Special Ed 101 IEP Presentation.pdf - West End SELPA

Training for
West End SELPA
Community Advisory Committee
October 9, 2012
Special Education 101
Presented by
Amy Foody, Program Manager
Susan Bobbitt-Voth, SELPA Administrator

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Special Education 101
Table of Contents
Introduction
Parent/Guardian Notice Of Individualized Education Program Meeting
Meeting Notices
Assessment Plan
Prior Written Notice for Assessment
IEP Form – IEP Cover Page
IEP Form – Present Levels of Academic Achievement & Functional Performance
Behavior Support Plan
IEP Form – Accommodations and Testing
IEP Form – Individual Transition Plan (ITP)
IEP Form – Annual Goals
Progress Reports
IEP Form – Services – Offer of FAPE
IEP Form – IEP Team Meeting Notes
Specific Learning Disability Team Determination of Eligibility
Specific Learning Disability Discrepancy Documentation Report
(Individualized Education Program Team Certification)
English Language Development (ELD)for English Language Learners(ELL)
IEP Form – Signature and Parent Consent
Appendix A – Special Education Timelines
Appendix B – Glossary of Terms
Appendix C – 2010-2011 CASEMIS Codes
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TIPS FOR PARENT PARTICIPATION IN IEP MEETINGS
Introduction
As parents, your involvement in the individualized education program (IEP) meeting is vital. For students under age 18 for
whom no guardian or conservator has been appointed, no part of the student's IEP will be implemented without your
written consent. You may consent to the entire plan, or may give consent to only those parts you feel are appropriate for
the student's educational program.
Before the IEP Team Meeting
Become knowledgeable about your student's disability and abilities, and how they impact school performance.
Form a relationship with your student’s special education teacher and establish a mutually agreed upon homeschool
communication system. Talk to your student's special education teacher before an IEP meeting so you
both can think about successful options or outcomes for your student.
Whenever possible, it is helpful for both parents to attend the IEP meeting. If this is not possible, you may want a
friend or relative to attend with you.
If there is someone you would like to be at the IEP meeting, let the case manager know so that person can be
invited, or you may personally invite that person.
Should you not be able to attend a scheduled IEP meeting, you can:
o ask that it be rescheduled;
o participate via a conference call;
o send a representative; or
o speak to the student's special education teacher or case manager and determine if the IEP meeting can
proceed and the paperwork can be sent to you for your approval.
If you need more than the time allotted on the notice of meeting, call the case manager to reschedule your
meeting.
Review your student’s current IEP and other reports you may have on file. If you don’t have your student’s last IEP,
contact your case manager for a copy.
Discuss with your student any concerns or questions he/she may have regarding their educational needs. Involving
your student in their IEP meeting is crucial in developing self-advocacy skills and an awareness of their strengths and
weaknesses.
Make a list of questions or concerns before the meeting so that you don’t forget them as the meeting proceeds.
During the IEP Team Meeting
Be an assertive parent. Assertiveness is the key to effective communication. It involves parents organizing their
thoughts, clearly expressing their opinions and requesting reasonable options in planning for their student. It also
involves listening carefully to the opinions of school personnel, asking questions for clarification, and remaining
objective about suggestions given. Assertiveness is not the same as aggressiveness.
Above all, ask questions at the IEP meeting. Some parents do not ask questions because they feel it makes them
appear unintelligent or unsophisticated. Feel free to ask those questions! The other team members will appreciate
your questions and realize that you are there to do the best job possible for your student. Some possible questions
might include:
o What kind of disability does my student have
o What does the disability specifically mean/involve
o What is my son’s/daughter’s learning style
o How can I assist my student at home
o Will my student “outgrow” his/her disability
o Will my student be able to earn a diploma
o Will my student be able to obtain a job after graduation
o
o
What can I do to help develop the individualized transition plan
Will my student need any special assistance outside of the classroom or the school system What help is
available

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Are there support groups available to me
If a program or service is being discussed, ask what that program or service can provide your student. If you need
more information before you can give informed consent regarding a proposed program or service, ask to schedule
another IEP meeting and thereby provide you with time to look into the proposed options.
