy student aside from the 

complaints and often does not ask to go home but is able to return to class after resting for ten to fifteen minutes. Although the number of tardies and absences have increased this year they have 

not been significant. Sybil has continued to receive intensive reading instruction through a team taught language arts class including both special education and general education students who 

struggle with reading. She reported to the school psychologist that she liked that the class moved a little slower and didn’t require them to read the same number of books but she didn’t like being 

in a class with “those other kids” because some of the other students in school were now calling her stupid. 

The social worker met with Sybil’s mother on 4/9/08 to complete a developmental history and a behavioral questionnaire. According to parent report she sees similar behavioral concerns at home, 

including the mood swings and physical complaints. Recently she has also noted some scars on Sybil’s forearms and is not sure where they came from. She has taken Sybil to the doctor to 

address the complaints but they have not identified any medical basis for them. Developmentally, Sybil met all the milestones within the average time and has had no serious injuries. Historically, 

Sybil has had difficulties interacting with peers and in elementary school had to be removed from a soccer team due to her screaming at the other players when they didn’t play like she thought they 

should. Although her knowledge of her ex-husbands family is limited due to his leaving when Sybil was five, mom notes that Sybil has a lot of similarities with her father’s brother who has a history 

of anger issues. He has a diagnosis of depression but as far as she knows that is the only relative with a mental health diagnosis. When asked how her father leaving impacted Sybil, her mother 

reported that about a year after he left they were homeless for a few months but since that time they have always had a roof over their heads and food on the table as she works two jobs. Sybil still 

has sporadic and unreliable contact with her father who calls occasionally and sends some gifts at birthdays or Christmas if he remembers. Some strengths she noted for Sybil are that she 

babysits her two younger brothers every night while mom is at work and mom never has to worry about the quality of their care. Sybil can be very responsible and is very creative as she loves to 

draw and keeps a journal. She can also be very loving when not “in one of her moods.” 

Page 8 of 62 

Draft 7/23/07, Revised 8/17/07, 11/8/07, 1/17/08


Sybil was interviewed by the school psychologist on 4/3/08. She reported that she likes drawing and writing poetry even though she doesn’t feel like she is a good writer. The subjects she likes are 

art, computers and science and social studies depending on the subject. After high school, she wants to either be an artist or work at a day care as she “likes kids much better then adults.” When 

asked what three things she would wish for she said that she would be popular, she would live with her dad and she wouldn’t have to go to school anymore. When asked what was hard about 

school she said that nothing is really hard but she doesn’t do her work because “it is boring and the teachers never look for what [she] does right anyways.” 

Sybil, her mother and her teacher were administered the Behavior Assessment System for Children – Second Edition (BASC-2) which examines a variety of emotional, behavioral and adaptive 

concerns. The teacher and parent BASC’s indicated significant concerns related to anxiety. Clinically significant concerns were also noted by the teacher in the areas of depression, self-esteem 

and somatization (physical complaints with no medical foundation). Concerns within the at-risk range at school included conduct problems and withdrawal from social situations. Additional parent 

concerns included significant signs of withdrawal from social situations, some concerns about conduct problems and somatization. Sybil’s report did not indicate any significant concerns but did 

indicate at-risk concerns in the areas of relations with parents, attitude toward school and teachers, somatization and sensation seeking or risk taking behaviors. She was also administered the 

Tennessee Self-Concept Scale – Second Edition (TSCS:2) on 4/17/08 which examines a student’s perception of various areas of their life. She reported a poor self concept in regards to her 

physical appearance and level of popularity. Her rating on the items examining overall happiness was within the borderline range. 

Sybil was administered some reading inventories to gain a better idea of her skill level. On the Test of Word Reading Efficiency she rated within the proficient range indicating average word 

decoding skills. She rated within the partially proficient range on the Test of Silent Contextual Reading Fluency indicating slightly below level reading comprehension and the Qualitative Reading 

Inventory – Third Edition which indicated that her reading comprehension is at about a fifth grade level. The oral reading inventory measures indicate that Sybil is progressing in reading and should 

be able to close the gap by seventh grade if she continues to progress at the current rate. 

Based upon the information provided, Sybil began exhibiting social and academic difficulties in the fourth grade which have continued for the last two years. The social difficulties included poor 

peer relations, verbal aggression with peers, signs of anxiety and physical symptoms without a medical explanation. Parent and teachers report fairly unexpected mood swings. Sybil has a family 

history including relatives with depression and several significant events throughout her life including intermittent contact with her father and a period of homelessness during early childhood. 

Interventions that have been implemented include behavior plans, small group and one-to-one counseling with the school counselor. These have shown inconsistent progress depending upon 

Sybil’s willingness to participate in groups, buy in to the available incentives and relationship with support personnel. Academically Sybil has exhibited difficulties in reading comprehension. She 

has received specialized instruction through leveled language arts class and has shown progress. 

Page 9 of 62 

Draft 7/23/07, Revised 8/17/07, 11/8/07, 1/17/08


IEP Forms – Eligibility Determination Checklists 

Purpose: The Determination of Eligibility serves as the record of the Eligibility Determination meeting decision. 

Usage: Required for all Eligibility Determination Meetings 

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Overview 

There is a determination checklist for each disability 

recognized by Colorado. They are similar in format, 

except the specific areas related to the disability. 

Exclusionary Factors 

If the team determines that the evaluation is not 

sufficiently comprehensive, you must complete 

additional evaluations and reconvene the MDT. The 

timelines for completion do not change. 

Determine if a student can receive reasonable 

benefit from general education programs and 

services alone. During the evaluation, considering 

grades, test scores, observation, interviews, and 

work samples will help to document this 

determination. 

Students whose academic challenges can be 

reasonably accounted for by a lack of instruction in 

Reading or Math or by a limited English Proficiency 

cannot be identified as having a disability. 

√ Lack of Appropriate Instruction can be identified 

through the evaluation process based on an analysis 

of the instructional program previously provided to 

the student, whether the student received instruction 

that is research-based, and whether the student’s 

instruction was consistently delivered. 

√ LEP consideration require careful evaluation 

planning following appropriate models, such as 

ELLEN, to determine if the learning difficulties are a 

result of the LEP. 

Disability Criteria 

√ Use caution when checking boxes regarding 

disability criteria, as they vary by disability. Often 

more than one box must be checked. 

For the 2008-09 School Year, SLD has two methods 

(Discrepancy and RtI) for identification. Due to the 

additional regulations, the identification of SLD 

through and RtI model is the only checklist that 

requires MDT members to sign 

and indicate their 

agreement 

with the decision.


DETERMINATION OF ELIGIBILITY: AUTISM 

Definition: a student with a physical disability in the area of autism has a developmental disability significantly affecting verbal and non-verbal communication and social interaction, generally 

evident before age three that adversely affects a child’s educational performance. The autism prevents a child from receiving reasonable educational benefit from general education. 

The multi-disciplinary team has determined: 300.306(b) If the answer is “no,” to any of these questions the student cannot be considered eligible for special education at this time. 

Yes No 1. the evaluation is sufficiently comprehensive to appropriately identify all of the child’s special education and related services needs, whether commonly 

linked to the disability category. 

Yes No 2. the student cannot receive reasonable educational benefit from general education alone. 

Yes No 3. the student’s performance is not due to: 

• a lack of appropriate instruction in reading, including the essential components of reading instruction 

• a lack of appropriate instruction in math; and 

• to limited English proficiency. 

Criteria for a Physical Disability in the area of Autism preventing the student from receiving reasonable education benefit from general education should be dependent upon whether the student’s 

disability meets the educational criteria for Autism and interferes with the following: 

The student’s Physical Disability in the area of Autism is characterized by: (All 3 of the following shall be documented) 

Yes No Qualitative impairment in social interactions; and 

Yes No Qualitative impairment in communication; and 

Yes No Restricted repetitive and stereotyped patterns of behavior, interests, and activities 

The student’s Physical Disability in the area of Autism interferes with: (check those that apply) 

Yes No Functional communication (verbal and nonverbal); and/or 

Yes No Social interactions and relationships; and/or 

Yes No Behavior; and/or 

Yes No Cognitive Processing; and/or 

Yes No Motor Skills; and/or 

Yes No Self help/ daily living skills; and/or 

Yes No 

The student has a disability as defined in the State Rules for the Administration of the Exceptional Children’s Educational Act and is eligible 

for special education. 

Multidisciplinary Team Members 4.02(6)(b); 300.306(a)(1) Title 

A copy of the evaluation report(s) and the eligibility statement has been provided to the parent(s). 300.306(a)(2) 

Page 11 of 62 

1/16/08

Legal Name of Student Sate Student ID (SASID) Date of Birth Date 

DETERMINATION OF ELIGIBILITY: HEARING DISABILITY 

Definition: A student with a hearing disability shall have a deficiency in hearing sensitivity as demonstrated by an elevated threshold of auditory sensitivity to pure tones or speech where, even 

with the help of amplification, the student is prevented from receiving reasonable educational benefit from general education 

The team has determined: 300.306(b) If the answer is “no,” to any of these questions the student cannot be considered eligible for special education at this time. 

Yes No 1. the evaluation is sufficiently comprehensive to appropriately identify all of the child’s special education and related services needs, whether or not 

commonly linked to the disability category 

Yes No 2. the student cannot receive reasonable educational benefit from general education alone 

3. the student’s performance: 




A "deficiency in hearing sensitivity" shall be one of the following: ECEA 2.08(3) 

Yes No An average pure tone hearing loss in the speech range (500 - 2000 Hz) of at least 20 dBHL in the better ear which is not reversible within a reasonable period 

of time. 

Yes No An average high frequency, pure tone hearing loss of at least 35 dBHL in the better ear for two or more of the following frequencies: 2000, 4000 or 6000 Hz. 

Yes No A unilateral hearing loss of at least 35 dBHL which is not reversible within a reasonable period of time. 

The student meets one or more of the following criteria: 

Yes No Sound-field word recognition (unaided) of less than 75% in quiet as measured with standardized open-set audiometric speech discrimination tests presented 

at average conversational speech (50-55 dBHL). Interpretation shall be modified for closed-set tests. 

Yes No Receptive and/or expressive language delay as determined by standardized tests 

under 3 years: less than one-half of expected development for chronological age. 

3 to 8 years: 1 year delay or more. 

9 to 13 years: 2 years delay or more. 

14 to 21 years: 3 years delay or more. 

Yes No An impairment of speech articulation, voice and/or fluency. 

Yes No Significant discrepancy between verbal and nonverbal performance on a standardized intelligence test. 

Yes No Delay in reading comprehension due to language deficit. 

Yes No Poor academic achievement. 

Yes No Inattentive, inconsistent and/or inappropriate classroom behavior. 

Yes No 

The student has a disability as defined in the State Rules for the Administration of the Exceptional Children’s Educational Act and is eligible for 

special education. 