If your student is different at home than he/she is being described at school, share that important information with
the IEP team. You know your student the best. Share what strategies you have found to be successful with your
student. Also, share what you know has not worked with your student in the past.
Request definitions of unfamiliar terms. Sometimes school personnel forget that you don’t use these terms on a
daily basis and assume you understand.
After the IEP Team Meeting
Make sure that you receive a clear, readable copy of the IEP.
When you leave the IEP meeting, you should be able to discuss your student's strengths and challenges. You
should also understand what services will be provided to help your student in his/her areas of need. Should you
get home and have questions, call your student’s special education teacher or case manager for clarification. If
another meeting is needed, it can be scheduled through the case manager.
Follow-up and report back to the IEP team if you agree to carry out a recommendation.
Monitor your student’s progress. If things are not going well, contact your student’s special education teacher.
Another IEP meeting may need to be scheduled.
Express appreciation to the other team members! Write a note to the supervisor of the people who have gone
out of their way to be helpful. (Sometimes we are quick to put our complaints and demands in writing. We should
be just as quick to write a note of appreciation. “Thank you notes” are rare and very much appreciated.)
Remember - It’s a Cooperative Effort
The IEP team's purpose is to help your student be successful in his/her education. It is a partnership between all
members. Let the school know if there are ways we can better serve you or your student.
Tips to Using this Handbook
The materials in this handbook are organized in a manner to assist parents in understanding the construction of the IEP
document. The forms that are most commonly included in IEPs are included. IEP meetings are held for a variety of
reasons and additional forms are used for those purposes.
The forms are those adopted by the West End SELPA for 2012-13. Comments from the IEP Manual have been added to
the forms in an effort to inform the reader of the contents to be included in the sections of the forms contained in this
handbook.
This handbook has been designed for the CAC Special Education 101 training to be presented on October 9, 2012.
Our motto at West End SELPA is “There is a child in everything we do.” The IEP is a tool that when designed through the
collaborative effort by the IEP team leads to a student-centered plan.
Credit: Grossmont Union High School District: Parent Handbook
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PARENT/GUARDIAN NOTICE OF INDIVIDUALIZED EDUCATION PROGRAM MEETING
The meeting notice is used to notify a parent and members of a student’s IEP team of an upcoming
IEP meeting. Parents or guardians shall be notified of the IEP meeting early enough to ensure an
opportunity to attend. WESELPA suggests that a minimum of ten days’ notice is appropriate. The
meeting shall be scheduled at a mutually agreed upon time and place.
IEP meetings are required at least annually to review the pupil’s progress.
IEP meetings are also required to review the results of an assessment, when the
student demonstrates a lack of anticipated progress, or when the parent requests a
meeting to develop, review or revise the individual education program.
An IEP shall be in place prior to the beginning of the school year for every eligible
student.
An IEP meeting requested by a parent to review the IEP shall be held within 30 days,
not counting days between the pupil’s regular school sessions, terms or days of school
vacation in excess of 5 school days, from the date of receipt of the parent’s written
request. If a parent makes an oral request, the school district shall notify the parent
of the need for a written request and the procedure for filing a written request.

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PARENT/GUARDIAN NOTICE OF INDIVIDUALIZED EDUCATION PROGRAM MEETING
SELPA: West End SELPA
DISTRICT:
Last Name First Name DOB School:
Address: Contact Phone:
We are planning a meeting to discuss or review your child’s need for special education and/or services; to recommend an
appropriate educational placement; if special education is appropriate; to develop an individualized educational program (IEP).
You will be provided a copy of your child’s assessment(s). You are invited to attend and participate in your child’s IEP meeting. In
addition, you may bring a representative with you or designate another person to be your representative if you are unable to
attend. You also have the right to bring additional participants who have knowledge or special expertise regarding your child to the
meeting.