A copy of the evaluation report(s) and the eligibility statement has been provided to the parent(s). 300.306(a)(2) Page 12 of 62 

1/16/08


DETERMINATION OF ELIGIBILITY: MULTIPLE DISABILITIES 

Definition: A student with multiple disabilities shall have two or more areas of significant impairment, one of which shall be a cognitive impairment except in the case of deaf-blindness. Cognitive 

impairment shall mean significant limited intellectual capacity. The other areas of significant impairment include: physical, visual, auditory, communicative or emotional. The combination of such 

impairments creates a unique condition that is evidenced through a multiplicity of needs which prevent the student from receiving reasonable educational benefit from general education. The 

definition of impairment shall be the same as that for each of the single disabilities (include determination of disability form for each disability considered) 








• to limited English proficiency 

Criteria for multiple disabilities preventing a student from receiving reasonable educational benefit from general education shall be the same as that considered for each of the single disabilities 

and shall include documentation of: (check all that apply) 

Significant limited intellectual capacity And Significant identifiable emotional disability 

Hearing disability 

Vision disability 

Physical disability 

Speech/language disability 

And/Or Deaf-Blind 

Indicators for the combination of impairments creating a unique condition shall be: 2.08(8) 

Yes No Inability to comprehend and utilize instructional information. 

Yes No Inability to generalize skills consistently. 

Yes No Inability to communicate fluently. 

Yes No Inability to demonstrate problem solving skills when such information is presented in a traditional academic curriculum. 

Yes No 

The student has a disability as defined in the State Rules for the Administration of the Exceptional Children’s Educational Act and is eligible for 

special education. 



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1/1/08


DETERMINATION OF DISABILITY: PHYSICAL DISABILITY 

Definition: a child with a physical disability shall have a sustained illness or disabling physical condition which prevents the child from receiving reasonable educational benefit from general 

education. A sustained illness means a prolonged, abnormal physical condition requiring continued monitoring characterized by limited strength, vitality, or alertness due to chronic or acute health 

problems and a disabling condition means a severe physical impairment. Conditions such as, but not limited to, traumatic brain injury, autism, attention deficit disorder and cerebral palsy may 

qualify as a physical disability, if they prevent a child from receiving reasonable educational benefit from general education. 









Criteria for a physical disability preventing the child from receiving reasonable educational benefit from general education should be dependent upon the child's diagnosis and 

degree of involvement in the general school setting as characterized by any of the following: 2.08(1) 

The student's chronic health problem or sustained illness requires (check all that apply): 

continual monitoring intervention specialized programming 

in order to accommodate the effects of the illness so as to reasonably benefit from the education program. 

AND/OR 

The student's disabling condition interferes with: (check all that apply) 

ambulation attention hand movements coordination 

communication self-help skills other activities of daily living 

…to such a degree that it requires special services, equipment, and/or transportation (check all that apply). 

special services equipment transportation 

Yes No The team agrees that this student has a disability as defined in the State Rules for the Administration of the Exceptional Children’s Educational Act 

and is eligible for special education. 



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1/16/08


DETERMINATION OF ELIGIBILITY: PRESCHOOL CHILD WITH A DISABILITY 

Definition: A preschool child with a disability shall be three through five years of age and shall, by reason of one or more of the following conditions, be unable to receive reasonable educational 

benefit from general education: long-term physical impairment or illness, significant limited intellectual capacity, significant identifiable emotional disorder, specific learning disability or speech 

language impairment. 

Note: for a preschool child who qualifies according to one of the categorical conditions listed in this definition above, complete the Determination of Disability form for the appropriate disability 

The team has considered: 300.306(b) 



Yes No 2. the student can receive reasonable educational benefit from general education alone 


is is not due to a lack of appropriate instruction in reading, including the essential components of reading instruction 

is is not due to a lack of appropriate instruction in math; and 

is is not due to limited English proficiency. 

Children ages three through five who would otherwise qualify according to one or more of the above categorical conditions but for whom the category cannot be appropriately 

determined may qualify for preschool special education if multiple sources of information are utilized and if such children meet one or more of the following criteria: 2.08(9) 

Yes No Children who rank at the seventh percentile or below on a valid standardized diagnostic instrument, or the technical equivalent in standard scores (76 if the 

mean is 100 and the standard deviation is 16) or standard deviations (1.5 standard deviations below the mean) in one or more of the following areas of 

development: cognition, communication, physical and psychosocial. 

Yes No Children with identifiable conditions known through empirical data to be associated with significant delays in development. 

Yes No In extraordinary cases when a standardized score cannot be determined, a child may be determined disabled based on the informed opinion of the 

assessment team which includes the parent(s) and with documentation of the rationale for the inability to obtain a standardized score. 

Criteria for a preschool child being unable to receive reasonable educational benefit from general education shall be a substantial discrepancy between the child's performance 

and behavior as compared to children of a comparable age. 

Yes No The team agrees that this student has a disability as defined in the State Rules for the Administration of the Exceptional Children’s Educational 

Act and is eligible for special education. 



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1/16/08


DETERMINATION OF ELIGIBILITY: SIGNIFICANT IDENTIFIABLE EMOTIONAL DISABILITY 

Definition: a child with a significant identifiable emotional disability shall have emotional or social functioning, which prevents the child from receiving reasonable benefit from general education. 





3. the student’s performance : 




Emotional or social functioning shall mean one or more of the following: ECEA 2.02(5); Proposed ECEA 2.08(5) 

Yes No Exhibits pervasive sad affect, depression and feelings of worthlessness; cries suddenly or frequently; 

Yes No Displays unexpected and atypical affect for the situation; 

Yes No Excessive fear and anxiety; 

Yes No Persistent physical complaints not due to a medical condition; 

Yes No Exhibits withdrawal, avoidance of social interaction and/or lack of personal care to an extent that maintenance of satisfactory interpersonal relationships is 

prevented; 

Yes No Out of touch with reality; has auditory and visual hallucinations, thought disorders, disorientation or delusions; 

Yes No Cannot get mind off certain thoughts or ideas; cannot keep self from engaging in repetitive and/or useless actions; 

Yes No Displays consistent pattern of aggression toward objects or persons to an extent that development or maintenance of satisfactory interpersonal 

relationships is prevented; 

Yes No Pervasive oppositional, defiant or noncompliant responses; 

Yes No Significantly limited self-control, including an impaired ability to pay attention; 

Yes No Exhibits persistent pattern of stealing, lying or cheating; 

Yes No Persistent pattern of bizarre and/or exaggerated behavior reactions to routine environments. 

The student meets one or both of the following criteria: 

Yes No Academic functioning: an inability to receive reasonable educational benefit from general education which is not primarily the result of intellectual, sensory 

or other health factors, but due to the identified emotional condition; 

Yes No Social/emotional functioning: an inability to build or maintain interpersonal relationships which significantly interferes with the child's social development. 

Social development involves those adaptive behaviors and social skills which enable a child to meet environmental demands and assume responsibility for 

his/her own and others' welfare. 

All four of the following qualifiers shall be documented for either of the above criteria demonstrated: 

Yes No A variety of instructional and/or behavioral interventions were implemented within general education and the child remains unable to receive reasonable 

educational benefit from general education or his/her presence continues to be detrimental to the education of others. 

Yes No Indicators of social/emotional dysfunction exist to a marked degree; that is, at a rate and intensity above the child's peers and outside of his/her ethnic and 

cultural norms and outside the range of normal development expectations. 

Yes No Indicators of social/emotional dysfunction are pervasive, and are observable in at least two different settings within the child's environment, one of which 

shall be school. 

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Yes No Indicators of social/emotional dysfunction have existed over a period of time and are not isolated incidents or transient, situational responses to stressors in 

the child's environment. 





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DETERMINATION OF ELIGIBILITY: SPEECH LANGUAGE IMPAIRMENT 

Definition: a student with a speech-language impairment shall have a communicative disorder which prevents the student from receiving reasonable educational benefit from general 

education. 









Speech-language impairment may be classified under the headings of articulation, fluency, voice, functional communication or delayed language development and shall 

mean a dysfunction in one or more of the following: ECEA 2.08(7) 

Yes No Receptive and expressive language (oral and written) difficulties including syntax (word order, word form, developmental level), semantics (vocabulary, 

concepts and word finding), and pragmatics (purposes and uses of language). 

Yes No Auditory processing, including sensation (acuity), perception (discrimination, sequencing, analysis and synthesis) association and auditory attention. 

Yes No Deficiency of structure and function of oral peripheral mechanism. 

Yes No Articulation including substitutions, omissions, distortions or additions of sound. 

Yes No Voice, including deviation of respiration, phonation (pitch, intensity, quality), and/or resonance. 

Yes No Fluency, including hesitant speech, stuttering, cluttering and related disorders. 

Yes No Problems in auditory perception such as discrimination and memory. 


Yes No Interference with oral and/or written communication in academic and social interactions in his/her primary language. 

Yes No Demonstration of undesirable or inappropriate behavior as a result of limited communication skills. 

Yes No The inability to communicate without the use of assistive, augmentative/alternative communication devices or systems. 

Yes No The team aggress that this student has a disability as defined in the State Rules for the Administration of the Exceptional Children’s 

Educational Act and is eligible for special education. 



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DETERMINATION OF ELIGIBILITY: SIGNIFICANT LIMITED INTELLECTUAL CAPACITY 

Definition: a child with a significant limited intellectual capacity shall have reduced general intellectual functioning, which prevents the child from receiving reasonable benefit from general 

education. Reduced general intellectual capacity shall mean limited functioning or ability which usually originates in the developmental period and exists concurrently with impairment in 

adaptive behavior. 









The student meets ALL of the following criteria: ECEA 2.08(4) 

Yes No A score of more than 2.0 standard deviations below the mean on individually administered measures of cognition 

Yes No Evidence that the level of independent adaptive behavior is significantly below the culturally imposed expectations of personal and social responsibilities; 

Yes No A deficiency in academic achievement, as indicated by scores 2.0 standard deviations below the mean in measures of language, reading and math. 

None of these indicators by itself shall be sufficient criterion for determination of a significant limited intellectual capacity. All three indicators shall be evident for the determination 

of this disability. Professional judgment shall be required for interpretation of scores and/or other findings 

Yes No The team agrees that this student has a disability as defined in the State Rules for the Administration of the Exceptional Children’s 

Educational Act and is eligible for special education. 



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DETERMINATION OF ELIGIBILITY: TRAUMATIC BRAIN INJURY 

Definition: Traumatic brain injury (TBI) means an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or 

both, that adversely affects a child's educational performance. Traumatic brain injury applies to open or closed head injuries resulting in impairments in one or more areas, such as cognition; 

language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; information processing; 

and speech. Traumatic brain injury does not apply to brain injuries that are congenital or degenerative, or to brain injuries induced by birth trauma 









Criteria for a Physical Disability in the area of TBI preventing the student from receiving reasonable education benefit from general education should be dependent upon whether the student’s 

disability meets the educational criteria for Traumatic Brain Injury and interferes with the following: 

The student’s Physical Disability in the area of TBI is characterized by: 

Yes No Medical documentation of a Traumatic Brain Injury or History of a Traumatic Brain Injury 

and 

Yes No Educational evidence of an deficits relating to the Traumatic Brain Injury 

The student’s Physical Disability in the area of TBI interferes with: (check those that apply) 

Yes No Walking, writing, and self-help skills; and/or 

Yes No Ability to recall information and learn new material; and/or 

Yes No Language skills; and/or 

Yes No Attention/Memory; and/or 

Yes No Visual-spatial and motor deficits; and/or 

Yes No Planning and organization; and/or 





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DETERMINATION OF ELIGIBILITY: VISION DISABILITY 

Definition: a student with vision impairment shall have a deficiency in visual acuity and/or visual field and/or visual performance where, even with the use of lenses or corrective devices, he/she is 

prevented from receiving reasonable educational benefit from general education. 









A vision disability shall be one or more of the following: ECEA 2.08(2) 

Yes No Visual acuity of no better than 20/70 in the better eye after correction. 

Yes No Visual field restriction to 20 degrees or less. 

Yes No A physical condition of visual system which cannot be medically corrected and as such affects visual functioning to the extent that specially designed 

instruction is needed. These criteria are reserved for special situations such as, but not restricted to, oculomotor apraxia, cortical visual impairment, 

and/or a progressive visual loss where field and acuity deficits alone may not meet the aforementioned criteria. 

The term “visual disability” does not include children who have learning problems which are primarily the result of visual perceptual and/or visual motor difficulties. 


Yes No Requirement for Braille and/or adaptation of educational material, or 

Yes No Requirement of specialized methods, aids, and/or equipment for learning, literacy, and/or mobility. 





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IEP Forms – Initial Consent for Provision of Special Education 

Purpose: Provided for initial consent for the general provision of special 

education and related services. 

Usage: Required the first time a student is found to be eligible for special 

education and prior to the development of the IEP. Also required on transfer, 

if the original is not found. 

Page 22 of 62 

Overview 

Permission to place a student in special education is 

required the first time a student is found to be 

eligible. 

After consent has been received and services begun, 

a parent cannot withdraw their consent. The federal 

regulations governing this are currently being 

revised—stay tuned! 

Instructions • Describe the reason why special education is being 

proposed, e.g., “The student was found to have a 

disability and is in need of specially designed 

instruction and related services.” 

• Describe the documentation, records, and other 

information used in making this decision, e.g., “This 

proposal is based on the Eligibility Meeting and 

Evaluation Reports dated 10/3/2008.” 

• Briefly describe what general education services 

were considered and why they were rejected. 

• Describe any other factors that were part of the 

decision to propose special education and related 

services. 

IE P Development 

• An IEP need not be developed prior to obtaining 

written consent for the provision of special education. 

If your team will be combining Eligibility Meetings and 

IEP Development meetings, then you might consider 

drafting some elements of the IEP prior to receiving 

signed consent.


IEP Forms – Consent to Invite Agencies 

Purpose: To obtain consent to invite community agencies to a transitionaged 

student’s IEP Meeting. 

Usage: Annually obtain consent to invite agencies who are likely to provide 

or pay for services for this student either currently or as an adult. 

Page 23 of 62 

Overview 

Before inviting an outside agency to a student’s IEP 

meeting, you must obtain written parental consent. 

This consent authorizes you to share confidential 

information about a student, specifically that the 

student has a disability. 

It is strongly encouraged that you do this annually in 

the fall for existing students. 

Instructions • Identify the relevant agencies. 

• Work with the parent to insure that they check the 

Yes/No box for each invited agency and sign/date 

the form. 

• Once you have the signed form back, you may invite 

the agencies. 

• Permission can only be valid for a year.


IEP Forms – Member Excusal 

Purpose: To provide flexibility for parents and schools in holding IEP 

meetings. 

Usage: All invited participants must attend the meeting in its entirety. The 

Excusal Form is for any invited member who will not attend the meeting in its 

entirety. 

Page 24 of 62 

Overview 

Because of the minimal number of required 

participants, the IEP Team Member Excusal will not 

be necessary in most situations. 

Only invite the necessary participants! Then you will 

not need to excuse people. 

Participants are now required to attend the entire 

meeting or they will have 

to go through the excusal 

process in advanced. 

You may NOT excuse 

the special education 

director/designee. 

Optional 

Participation Options 

• In person 

• By telephone 

or video conference 

Directions 

• Must be completed before the meeting and signed 

by 

the parent indicating their agreement. 

• Members whose area of specialization will be 

discussed or 

modified need to complete the narrative 

sections. 

IEP Team Participants 

Essential Members (not “required”) 

• Parent 

• Student, if appropriate, esp. transition) 

Required 

• Special Education Teacher or SLP 

• Individual able to interpret evaluation 

• Special Education Director or designee 

• General Education Teacher of student, if the 

student is or is likely to participate in the general 

education 

program. 

• ELL Specialist if student is LEP 

Optional 

• Other related services providers 

• Community Service Agencies (must be invited for 

Transition students, per parent’s consent in writing 

on the Permission to Invite Agencies Related to 

Transition.)


IEP Forms – Cover Page 

Purpose: The Cover Page serves as a quick glance document for staff and parents. It also provides necessary data elements for State and 

Federal Reports. 

Usage: The Cover Page is used for both Eligibility and IEP meetings. Only one Cover Page is required, if the meetings are combined. 

Page 25 of 62 

Eligibility Meeting Types 

√ Initial Eligibility – First Eligibility Meeting Only 

√ 3 Year – Every 3 Years 

√ Special Evaluation – Other Evaluations 

IEP Meeting Types 

√ Initial IEP – First IEP Meeting Only 

√ Annual Review – Every 365 days 

√ Amendment – IEP Meetings between Annuals 

√ Other – Transition and other IEP Meetings 

√ N/A – Check if student Did Not Qualify 

Initial Consent for Services – this is the date that 

you received the initial consent for special 

education. 

Dates of Meetings 

• Next Eligibility – Every 3 Years 

• Next IEP Review – Annual Date 

• Initial Consent for Evaluation – Date you 

received Consent to Evaluate 

• Initial Evaluation Completed – Date you finished 

the Evaluation Report 

• Initial Eligibility Determination – Date of the First 

Eligibility Meeting 

• PSG Date – Date by which transition must be 

addressed – before the age of 15 and not later 

than the end of 9 th Grade 

Student and Family Information 

• Unit/ Facility of Attendance – only if placed out of 

district 

• Educational Surrogate Parent – assigned by 

Northwest BOCES


IEP Forms – Participant Page 

Purpose: The Participants page serves as a record of who actually attended the IEP meeting and documents that the parent received their 

Procedural Safeguards. 

Usage: The Participants page is only for IEP meetings. Eligibility Meeting Participants are documented on the Eligibility Checklists. 

Page 26 of 62 

Procedural Safeguards 

√ Make sure the parent checks “Yes.” If they check 

“No,” then take the time to answer any questions. 

Make sure to always have a copy on hand! 

Procedural Safeguards are provided once per year. 

In addition, they are provided when: 

• Obtaining Initial Permission to Evaluate 

• Due Process is requested 

• Disciplinary change in placement is considered 

(including Manifestation Determinations) 

• Upon any other request 

IEP Meeting Participants - Required 

• Special Education Teacher or SLP for students 

receiving only speech/language. 

• An Individual who can interpret evaluations – may be 

the same person as above. 

• Special Education Director/Designee – may be a 

special education representative. 

• Bilingual Specialist for LEP students 

• General Education Teacher of the student or one 

currently assigned to teach in a classroom of the 

same age/grade of the student (only if the student is 

or may be participating in the general education 

program). 

Other IEP Meeting Participants 

• Parents are required to be invited 

• Students as appropriate, especially transition age 

• Related Service Providers 

• Community Service Agencies must be invited per 

parent authorization. 

Participant signatures only indicate their presence at 

the IEP Meeting. If a party does not want to sign, the 

case manager or other party can document their 

presence. 

Special Education Teachers and Related Services 

Personnel can sign for the special education director 

or designee. However, you will require 

administrative approval through your district in order 

to allocate resources.


IEP Forms – Present Levels 

Purpose: The Present Levels page summarizes the team’s understanding of the student and serves as a foundation for determining 

goals, services, accommodations, modifications, and other supports required to lead to meaningful educational benefit. 

Usage: The Present Levels page is required for all IEP meetings. 

Page 27 of 62 

Student Strengths, Preferences, Interests 

• List relevant strengths, preferences, and interests of 

the student to maximize and support educational 

programming. 

Educational Performance Summary 

• Summarize critical results from the most recent 

evaluation. You can update this with general 

information from progress monitoring or outside 

evaluation data considered as appropriate. 

Transition Assessment Process 

• Effective Transition planning requires strong and 

ongoing transition assessment. The process need 

not be a set of formal assessments, but should be of 

a nature that provides objective information 

necessary to assist the team in developing 

Measurable Post-School Goals, planning for 

services, and connecting students to agencies. 

Student Needs and Impact of Disability 

• Needs should be organized into chunks with a 

general need summarizing more specific component 

needs. All needs must be specifically linked to 

Goals/Objectives, Supplemental Plans (such as BIP), 

Accommodations, Modifications, or other services. 

Measurable Post-School Goals 

• This section is addressed on the Transition Page. 

However, determining what the student will do when 

they leave the K-12 education system is vital to 

developing the rest of the IEP.


IEP Forms – Special Factors 

Purpose: Special Factors call attention to a variety of additional services and documentation requiring consideration by the IEP team. 

Usage: The Special Factors page is required for all IEP meetings. 

Page 28 of 62 

A. Behavior Intervention Plan 

• Students whose behavior interferes with learning 

require a BIP. 

B. Blind or Visually Impaired 

• Teachers of the Visually Impaired are qualified to 

mark “Yes.” Requires plan. 

• 

C. Deaf or Hard of Hearing 

• Teachers of the Deaf and Hard of Hearing are 

qualified to mark “Yes.” Requires plan. 

D. Deaf- Blind 

• TVI and DHH are qualified to mark “Yes.” Requires 

both plans. 

E. Health Care Plan 

• School Health Personnel maintain health care plans 

on students. Work with your staff to determine the 

appropriate answers. 

F. Limited English Proficiency 

• Using the appropriate school personnel— bilingual or 

second language staff—address how a student’s 

English learning needs will be met. 

G. Assistive Technology 

• Students needing assistive technology must have 

their need addressed. AT can range from low tech – 

picture schedules – to high tech devices. Make sure 

the team can commit district resources prior to the 

IEP meeting. 

H. Special Transportation 

• Special Transportation is required when general 

transportation offerings are not sufficient to deliver 

the student to the school to receive their educational 

program. Work with your administration on 

committing this resource.