Parent/Guardian:
Purpose of Meeting: Check the box to indicate what
type of meeting is being proposed.
Initial Annual Triennial ITP
Post-Secondary Goals and/or Transition Services
Other:
Case Manager: Enter the name of the case
manager and his/her telephone number.
Contact Info:
Date Delivered/Mailed Notice:
We have scheduled the IEP meeting for:
Date: Enter the date of the IEP meeting.
Time: Place:
Address: Enter the address of the building where the
meeting is being held
IEP Team Members invited to attend: Check all appropriate boxes. The line next to the title may be used to indicate the name of the person in the role.
The following area would be completed to excuse a member of the IEP team in whole or in part if both the
parent and LEA agree.
Each district designates who may on behalf of the district provide consent for excusal.
By mutual agreement between the parent/adult student and designated representative of the local education agency, the
attendance and participation of the IEP member(s) identified below is not necessary and has been excused from attending and
participating in the meeting scheduled above because 1) the member’s area of the curriculum or related services is not being
modified or discussed in the meeting; or 2) the meeting involves a modification to or discussion of the member’s area of curriculum
or related services and the member has conferred with the parent/guardian/adult student and submitted, in writing to the
parent/guardian/adult student and the IEP team input into the development of the IEP prior to the meeting.
IEP Team Member(s)
Identify by title the IEP team member
being excused.
Area of Curriculum or Related
Services
Identify the area of
curriculum or related
service that pertains to
the IEP team member
being excused.
(1) Not Being
Modified or
Discussed
Check if the
area of curriculum
or related service
is not going to be
discussed at the
meeting.
Please Check Your Participation, Sign and Return this Notice Prior to the IEP Meeting
I plan to attend the meeting.
I plan to attend and I will be bringing a representative.
I do not plan to attend the meeting but request the meeting be held in my absence.
I cannot attend the meeting but plan on sending the following representative:
This date would be difficult for me to attend; the following three dates would better allow for my participation:
(2) Written Input to be
Provided Prior to Meeting
Check when the area of
curriculum or related
service is not going to be
discussed at the meeting.
If this is the case the
member seeking excusal
must provide the parent
and team a written report
prior to the meeting
The bottom area is reserved for the parent to use to communicate to the school his/her attendance
Date Date Date
Parent's Signature or Adult Student's Signature (Age 18-21)
Date
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ASSESSMENT PLAN
The assessment plan is to be completed by the assessment team and approved by the parent in writing at the initial
referral for special education and/or request for assessment and each time the Local Education Agency (LEA)/District
proposes to conduct assessment.
For assessments, Prior Written Notice Form and procedural safeguards must be sent.
An assessment plan must be completed and signed and agreed to by the parent if the
district plans to administer testing to the student that is not part of an assessment being
administered to all or a group of students.
1. Student Information: fill in information about the student as stated.
2. Purpose: Check the box indicating the reason for the assessment.
3. Areas of Assessment: Check the boxes to the left of each category of assessment that will be administered.
On the line at the bottom of the box, state the professional title of the examiner that will be administering the
assessment such as Speech & Language Specialist, Special Education Teacher, School Psychologist, NPA, etc.
For “additional and/or alternate means of assessment” list the alternate types of assessment that will be
conducted such as criterion referenced, observation.
4. Parental Consent for Assessment: Parent uses this area to indicate consent to the assessment.
If parent does not indicate consent or modifies the assessment plan contact the district
Director of Special Education.
For Office Use Only
1. Date delivered/mailed to parent/guardian: Enter date the assessment plan was sent to or given to the
parents.