IEP Forms – Post-School Considerations 

Purpose: Post-School Considerations identify intentional post-school outcomes and the required course of study, transition services, 

and agency connection that are necessary to prepare the student to achieve the post-school goals IEP team. 

Usage: The Post-School Considerations page is required for IEP meetings prior to the student turning 15 years old, but not later than 

the end of 9 th grade. 

Page 29 of 62 

Projected Graduation 

• Identify a projected graduation/completion date. 

• List type of documentation the student will receive 

(Regular Diploma, Certificate of Attendance or other 

that your district offers). 

Post-School Goals 

• PSGs represent the reason for special education – 

the “what for.” What WILL they actually do after 

leaving the educational system? 

• All Student IEPs are required to have a PSG in 

Education/Training and Career Employment. 

• When appropriate, identify an Independent Living 

Skills Goal. 

Course of Study 

• General Educational, Career, College, and Special 

Education classes are required to lead to the 

attainment of the student’s PSG’s. 

• It should indicate a multi-year high school plan. 

• Consider student interests and needs in identifying 

the course of study. 

• Should be more detailed than “student will complete 

graduation requirements.” 

• Should be able to be interpreted by another school. 

Transition Services 

• Familiar: Special and General Education Instruction, 

Transportation, Related Services 

• Community Experiences: work experience, job site 

experience, banking, shopping, recreation 

• Daily Living: meal preparation, budgeting, bills, 

maintaining a home or apartment, grooming 

Agencies 

• Identify any community agencies that are likely to 

provide or pay for services for a student. 

• Provide the agency name, their role, and personal 

contact information, giving the family guidance on 

how to access the services. 

Age of Majority 

√ For students who will turn 20 during the next year, 

inform of transfer of rights and when services will 

end. Services end the semester in which the student 

turns 21 or at the end of the preceding school year, if 

the DOB is in the summer.


IEP Forms – Goals / Objectives 

Purpose: Goals (and objectives when required) identify the progress-monitoring tool used to evaluate the effectiveness of the student’s 

special education program. They do not represent a scope and sequence or identify a curriculum. Rather, goals should identify ambitious 

annual measurable outcomes related to the needs of the student. 

Usage: Annual measurable goals are required for all students. Objectives are only required for students taking alternate assessments 

aligned to alternate achievement standards (District Alternate, or CSAP A). 

Page 30 of 62 

Transition Considerations 

√ Check the area(s) to which this goal pertains. 

• Clearly link PSGs to the Goals and Objectives by 

using the phrase, “In order to meet their post-school 

goal of (list post-school goal), (annual goal).” 

Area of Need 

• Should be connected to broader headings of need in 

Present Levels Section. 

Measureable Goal 

Verb…Area…from X to Y by when. 

• e.g., “Jenny will increase {verb} her reading {area} 

from 65 to 98 Words Read Correctly per minute on a 

4 th grade passage {when is assumed to be a year, 

unless otherwise specified}.” 

• Must lend itself to progress monitoring. 

Unit of Measurement 

• If you write your goals/objectives as presented, the 

Unit of Measurement is built into the goal. 

• It defines the Baseline Data point (65 of what?). 

• In the above example, the unit is WRC per minute. 

Standard, Benchmark, Access Skill 

• List the broad category of Educational Standard, 

Expanded Benchmark, Access Skill, or Key 

Component. 

Baseline Data Point 

• A number representing exactly where the student is 

currently functioning, not your educated guess 

• If you do not have a baseline data point because a 

goal was developed for which you have no current 

data, conduct a baseline assessment within the next 

few days. 

Evaluation Method 

• Identify what method you will use to monitor progress 

on the goal. 

Progress Report (Describe how…) 

• List how (in writing, at a meeting) will parents be 

informed of progress and how frequently. 

Reporting Progress 

• Only use the 4 reporting key categories 

• Must include actual data point consistent with the unit 

of measurement and baseline data point.


IEP Forms – Accommodations and Modifications 

Purpose: Accommodations and Modifications are central to supporting a student with disabilities. ESY is a special education service 

that is essential for some students to receive a free appropriate public education. 

Usage: Accommodations are required for all students. Modifications occur for some students. ESY Determination is required for all 

students. If you are going to postpone the ESY determination, you may use the IEP Amendment Process, if the parents agree. 

Page 31 of 62 

General 

The difference between accommodations and 

modifications is subtle, and you need not lose sleep 

getting them in the right box! 

• Accommodations support accessing the curriculum 

that is based on the same standards and 

expectations. They fall into broad categories of 

adapting instructional strategies: 

• Adaptation of materials 

• Adjusting the mode of presentation 

• Grouping 

• Format 

• Environmental adaptations 

• Modifications necessitate changing curriculum and 

are extensive in that they significantly alter the scope 

or content. 

Extended School Year Determination 

ESY services are to support students who 

experience extraordinary difficulties with losing skills 

over the summer break and regaining those skills 

upon return to school. 

√ Documentation of regression is achieved through 

conducting IEP Progress reports before and after a 

break. 

√ Recoupment is determined by monitoring progress 

using the IEP Progress reports each week after 

return from the break until the student has recouped 

the skill. 

√ Other Factors is checked “Yes” when a student’s IEP 

team determines that the “predictive factors” are 

critical to the determination for ESY. 

ESY services are tied directly to the student’s 

specific goals/objectives that are linked to 

regression/recoupment issues.


IEP Forms – Assessments 

Purpose: Participation in State and District-wide assessment programs is documented on this form. 

Usage: The Assessment section is required for all IEP meetings. 

Page 32 of 62 

District Assessments 

• Students must either take the District Assessments 

(those offered across the district), or an Alternate 

must be available. 

Decision Considerations 

• Significant cognitive challenge 

• Performance on CSAP 

• Student Curriculum 

• Eligibility Checklist (CDE) 

• Response access 

• Grade-level assignment 

State Assessments 

√ Check how the student will participate in the 

assessments. 

√ Provide justification for CSAPA and list any CSAPA 

Accommodations/Adaptations. 

√ Check the Standard Accommodations the student 

will require for CSAP administration. These must be 

marked on the test. 

√ Other standard accommodations must be listed but 

not marked on the CSAP Booklet. The use of these 

depends on the subject of the test: 

• CCTV, Handheld Magnifiers, Audio Amplification 

devices 

• Change of location, grouping of students, time of 

day, multiple or frequent breaks 

• Talking Calculator, spelling of words, highlighting 

by the student, noise buffers, color overlays, pencil 

grips, or large pencils 

√ If the student is taking an alternate assessment, you 

must explain to the parents the difference between 

the assessments and the impact of the differences.


IEP Forms – Service Delivery 

Purpose: The Services page documents a commitment of district resources toward addressing the needs of the student. In addition, it 

summarizes the process of decision-making regarding the placement of the student in the least restrictive environment. 

Usage: The Service Delivery page is required for all IEP meetings. 

Page 33 of 62 

Statement 

• Describe the nature and location of the services to be 

provided to the student. 

• Clarify confusing items (such as services provided at 

a frequency other than weekly). 

• Inform parents that services follow the school 

calendar and may be missed for special events in the 

school community. 

Services Table 

• Specialized Instruction Area – a brief description of 

the area to be provided, e.g., Reading, Math, Writing, 

Academics, Safety, Access to the Curriculum, 

Articulation, Environmental Modification, Behavior 

Management, etc. 

• Services Provider – list the provider’s title (not 

name). 

• Dates – Generally these dates span a year. However 

there are times when services are expected to 

change during the year (such as changes between 

schools) and dates can be staggered. 

• Frequency – Enter hours in decimal format for one 

frequency (day, week, month) only. 

Documenting ESY Services 

• ESY is a special education service. Services should 

be listed in this table and in the description, unless 

you are postponing the decision. 

Placement in LRE 

Summarize your decision process as a team for why 

the selected placement option is appropriate. 

Including reason for not choosing other options. 

√ You must discuss at least two options. List options in 

plain language (Resource Room, Homebound, etc). 

Check appropriate boxes. 

√ Check appropriate General Educational Services and 

Educational Environment (see LRE page).


IEP Forms – Least Restrictive Environment 

Educational Environment 

√ Divide the number of hours the child spends in the general education classroom by the total number of hours in the school day 

(including lunch, recess, and study periods). The result is multiplied by 100. Time spent outside the general education classroom 

receiving services unrelated to the child’s disability (e.g., time receiving limited English proficiency services) should be considered time 

in the general education classroom. Educational time spent in age-appropriate community-based settings that include individuals with 

and without disabilities (e.g., college campuses, vocational sites) should be counted as time spent in the general education classroom. 

• General education class 80 percent or more of the time – Report children who receive special education and related services in the 

general education classroom for 80 percent or more of the time. (These are children who receive special education and related 

services out of the general education classroom for less than 21 percent of the time.) 

• General education class no more than 79 percent of the time and no less than 40 percent of the time – Report children who receive 

special education and related services in the general education classroom for no more than 79 percent of the time and no less than 40 

percent of the time. 

• General education class less than 40 percent of the time - Report children who receive special education and related services in the 

general education classroom less than 40 percent of the time. 

• Separate school - Report children who receive their educational programs in public or private separate day school facilities. This 

includes children with disabilities receiving special education and related services, at public expense, for greater than 50 percent of the 

time in public or private separate schools. This may include children placed in: (a) public and private day schools for children with 

disabilities; (b) public and private day schools for children with disabilities for a portion of the school day (greater than 50 percent) and 

in general education school buildings for the remainder of the school day; or (c) public and private residential facilities if the student 

does not live at the facility. 

• Residential facility - Report children who receive their educational programs in, and live in, public or private residential facilities during 

the school week. This includes children with disabilities receiving special education and related services, at public expense, for greater 

than 50 percent of the school day in public or private residential facilities. This may include children placed in: (a) public and private 

residential schools for students with disabilities; or (b) public and private residential schools for children with disabilities for a portion of 

the school day (greater than 50 percent) and in separate day schools or general education school buildings for the remainder of the 

school day. Do not include students who receive education programs at the facility but do not live there. 

• Homebound/hospital - Report children who receive education programs in a homebound/hospital environment. This includes children 

with disabilities placed in and receiving special education and related services in: (a) hospital programs, or (b) homebound programs. 

Do not include children with disabilities whose parents have opted to provide home schooling and who receive special education at the 

public expense. 

• Correctional facilities - Report children who receive special education in correctional facilities. These data provide a census of all 

children receiving special education in: (a) short-term detention facilities (community based or residential); or (b) correctional facilities. 

Page 34 of 62 

Early Childhood (Age 3-5) 

General Education Services 

• Document time students ages 3-5 spend in an 

integrated education preschool program for per-pupil 

funding purposes: 

√ If appropriate, check “integrated education 

program.” 

• Record number of hours per week the student 

spends in the program. 

Educational Environment 

Speak with the parent to determine if the child 

attends a childcare setting or other general early 

childhood program in the community for any part of 

their week. 

General Early Childhood Programs (GECP) include: 

• District preschool


IEP Forms – IEP Section 15 - Prior Written Notice 

Purpose: Provides for a simple method of addressing the Prior Written Notice components within the IEP. 

Usage: Required for all IEP meetings unless you choose to use the separate Prior Written Notice form. 

Page 35 of 62 

Overview of Prior Written Notice 

Prior written notice is a legal concept that has been 

part of special education for since 1997. Colorado 

took advantage of PWN in designing some of the old 

forms, but did not completely cover the concept in 

the old form set. 

The intent of PWN is to afford parents the opportunity 

initiate Dispute Resolution procedures PRIOR to a 

school implementing or changing special education 

programming for a student. 

Components of PWN 

• The body of the IEP contains the description of what 

is being proposed, the information that the proposed 

IEP was based on. 

• Documentation of the other options considered and 

why they were rejected. Other options might include: 

• Different placements on the continuum of services 

• Different levels of services 

• Any other factors influencing the decision.


IEP Forms – Behavior Intervention Plan 

Purpose: Document the use of positive behavior interventions, supports, and other strategies to address the behavior of a child whose 

behavior impedes the child’s learning or that of others. 

Usage: Used for only those students where it is checked as a special factor. A Behavior Intervention Plan should be developed in 

conjunction with a Functional Behavior Assessment. 

Page 36 of 62 

Sources of Information: 

• Document all sources of information that were used 

in developing the behavior plan (e.g. ,interviews, 

observations, checklists, academic assessments, 

record reviews). Information to be obtained from a 

wide variety of sources. 

Strength-Based Profile: 

• Document the student’s strengths and interests. Also 

include other protective factors such as academic 

assets, hobbies, talents, or special interests. 

(FBA) Summary Statement: 

• Based on observations, interviews, background 

information, and other data, generate a hypothesis 

regarding the motivation behind the problem 

behavior. The summary statement includes factors 

such as the setting where the behavior occurs, 

antecedents to the problem behavior, a description of 

the problem behavior, and reinforcing consequences 

of the behavior. 

BIP Strategies/Outcomes Worksheet: 

• Setting Event Strategies: These strategies are 

designed to prevent the child’s problem behavior, 

make the behavior irrelevant, or reduce the likelihood 

that the problem behavior will occur (such as 

modifying the activity schedule, adding prompts for 

appropriate behavior, and considering environmental 

arrangements). 

• Antecedent Strategies: These preventative strategies 

address the events that most likely trigger the 

problem behavior. An antecedent is an immediate 

predictor of the problem behavior. 

• Behavior Teaching Strategies (Alternative 

Behaviors): These are strategies designed to make 

the problem behavior less efficient in gaining the 

reinforcing consequences described in the FBA 

Summary Statement. Behavior teaching strategies 

may include teaching the child an alternative 

behavior or teaching the child adaptive social skills. 

• Reinforcement Strategies (Consequences): 

Reinforcement strategies refer to strategies that 

make the problem behavior less effective.


IEP Forms – Behavior Intervention Plan 

Purpose: Document the use of positive behavior interventions, supports, and other strategies to address the behavior of a child whose 

behavior impedes the child’s learning or that of others. 

Usage: Used for only those students where it is checked as a special factor. A Behavior Intervention Plan should be developed in 

conjunction with a Functional Behavior Assessment. 

Colorado Behavior Resource Manual available at: www.cde.state.co.us/cdesped/BehaviorResourceManual 

Page 37 of 62 

Crisis Intervention Plan: 

• If the student displays unsafe behaviors, a crisis 

intervention plan that emphasizes prevention, 

positive intervention, and de-escalation techniques 

should be developed and attached to the BIP. The 

Crisis Intervention Plan should be readily accessible, 

communicated and distributed to all relevant parties, 

should be aligned with district and state policies, and 

should support the school or district safety plan. If the 

student’s behaviors do not warrant a crisis plan, 

there is no need to include one in the BIP. 

Evaluation: 

• Describe the ongoing evaluation of the effectiveness 

of the plan including how the progress will be 

monitored, the criteria for success, the person 

responsible for monitoring progress, and a follow-up 

meeting date. 

Contextual Fit: 

• Describe how the plan is designed specifically for the 

environment in which it will be implemented including 

the skills, resources, budget and impact of time 

constraints that may affect the ability to implement 

the plan with fidelity. 

Communication Plan: 

• Identify who needs to be notified and who needs 

copies of the plan. Indicate how contact will be made, 

who will be responsible for making contact, and the 

date and frequency of contact. Identify who will 

communicate revisions and updates. 

Team members: 

• Record the names of members of the planning team. 

Parent Provided a Copy of Plan: 

√ A Parent should always receive a copy of the most 

recent BIP. Check this box when the parent receives 

a copy of the plan.


IEP Forms – Communication Plan 

Purpose: Create a mechanism for problem solving and taking action where communication gaps are identified in the student’s access to 

the educational day. 

Usage: Used for only those students who are deaf or hard of hearing (or Deaf-Blind) as checked as a Special Factor. Typically 

completed in conjunction with a Teacher of the Deaf and Hard of Hearing. 

Page 38 of 62 

Language and Communication 

√ Enter the student’s primary language and 

communication modes.


IEP Forms – Communication Plan 

Purpose: Create a mechanism for problem solving and taking action where communication gaps are identified in the student’s access to 

the educational day. 

Usage: Used for only those students who are deaf or hard of hearing (or Deaf-Blind) as checked as a Special Factor. Typically 

completed in conjunction with a Teacher of the Deaf and Hard of Hearing. 

For further instructions and guidelines, see the Colorado FastFacts and the Colorado Guidelines for Schools, and the 

Colorado Resource Guide. 

Page 39 of 62 

Student Needs 

• Consider the child’s communication needs, including 

opportunities for direct instruction from professionals 

and direct communication with peers, professionals, 

and deaf/hard of hearing adult role models in the 

child’s communication mode. 

Educational Options 

• Describe all of the educational options available to 

the student as available to the district. 

Demonstrated Proficiency 

• The staff’s demonstrated communication proficiency 

to accommodate for the student’s unique needs in 

academic instruction, school services, and 

extracurricular activities must be considered. 

Communication Accessibility 

• Describe how the student’s communication modes 

will be accessible throughout the school day and 

extracurricular activities.


IEP Forms – Learning Media Plan 

Purpose: This form is used to identify the student’s primary literacy mode. 

Usage: Used for only those students with a visual impairment or blindness (or Deaf-Blind) as checked as a Special Factor. Typically 

completed in conjunction with a Teacher of the Visually Impaired. 

Page 40 of 62 

Learning Media Plan 

• The Learning Media Plan must include a statement 

about the selection of a student’s primary literacy 

mode(s) and possible secondary literacy mode(s): 

• Auditory Mode 

• Braille 

• Print enlargement 

• Regular print 


of how the selected learning and literacy mode(s) will 

be implemented in the student’s educational 

program. 


of how the student’s instruction in the selected 

learning and literacy mode(s) will be integrated into 

educational activities. 

• The Learning Media Plan should include a date on 

which the student’s instruction, in the selected 

mode(s), as appropriate, shall commence. For 

example, if the student is learning Braille, the date of 

beginning/ongoing instruction should be noted in the 

Learning Media Plan. 

• The Learning Media Plan should include a statement 

of the level of student competency in each selected 

literacy mode(s) that the student should achieve by 

the end of the period covered by the IEP. 

• Colorado teachers licensed and endorsed in the area 

of visual impairment must have demonstrated 

competency in reading and writing literacy Braille per 

the guidelines developed by CDE.


IEP Forms – Transfer Student from within Colorado 

Purpose: To define service delivery for students transferring from a district within Colorado. 

Usage: Upon receipt of enrollment of a student with a disability from another district in Colorado. 

Page 41 of 62 

Instructions 

√ Indicate whether the goals, objectives, and service 

are accepted. 

• If you do not accept the IEP, then develop an interim 

service delivery description and complete the table. 

• Document notification of the IEP team. 

• Obtain parent permission to implement services. 

Make certain the parent checks the appropriate 

boxes. 

Services must begin within a reasonable time in 

order to continue a free appropriate public education. 

Depending on the nature of the services they could 

begin that school day. If adequate staff is not 

available to begin services within a reasonable time, 

bring the IEP team together and produce an interim 

plan for meeting the student’s needs. 

Additional demographic information will be required 

to count the student for funding. 

Submit the entire file received 

and the transfer page 

to the BOCES Office.


IEP Forms – Transfer Student from Another State 

Purpose: To define service delivery for students transferring from a district outside of Colorado. 

Usage: Upon receipt of enrollment of a student with a disability from another district outside of Colorado. 

Page 42 of 62 

Instructions 

Transfers from another State require a higher 

standard of review. 

√ Indicate whether the evaluation, eligibility 

determination, and IEP meet Colorado’s educational 

standards. 

• If you do not accept the IEP, then you must conduct 

an Initial Evaluation. Complete the Service Delivery 

Statement and table to be used on an interim basis 

until the Eligibility meeting is held and IEP developed 

(if appropriate). 

• Obtain parent permission to implement services. 

Make certain the parent checks the appropriate 

boxes. 

Services must begin within a reasonable time in 

order to continue a free appropriate public education. 

Depending on the nature of the services, they could 

begin that school day. If adequate staff is not 

available to begin services within a reasonable time, 

bring the IEP team together and produce an interim 

plan for meeting the student’s needs. 

Additional demographic information 

will be required 

to count the student for funding. 

 

Submit the entire file received and the transfer page 

to the BOCES Office.


IEP Forms – IEP Amendment 

Purpose: To document changes to an IEP in between annual reviews. 

Usage: Only in situations where the parent and district agree to the changes and it is not necessary to hold and IEP meeting. 

Amendments should only be used for minor changes. 

Page 43 of 62 

Overview 

IEPs can be changed between annuals by either 

reconvening the IEP Team or using the IEP 

Amendment form. 

This form should only be used to make relatively 

minor changes, such as changes to: 

• Goals / Objectives 

• Service Hours 

• Accommodations / Modifications 

• Related services like Special Transportation 

• Documenting ESY Determinations 

In general, do not use the IEP Amendment form to 

make significant changes in placement including the 

elimination of related services. 

Instructions 

Discuss the changes 

with the parent prior to sending 

the form home. 

√ Describe the current IEP. 

√ Document the Proposed Changes. 

√ Include the Rationale for the Changes and upon 

what information the change is proposed. 

√ Identify other options 

that were considered and why 

they are rejected. 

√ Identify any other factors influencing the decision. 

• Complete the Case Manager information and 

sign as 

the Special Education Director Designee. 

• Obtain the parent’s signature. 

• Notify the IEP 

Team after receipt of the parent’s 

signature.