2. Case Manager: Enter name of Case Manager.
3. Date received by case manager: Enter the date the signed assessment is received.
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INDIVIDUAL ASSESSMENT PLAN
The assessment plan is to be completed by the assessment team and approved by the parent in writing at the
initial referral for special education and/or request for assessment and each time the Local Education Agency
(LEA)/District proposes to conduct assessment
SELPA:
DISTRICT:
Last Name First Name DOB School:
CSIS ID: Primary Student Language: EL: No Yes
English Proficiency: Fluent Limited
Purpose: Initial Triennial Transition Other
This individual assessment plan is proposed to assist in determining your child's specific educational needs. All assessments will be given by appropriately qualified
personnel. The assessment will be in the areas checked below and may include pupil observation in a group setting, classroom work samples, district or statewide
group assessments, individualized testing, teacher interview(s), and an interview with you. It may also include a review of reports you have authorized us to request
or that already exist in our current records. No individualized education program will result from the assessment without the consent of the parent.
ACADEMIC/PRE-ACADEMIC ACHIEVEMENT
These observations and tests measures may include basic reading and
comprehension, written expression, math calculation and reasoning, oral
expression and/or listening comprehension.
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SOCIAL/EMOTIONAL BEHAVIORS STATUS
These observations and tests measure the ability to build and maintain
satisfactory relationships and demonstrate appropriate behavior across
situations.
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Personnel Responsible:
INTELLECTUAL DEVELOPMENT
These observations and tests measure the ability to utilize information to
problem solve in both familiar and new situations. These tests also reflect
learning rate and assist in predicting how well the individual may do in school.
Verbal and non-verbal tests may be used, as appropriate. These tests may
include the basic psychological processes of auditory, attention, visual and
sensory motor.
Personnel Responsible:
LANGUAGE/SPEECH/COMMUNICATION DEVELOPMENT
These observations and tests measure the ability to understand, relate to and
use language and speech clearly and appropriately. These tests may also
measure auditory processing skills.
Personnel Responsible:
PSYCHO-MOTOR DEVELOPMENT
These observations and tests measure the ability to coordinate body
movements in both small and large muscle activities. These tests may also
measure visual perceptual skills.
Personnel Responsible:
HEALTH/VISION/HEARING
These observations and tests measure vision, low vision, hearing, health,
developmental history and medical history, as well as a review of medical
records.
Personnel Responsible:
Personnel Responsible:
FUNCTIONAL BEHAVIORAL ASSESSMENT(FBA)
Functional Behavioral Assessment is considered to be a problem-solving
process for addressing student problem behavior. It relies on a variety of direct
and indirect techniques and strategies to identify the purposes of specific
behavior and to help the IEP team select interventions to directly address the
problem behavior.
Personnel Responsible:
FUNCTIONAL ANALYSIS ASSESSMENT(FAA)
The IEP team has identified a "serious behavior" that is interfering with the
student's ability to demonstrate progress towards their goals and previously
attempted behavioral/instructional approaches specified in the IEP have been
deemed ineffective. The team will expand to include a Behavioral Intervention
Case manager (BICM) and conduct a Functional Analysis Assessment (FAA).
Serious behavior defined in California Education Code 56520. is:(check all that
apply and define for the BICM)
Assaultive Serious property damage Self-injurious
Other pervasive maladaptive behavior:
Personnel Responsible:
ADDITIONAL AND/OR ALTERNATIVE ASSESSMENT
Describe any additional and/or alternative assessments to be used when typical
standard assessments are not advised or may be considered invalid:
Personnel Responsible:
SELF-HELP/CAREER/VOCATIONAL ABILITIES
RECENT EVALUATIONS/INDEPENDENT EVALUATIONS
These observations and tests measure a student's daily living skills and adaptive The following will be considered:
functioning across different settings. In addition career and vocational tests
measure interest and abilities relative to levels of skill development, work
readiness, and/or occupational preparation.
Personnel Responsible:
Personnel Responsible:
PARENTAL CONSENT FOR ASSESSMENT
Yes, I give my permission to conduct this assessment
No, I do not give my permission for this assessment
I would like the following assessment information to also be considered:
Parent Signature:
Please sign, retain a copy for your own records, and return the original assessment plan within 15 calendar days.