IEP Forms – Prior Written Notice 

Purpose: To provide parents with an opportunity to initiate dispute resolution 

procedures prior to the initiation of a change or service when they do not agree with the 

proposal of the district. 

Usage: Whenever the district is proposing or refusing something that might not be 

accepted by the parents. Only use this form under the direction of your special education 

administrator. 

Page 44 of 62 

Overview of Prior Written Notice 

Prior written notice is a legal concept that has been 

part of special education for since 1997. Colorado 

took advantage of PWN in designing some of the old 

forms, but did not completely cover the concept in 

the old form set. 

The intent of PWN is to afford parents the opportunity 

initiate Dispute Resolution procedures PRIOR to a 

school implementing or changing special education 

programming for a student. 

Components of PWN 

• A description of the action 

• A statement about why it is being proposed or 

refused 

• A description of the information was used to arrive at 

the decision; this may include: 

Cumulative File Review, grades, discipline reports, 

CSAP and other assessment, IEP, Eligibility 

Determination, ELL assessments 

• Documentation of the other options considered and 

why they were rejected 

• Any other factors influencing the decision 

• How to obtain information about their procedural 

safeguard 

When to Use This Form? 

• Prior written notice is embedded in the following 

forms and 

need not be completed separately: 

• IEP 

• IEP Amendment 

• Prior Notice and Consent for Evaluation 

• Prior Notice and Consent for Initial Provision of 

Special Education and Related Services 

• Only use this for other situations such as: 

• Contended change of placements 

• When parents request things in writing that are 

being refused 

• Refusal of a proposal of a parent such as to refer, 

evaluate, or for a specific service 

Involve your Director of Special Education in this 

process and the Director 

should be the only one to 

sign on a PWN refusal


IEP Forms List 

Eligibility Determination 

Special Education Referral (for Initial Eligibility) 

Prior Notice and Consent for Evaluation (signed) 

Optional – Referral Review and Evaluation Plan 

Notice of Meeting 

Evaluation Report 

Determination of Eligibility (for each area of suspected disability) 

Prior Notice and Initial Consent for Special Education and Related 

Services (signed) 

IEP Meeting 

Notice of Meeting (unless continued from Eligibility) 

IEP Team Member Excusal (signed) (if required) 

IEP Cover Page 

IEP Participants Page 

IEP Present Levels 

IEP Special Factors 

o Behavior Intervention Plan 

o Learning Media Plan 

o Communication Plan 

IEP Post School Considerations (age 15 or end of 9 th grade) 

IEP Goals and Objectives 

Past IEP Goals and Objectives with Progress Reported 

IEP Accommodations and Modifications 

IEP State and District Assessments 

IEP Service Delivery 

IEP Prior Written Notice 

Permission to Invite Agencies Related to Transition (age 15 or end of 

9 th grade) 

Page 45 of 62 

Transfer Students 

Transfer from within State (including entire file) 

Transfer from Another State (including entire file) 

Prior Notice and Initial Consent for Special Education and Related 

Services - Signed (if original is not part of the record) 

IEP Amendments 

Entire IEP or Signed IEP Amendment Form only 

Other Forms 

Prior Written Notice 

Request to Release of Secure Confidential Information 

ESY Determination 

IEP Progress Reports 

o Before Break 

o After Break 

o Weekly until skill is recouped 

Complete IEP Packet or IEP Amendment

Transition Requirements: 

Age appropriate transition assessment process used to develop the post school goals 

(page 3) 

Assessment data serve as the common thread in the transition process and form the basis for defining goals and services to 

be included in the Individualized Education Program (IEP). When a student is 15, but no later than the 9 th grade, an ageappropriate, 

transition focused assessment process must be used to identify post-school goals. This ongoing process 

includes both formal and informal methods of gathering data related to the student’s interests, preferences, aptitudes and 

abilities as they relate to and align with the skills needed for the student’s given interest area. Also, the demands of current 

and future employment, educational, living, and personal and social environments are considered. The assessment 

process evaluates all data to formulate decisions regarding the development of the transition/post-school plan; it is not the 

administration of a single assessment instrument. 

Types of transition assessments include behavioral assessment information, aptitude tests, interest and work values 

inventories, intelligence tests and achievement tests, personality or preference tests, career maturity or readiness tests, 

self-determination assessments, work-related temperament scales, and transition planning inventories. Transition-focused 

assessment is not required for eligibility and may not require parental permission to administer. Any assessment process 

should be indentified in this section of the IEP. 

Measurable Post-School Goals (page 3) are written for students who are age 15 (but not later than the 9 th grade). These 

goals identify dreams and plans for the future including work, academics, and adult living. It is critical that the student 

participates in the development of his or her measurable post-school goals. Measurable post-school goals must indicate 

what the student “will do” after graduation or exiting school district services through attainment of the maximum age of 

service provision (age 21). Measureable post-school goal statements should be written as complete sentences with an 

established timeline and observable (countable) outcome. 

Measurable post-school goals are required for two domains: postsecondary education and/or training and employment. A 

post-school goal for the domain reflecting independent living skills is required “when appropriate” based on the individual 

needs of the student as identified through the analysis of the age-appropriate transition focused assessment. Post-school 

goals are generally understood to refer to those goals that a child will achieve after leaving secondary school (i.e., high 

school), and are not the annual goals used to pursue annual academic, behavioral, and adult living skills. Rather, they guide 

the annual goals toward desired post-school aspirations. 

Measurable post-school goals are the cornerstone of effective transition planning and are written before the annual goals 

are developed so as to guide the planning process. Without a clear direction for post-school living, working, and learning, a 

comprehensive plan reflecting a coordinated set of activities designed within a results-oriented plan cannot occur. As teams 

design post-school goals, adherence to the following must be complete: 

• The Post School-Goals reflect an outcome NOT a process 

• Must be measurable (observable and defined) 

• Should reflect a real intent or plan (not simply stating the hopes and desires of a student, but an intentional plan to 

achieve the goal) 

• Must reflect the student’s interests and preferences 

• Must utilize assessment for development 

Sensitivity to the student and his/her family’s cultural, racial, and ethnic value systems must be considered in the 

development of the Post-School Goals. The family structure, personal resources, and familiar cultural norms are potentially 

all elements of scrutiny and consideration when developing the Post-School Goals and will guide the rest of the IEP. 

Examples and Non-Examples of Post-School Goals can be found in the Exemplars section of this manual. 

Completing Section 8 

Page 46 of 62 

Draft 5/19/08 96

To accurately complete the Section 8 of the IEP, the guidelines in the transition requirements section are essential and 

required. The post-school goals (Education/Training, Employment, and Independent Living Skills) need not be explicitly 

restated as they are already recorded in Section 6; however, accurate references to the stated post-school goals (PSGs) 

must be included. 

For each portion of Section 8, the components of transition planning and services have been listed separately in order to 

provide specific courses, services, and agency connections. Each of these components must be completed entirely so it 

can be used and implemented by school, family, and agency professionals. An appropriate description of the agency 

connection necessary including contact information, and steps for student/parents and the school to ensure the student is 

connected to the appropriate agency. 

It should be observed that although course of study and transition services are required, agency connections need only be 

identified if the agency is likely to pay for or provide services within the next 12-month period of the IEP. If agency 

connections are not required, a short explanation indicating why is suggested. 

Planned Course of Study 

A course of study can include course titles and descriptions of how the courses will lead to the acquisition of post-school 

goals. The course of study should: 

• Promote movement toward and skill acquisition for the post school goals 

• Indicate multi-year high school plan (current status to anticipated exit date) 

• Reflect the student’s preferences interests 

• Be related to student’s needs 

• Must be more specific than just completing graduation requirements 

• Should pass the stranger test (e.g., would someone unfamiliar with the student completely understand the 

courses necessary to facilitate a meaningful and effective transition-focused class schedule?) 

• Should be clearly transferable (e.g., can another school build a schedule based on the information in the 

course of study?) 

• Reflects skills (rather than course titles) to be obtained through courses (e.g., skills to develop a resume 

may be found in English III) 

• Provides a clear description of course needs resulting in the attainment of a diploma (or other completion 

document) and the post-school goals) 

Transition Services and Activities 

Instruction is one component of a transition program that the student needs to receive in specific areas to: 

• Complete needed courses 

• Succeed in the general curriculum 

• Gain needed skills 

Transition Services and activities may include related services, community experiences, and services related to employment 

and other adult living objectives such as acquisition of daily living skills. Related services include: 

• Transportation, 

• Developmental, corrective, and other supportive services including: 

√ speech-language pathology and audiology services, 

√ interpreting services 

√ psychological services 

√ physical and occupational therapy 

√ recreation, including therapeutic recreation 

√ social work services 

√ school nurse services 

√ counseling services including rehabilitation counseling 

√ orientation and mobility services 

√ medical services Page 47 of 62 

Draft 5/19/08 97

Community experiences are one component of a transition program that are provided outside the school building or in 

community settings. Examples could include: 

• Community-based work experiences and/ or exploration 

• Job site training 

• Banking 

• Shopping 

• Transportation 

• Counseling and recreation activities 

Employment and other post-school adult living objectives are components of a transition program required to achieve 

desired post-school goals. These objectives could range from services leading to a job or career to those that support 

activities done occasionally such as registering to vote, filing taxes, renting a home, accessing medical services, filing for 

insurance or accessing adult services such as Social Security Income (SSI). 

The acquisition of daily living skills describes one component of a transition program that may be considered “if appropriate” 

to support students’ ability to do the routine tasks of adulthood. These may include 

• Preparing meals 

• Budgeting 

• Maintaining a home 

• Paying bills 

• Caring for clothes 

• Grooming 

For each portion of Section 8 (page 5) that refers to Transition Services, the IEP Team must consider the aforementioned 

components while also including in the IEP documentation what the school (or adults in the student’s life) will provide for 

each post-school goal domain. There MUST be at least one Transition Service for each Post-School Goal Domain; 

however, it is possible that a number of the Transition Services components described above might apply to more than one 

post-school goal. The description of these services need not be duplications of the services outlined on the special 

education services page, but should include those services specifically designed to help the student move toward the 

attainment of his/her Post-School Goals. Examples can be found in the final section of this document, Exemplars (page 

____) 

Agency that may provide transition services in the coming school year 

The IEP Team must identify any potential adult service agencies that are necessary to facilitate transition to the 

implementation of Post-School Goals. These agencies may fund or provide transition services or supports in the coming 

year. Prior to inviting any agency(ies), the school must obtain written prior consent from the parent. Once an agency 

connection has been identified and the school has obtained the appropriate written consent to invite the agency, invitations 

to the appropriate agency(ies) should be extended. If a representative from agency is unable to attend, the school must 

ensure the parents/student understand the need to connect with the agency. Since actual eligibility for services from most 

agencies each requires unique intake processes, schools must make an effort to assist parents and students in compiling 

the necessary eligibility information. It is recommended that if an adult service agency’s involvement in essential for the 

effective transition of a student to his/her Post-School Goals, the following information be documented: 

• Agency name 

• Agency role (description of potential services) 

• Agency contact person including name, phone number, address, and email if available 

• A description of steps taken to involve the agency in the IEP planning process 

• A description of next steps the student and family should pursue in order to become eligible for services 

Again, if an adult service agency is NOT currently needed due to the student’s age, current needs for such services, or 

other factors, a simple description reflecting why agency connections are not necessary should be indicated. Examples of 

this documentation include: Page 48 of 62 

Draft 5/19/08 98

• “Student name is not currently eligible for services related to this Post School Goal at this time” 

• “Student and family have been informed of agency connections and potential benefits of eligibility and 

services but decline to pursue services at this time” 

• “Student is too young or services from adult agencies at this time” 

Exiting the System 

A student can exit the school system for a variety of reasons. A student exits special education upon graduating from high 

school with a regular high school diploma or upon reaching the age of 21. A student may also exit special education if upon 

re-evaluation, it is found that the student is no longer eligible for special education. When students exit school on their own 

volition, prior to a formal exit, they are considered to have “dropped out” of the system. 

Page 49 of 62 

Draft 5/19/08 99

Exemplars: 

POST SCHOOL GOAL EXAMPLES & NON-EXAMPLES 

Post-School Training Goal 

• NON-EXAMPLE: Something in emergency medical services. 

Or 

• EXAMPLE: William will attend in an Emergency Medical Technician training program and work for the fire 

department, hospital, or ambulance service. 

Post-School Education Goal 

• NON-EXAMPLE: Go to some program in computers. 

Or 

• EXAMPLE: Tanya will attend college full time at the XYZ Community College and obtain an associates degree in 

computer networking. 

Employment Goal 

• NON-EXAMPLE: Something in computers. 

Or 

• Example: Josh will work as a computer technician repairing computers or developing and maintaining computer 

networks. 

Independent Living Skills Goal 

• NON-EXAMPLE On my own. 

Or 

• EXAMPLE: Mike will maintain his own apartment by independently paying bills on time, making meals, buying 

groceries, and maintaining sanitary conditions. 

More… 

Draft 5/19/08 

103 

• After leaving High School, Paul will enroll in the 2-year community college. 

• After graduation in the fall semester of 2007, Jane will attend the Lake Forrest Culinary Arts School. 

• Upon graduating from high school, Thomas will work part time in the food service industry. 

• After High School, Paulette will work full time in her community; she would like to pursue a job in retail. 

• After High school, Roger will work part time with support. 

• After leaving the Lafayette School District, Jamie will work at the Johnson County Community Based 

Employment Enclave with support. 

• In the fall of 2007 after graduation, Eric will use the local public transportation system to get him from home to 

work and back. 

• In the fall of 2007 after graduation, Annette will prepare a meal for herself independently once per week. 

• After graduating from high school, John will independently manage his own checkbook, bills, and budget. 

• After receiving her diploma, Mary will live at home with her parents until adults services resources can be 

acquired, during this time she will not work 

As an example, if a student were to have a Post-School Goal for Education/Training: “Amy will attend XYZ 

Community College after graduation to study nursing,” the IEP might contain the following service statement: 

During the course of the next year (IEP period), the special education staff will provide Amy with resource 

class support for language arts and writing. Specific skill development will target decoding of large 

medically-related terminology, utilization of context cues in reading to increase reading comprehension as 

well as effective use of dictionary or online resources. Amy will be provided support from the school nursing 

Page 50 of 62

Draft 5/19/08 

104 

staff to both teach Amy to self-administer her own Insulin as well as provide job shadowing experience and 

support related to the nursing profession. During the course of the school year, through coordination by 

Amy’s case manager, Amy will have the opportunity to visit at least three different nursing stations within 

the local community hospital. Amy will also be accompanied to the XYZ community college Disability 

Access Center to attain accommodations for her Accu-placer (college entry) exams as well as determine 

supports for attending college. The Disability Access Center has also agreed to provide a campus tour to 

orient Amy to the campus and its resources. Amy’s case manager will (with appropriate releases from Amy 

and her parents) provide copies of her most recent assessment data and IEP so Amy may provide this 

information to the XYZ community college Disability Access Center. In order to ensure Amy is able to get 

to and from home and college, Amy will be provided instruction in riding the local RTD as well as instruction 

in reading/interpreting the local bus maps. 

In the example above is designed to reflect the transition services for the Post-School Goal of Education and Training only, 

and illustrates instructional services, related services, community experiences and the acquisition of daily living skills. It is 

important to note that no one single transition services component solely aligns with any one single Post –School Goal 

Page 51 of 62

Linkin g Post-school 

Goals and Annual IEP Goals 

Provided by Julia Lang, Transition, Roaring Fork SD 

Post-School Goals 

A post-school goal is "generally understood to refer to those goals that a child hopes to achieve after leaving 

secondary school (i.e., high school)" (IDEA 2004 Part B Regulations, §300.320(b), discussion of Final Rule 

p. 46,668). 

√ A post-school goal (PSG) is not the process of pursuing or moving toward a desired outcome. 

√ A PSG must be “measurable.” 

√ A PSG must be a clear goal for the “next step” (12-24 months after the student’s high school 

graduation but not their dream life in 5,10, or 20 years). 1 

Annual IEP Goals 

Annual goals are "statements that describe what a child with a disability can reasonably be expected to 

accomplish (e.g., master some skill or knowledge [not an activity]) within a twelve month period in the child's 

special education program." (Source: Retrieved June 15, 2006, from 

http://www.calstat.org/iep/6_reading.shtml). 

√ Annual IEP Goals are skills needed for improvement. 

√ Annual IEP Goals are skills needed to reach PSG! 

√ Annual IEP Goals must link to the PSG (at least one… why not all?). 

√ see. 1 

Annual IEP Goals must have a verb/action word that you can 

Examples of Linking Post-school Goals with Annual IEP Goals: 

PSG= Post-school Goal, 

Post school Goal, Post school Outcome 

AG 

= Annual IEP Goal 

Education 

Training Domain: 

PSG Example: 

Upon completion of high school, John will enroll in courses at Ocean County Community College. 

AG Example: 

Given Ocean County Community College information, John will demonstrate knowledge of the college's 

admission requirements by verbally describing these requirements and identifying admission deadlines with 

90% accuracy by November 2007. 

Note that there would likely be less specificity in the post-school goals articulated by younger students than 

those in their last years of high school. John's goal could be made more 

specific by including a phrase such 

as "will enroll in the general 

Associates Degree program at...” 

PSG Example: 

Allison will obtain a four-year degree from a liberal arts college with major in Child Development. 

AG Example: 

Allison will increase algebra skills, as measured by pre and post-tests, by an increase of 30% by March 

th 

15 , 2008. 

Allison will demonstrate 

all classes every day. 

the organizational skills of using a planner to record her homework assignments for 

It is not necessary to specify the student's major for the goal to be measurable, however, increased 

specificity in post-school goal statements (when the student articulates this information) can improve the 

relevance of services provided during high school. 

Page 52 of 62

PSG Example: 

After graduation, Rolanda will participate in an in-home or center-based program designed to provide 

habilitative and vocational training with medical and therapeutic supports. 

AG Example: 

Given a board displaying four choices of classroom and community topics (e.g., instructional activities, 

work-based instruction activities, locations in the school, movies, music, locations in the community, 

people), Rolanda will use a pointer affixed to a head-piece to select the activity or item in which she wants 

to engage with 80% 

accuracy. 

PSG Example: 

The fall after high school, Jodi will enroll in courses (non-degree) at Gaston Community College. 

AG Example: 

Jodi will improve her reading comprehension scores by one grade level through daily instruction using highinterest 

reading materials such as the newspaper, teen magazines, and young adult women's magazines, 

school-approved websites, and short stories for adults by April 1, 2007. 

Employment Domain: 

PSG Example: 

John will work in an on-campus part-time job while in college. 

AG Example: 

John will be able to report three possible occupations for part-time employment, based on the results of 

career assessments 

through career counseling with the guidance counselor. 

PSG Example: 

After college, Allison will have a career in the field of early childhood education. 

AG Example: 

Allison will describe the similarities and differences of various early childhood careers in a two- page essay 

after conducting four structured interviews of employees in the field of early childhood including (a) a 

professor, (b) a child care director, and (c) a preschool teacher, during the fall semester of this IEP. 

PSG Example: 

In the future, Jamarreo will be a self-employed welder. 

AG Example: 

Jamarreo will achieve mastery (95% or better accuracy) of welding safety skills by completing an orientation 

course on welding safety by March 15, 2007. 

Independent Living Domain: 

PSG Example: 

Upon completion of high school, Lissette will utilize public transportation, including the public bus and 

uptown trolley. 

AG Example: 

Given travel-training situations, Lissette will demonstrate sitting quietly and refraining from talking to 

strangers while utilizing 

public transportation at least two out of three opportunities. 

PSG Example: 

Upon completion of high school, Jeremy will independently prepare for work each day, including dressing, 

making his bed, making his lunch, and accessing transportation. 

AG Example: 

Given the ingredients for a sandwich and task analysis, Jeremy will follow the steps to make a sandwich 

with 90% accuracy 

by June 2007. 

PSG Example: 

Upon completion of high school, Paulo will play soccer in a recreational soccer league at the YMCA. 

AG Example: 

Paulo will complete the YMCA application by writing his personal information in the spaces provided with 

90% accuracy by January 2008. 

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PSGs and Annual IEP Goal(s) may be written to include more than one domain (education training, 

employment, independent living). 

Both 

Education Training and Employment Domains: 

PSG Example: 

After graduating from high school, Jason will enroll in a four-year college to obtain his undergraduate 

degree in history and education, to become a high school social studies teacher. 

AG Example: 

Through participation in the district's teacher mentor program, Jason will write an essay about his 

expectations for his future career, including statements of (a) a goal (b) 3 or more negative aspects of 

teaching, (c) 3 or more positive aspects of teaching and (d) a summary statement of the mentor program 

experience with 80% or better accuracy in grammar and spelling by March 2008. 

1 Resources Cited: 

NSTTAC Web-based Training Materials, September 2007 

Colorado 

Department of Education Summer Institute, June 2008, JonPaul Burden, Triangulating Annual Goals 

with 

Post-school Goals, State Standards & Industry Skill Competencies PowerPoint Presentation 

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POST SCHOOL OUTCOMES EXIT SURVEY 

This page must be completed for all students, 16 years or older, with an IEP and exiting secondary school. 

Return this Form to the BOCES Office for follow-up one year after exit. 

Student Name: Date of Birth: 

State Student Identification Number: (SASID) Date Student Exited School: 

Exit Reason: (Check each option that applies) 

Graduated with a Diploma (6) Certificate of Completion, Modified Diploma (7) 

Reached Maximum Age (8) Completed a GED 

Dropped Out of School (5) Moved/Not Known to be Continuing (4) 

1. Is/was a postsecondary transition(s) goal(s) included on the student’s IEP in the final year of high school? 

NO 

YES If Yes, indicate goal(s): (Check each option that applies) 

Employment Postsecondary Education/Training 

Independent Living Information Is Not Available/Don’t Know 

Other (please specify): 

2. Prior to exiting public school, does/did the student participate in any of the following? (Check each option that applies.) 

Volunteer Work Experience/Work Study/Internship 

Paid/Competitive Employment Information Is Not Available/Don’t Know 

3. Prior to exiting public school, is/was the student referred to any of the following? (Check each option that applies.) 

Vocational Rehabilitation or SWAP (School to Work Alliance Program) 

Mental Health Services 

Social Security Administration for Benefits 

Community Centered Board (CCB) (Developmental Disabilities Services) 

Other (please specify): 

Information Is Not Available/Don’t Know 

CONTACT INFORMATION AFTER LEAVING HIGH SCHOOL 

Please indicate most permanent or reliable information. 

Student Name: 

Permanent Address: 

City: State: Zip Code: 

Home Phone: Cell Phone: E-Mail: 

Family Member Name: 




Additional Contact: 




Optional Signature Section 

I have been notified that I may be contacted one year after exiting from secondary school for follow-up. I understand that my 

signature is recognition of notification and does not obligate me to participate in the follow-up data collection. 

Student Signature Date Parent Signature Date 

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POST SCHOOL OUTCOMES EXIT SURVEY 

DIRECTIONS 

The Post School Outcomes Exit Survey is designed to gather contact information from students 

16 years of age or older with IEPs who are exiting secondary education. This information will be used 

to contact a random sample of students one year after exiting to gather information on their post school 

activities. This collection is a federal requirement under IDEA 04. More importantly, this data will help 

school districts and the Colorado Department of Education answer the “so what” question regarding 

secondary education, special education, and transition services. It is important to understand the 

relationships between services and outcomes to help the education community continue to improve 

services for all students. 

Please carefully complete the following survey. The contact information is critical for the one 

year follow-up data collection effort. Gather the contact information from the student and his/her 

parent/guardian with an emphasis on attaining the most permanent contact information, and explain that 

a follow-up survey will be conducted one year from exiting the secondary education system. Included is 

a signature section which is optional, but best practice is to have both the student and parent sign the 

form. It is important to note that the signatures indicate notification of this process and does not obligate 

either the student or parent to participate in the follow-up. Please assure students and parents/guardians 

that completion of the follow-up survey is important and meaningful to education in Colorado. 

The Colorado Department of Education suggests that this exit survey be completed with the 

Summary of Performance process. For students who exit by means other than the attainment of a 

diploma or aging out, the exit survey will need to be completed without the Summary of Performance 

process. This form will be used beginning the 2005-06 school year and continued each year. For 

students who exit the education system during the school year, it is recommended that this form be 

completed within 30 days after the student leaves. 

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SUMMARY OF PERFORMANCE 

Part 1: Student Information: Complete and up-to-date information is crucial 

Student Name: DOB: Exit Date: Date form Completed: 

Primary disability: _______________________ Secondary disability: _______________________ 

Address: 

Street Town/City Zip Code 

Phone: Cell #: Email: 

Name person completing this form: 

To obtain a copy of transcripts, contact the school guidance office at: 

Phone 

To obtain copies of Special Education documentation, contact the Office of Special Education at: 

Part 2: Summary of Performance: Based on age-appropriate abilities, assessment and tied to the student’s post high school goals. 

Academic Achievement & 

Cognitive Performance 

Reading 

(Basic reading/decoding, reading 

comprehension, reading speed) 

Math 

(Calculation skills, math problem 

solving) 

Written Language 

(Written composition, written 

expression, spelling) 

Learning styles & needs 

(class participation, note taking, 

keyboarding, organization, homework 

management, time management, 

study skills, test-taking skills) 

General Ability and 

Problem Solving 

(reasoning/processing) 

Strength 

Limitation 

For each applicable content area, include a brief description of the 

Current Level of Performance (strengths, needs, grade level, 

assessment summary) 

Attention and Executive 

Functioning 

(energy level, sustained attention, 

memory functions, processing speed, 

impulse control, activity level) 

Currently Utilized and Anticipated Effective Accommodations, modifications, Assistive Technology and Supports 

Colorado Department of Education, Exceptional Student Services Unit 

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Part 2: Summary of Performance: Based on age appropriate abilities, assessment, and the student’s post high school goals. 

Functional Performance 

Social, Interpersonal, 

Behavior Skills 

(Interactions with others, emotional or 

behavioral issues related to learning 

and/or attention) 

Independent Living Skills 

(Self-care, leisure skills, personal 

safety, Personal Hygiene, 

transportation, banking, budgeting) 

Environmental Access/ 

Motor & Mobility Skills 

(assistive technology or other special 

accommodations) 

Self Determination & 

Advocacy 

(ability to identify and articulate 

learning strengths and needs, ability 

to ask for assistance with learning and 

independence) 

Self Direction 

(Ability to: follow & understand 

directions (written or verbal), complete 

tasks, work independently, ask for 

assistance when necessary, use 

feedback to improve or correct work 

performance, initiate work activity) 

Communication 

(speech/language, augmentative 

communication) 

Career & Vocational 

(Career interests, career exploration 

opportunities, job-training 

opportunities) 

Work Tolerance & 

Work Skills 

(The capacity to meet the physical 

and psychological demands of work 

and to learn and perform job tasks) 

Strength 

Limitation 

If marked strength or limitation, describe functional capacities and how 

they may relate to post high school performance in work, community, or 

educational settings. 

Additional important information and considerations that can assist in making decisions about disability determination and 

needed accommodations (e.g., medical problems, family concerns, sleep disturbance) 


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Part 3: Recommendations to Assist the Student in Achieving Measurable Post High School Goals: 

This section presents recommendations to the student, family and others utilizing this form for accommodations, adaptive devices, 

assistive services, compensatory strategies, and/or support services, to enhance access and participation in post high school goals. 

(These recommendations in no way obligate any post high school agency to such recommendations.) 

Recommendations to Assist the Student in Achieving Measurable Post high school Goals 

Post High School 

Area 

Employment 

Education 

Training 

Independent 

Living (where 

appropriate): 

Recommendations to Assist the Student in Meeting 

Post High School Goals 


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Agency(s) Contact Information : name and/or 

Title, Phone Number, Address, or Email 

(include both agencies currently contacted and those that may need 

contacted) 

Part 4: Associated Relevant Documentation Summary: List student documentation attached to and provided with 

this summary (important documentation might include: most recent Triennial IEP, Assessment documentation, psychological 

reports, aptitude results, interest inventories… any documentation related to eligibility or associated with attainment of post high 

school goals). 

I have received a copy of the Summary of Performance and have reviewed its contents with the primary Special Education 

Provider. 

____________________________________ _______ _ ________________________________ _______ 

Student Signature Date Parent Signature Date

Part 5: Student Input (Recommended/Supplemental Information): Review these questions with the student 

prior to completion of the Summary of Performance. (Questions may be read to the student and written by teacher as 

accommodation if necessary. 

A. How or in which area(s) does your disability affect your schoolwork and school activities such as: (check all that 

apply) 

time extra-curricular 

Grades relationships assignment projects communication on tests mobility activities 

Please describe how: 

Other (please describe): 

B. What supports or accommodations have helped you to succeed in school? (check all that apply) 

adaptive extra time audio teacher alternative study 

equipment tests/assignments books notes assignments hall 

Other (please describe): 

C. What supports or accommodations do you feel you will need to achieve your goals after high school? 

D. If you believe that you will need services, supports, programs, or accommodations: 

Have you and your family made a connection with the agencies (other than your current school) that can help 

you with these needs? 

Will you need help to obtain any needed services, supports, programs, or accommodations after you leave high 

school? 

E. What strengths and needs should future employers or teachers know about you as you enter the college or work 

environment? 

Student Signature: ______________________________________ Date: _____________________ 


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IEP Roles and Responsibilities in Charter Schools: 

Children with disabilities who attend public charter schools and their parents retain all of the rights and protections of the 

IDEA. An administrative unit must serve children with disabilities attending charter schools in the same manner as the 

administrative unit serves children with disabilities in its other schools, including providing supplementary and related 

services on site at the charter school to the same extent to which the administrative unit provides such services on the site 

to its other public schools. 

In Colorado, how an administrative unit provides special education services is based on the service delivery/funding model 

that is negotiated between the charter school and its authorizer. There are several service delivery models: 

Draft 5/19/08 

100 

• Insurance model: Under the insurance model, the charter school pays an “insurance” premium to the 

administrative unit to provide all special education and related services for children with disabilities 

attending the charter school. 

• Contracted model: Under the contracted model, the administrative unit passes through to the charter school 

its share of special education funding and the charter school hires or contracts with third party special 

education service providers to provide special education and related services for children with disabilities 

attending the school. 

• Combination/Modified Insurance model: Under the combination/modified insurance model, the charter 

school and its authorizer negotiate responsibility and funding for special education and related services. 

The charter school may hire some of its staff and negotiate with its authorizer for the administrative unit to 

provide some services. 

Responsibility for the referral, evaluation and IEP processes are determined by the service delivery model negotiated by the 

charter school and its authorizer. However, the same referral, evaluation, and IEP requirements apply to children with 

disabilities attending charter schools. Additionally, an IEP for a charter school student must contain a statement that 

specifies whether the child shall achieve the content standards adopted by the school district in which the child is enrolled or 

the charter school institute; or whether the child shall achieve individualized standards which would indicate that the child 

has met the requirements of his/her IEP. 

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IEP Roles and Responsibilities for Parentally-Placed 

Private School Children with Disabilities: 

The IDEA requires an administrative unit to locate, to identify, and to evaluate all children with disabilities who are enrolled 

by their parents in private, nonprofit (including religious) elementary and secondary schools located in their school district. 

This child find activity is designed to ensure the equitable participation of parentally-placed private school children and to get 

an accurate count of those children. The timelines for initial evaluations apply. An administrative unit must spend a 

proportional amount of Part B federal special education funding on providing education and related services including direct 

services to parentally placed private school children. How the funds are used for equitable participation is determined by 

meaningful consultation with private school representatives and representatives of parentally-placed private school children. 

When a parentally-placed private school child with a disability is identified, it is important to note that there is not an 

individual right to receive some or all of the special education and related services the child would receive if he/she were 

enrolled in a public school. If a parentally-placed private school child with a disability receives services, it is based on a 

services plan. Although similar, a services plan is not an IEP. A services plan need only describe the specific special 

education and related services that the administrative unit will provide to the child in light of the determination of how the 

administrative unit’s proportionate funds are spent. However, a services plan should be developed, reviewed, and revised 

consistent with the IEP timelines. 

Draft 5/19/08 

101 

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Forms Manual - NW Colorado BOCES

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