For Office Use Only:
Case Manager:
Date Delivered/Mailed to Parent/Guardian:
Date Received by Case Manager:
Enclosed(1):Parental Rights and Procedural Safeguards
Date:
Educational Benefit: Is the assessment complete and does it identify the student’s needs (Must assess all
areas of suspected disability
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Last Name First Name DOB IEP Date:
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IDEA requires districts to provide prior written notice any time a district proposes a change in the
identification, evaluation or education placement of a student. This prior written notice form meets this
requirement in regard to evaluation, and must be sent with the assessment plan.
Description of Proposed Action and Reason: Describe the type of evaluation being proposed.
The following were used as a basis for the proposed assessment: Identify the information that was reviewed when
determining an assessment was needed.
The following alternatives to an assessment were considered and rejected: Identify any options that were considered
instead of conducting the assessment. Other alternatives not listed might include intervention programs
offered, curriculum adaptations, etc.
The above alternatives were rejected for the following reasons: Provide a reason the alternatives to assessment were
rejected.
Other factors relevant to the district’s proposal for an assessment: List any relevant factors that were considered, for
example the student has been retained, the student is working far below grade level, the student has
received scientific- based intervention and has not responded, etc.
An individual Assessment Plan is attached which describes the types of assessments to be conducted. Your written consent is
required on this plan before any evaluation may occur. Please return this assessment plan within 15 calendar days of receiving it.
Assessments will be conducted by qualified staff and, when appropriate, utilizing qualified interpreters. You will be asked to
participate in a meeting of the Individualized Education Program (IEP) team following completion of the assessment. All
information and assessment results will be kept confidential. Your written consent will be required to authorize any proposed
special education services for your child.
Included with this assessment plan is a copy of the Notice of Procedural Safeguards. If you have any questions about the
proposed assessment or the procedural safeguards available to you, then please call:
Name and position: Enter name of person parent would contact.
Phone number: Enter the phone number of person parent would contact.
IDEA requires districts to provide prior written notice any time a district proposes a
change in the identification, evaluation or education placement of a student. This prior
written notice form meets this requirement in regard to evaluation, and must be sent
with the assessment plan.
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WEST END TRAINING SELPA
INDIVIDUALIZED EDUCATION PROGRAM
IEP FORM – COVER PAGE
1. SELPA: Enter West End SELPA, unless the student is on an inter SELPA permit.
2. District: Enter the district of service.
3. Case Manager: Enter the name of the individual responsible for affirming and attesting the IEP.
4. Purpose of Meeting: Select purpose of meeting.
• Initial is the IEP to determine eligibility after initial assessment.
• Annual is the IEP meeting to be held within one year of prior IEP.
• Triennial is the IEP meeting to be held after reassessment. This meeting may also include the Annual IEP Meeting.
• Transition means transition from infant to preschool, preschool to kindergarten, elementary to middle, middle to high
school, high school to transition placements, from public school setting to NPS or reverse, etc.
• Other specify the reason for the meeting, for example: Parent request, 30 day review of interim placement, review of
assessment, pre-expulsion, etc.
5. IEP Date: Enter the date of the meeting.
6. Current Annual IEP: Enter the date of the annual IEP meeting; this date will be the same as above, if the current meeting is
an annual review.
7. Current Evaluation: Enter the date of the most recently completed comprehensive assessment to determine or re-determine
eligibility for special education and related services (triennial or initial IEP date).
8. SPED Entry Date: Enter the date the student first received special education services, including IFSP (0-3 infant
services).
9. Next Annual IEP: Enter the next IEP date that will be one year form the present date in most cases.
10. Next Evaluation: Enter the date when the next triennial evaluation is due.
11. Name: Enter the student’s name.
12. DOB: Enter the exact birth date.
13. Age: The student’s age as of the IEP meeting date.
14. Gender: Check M or F.
15. Grade: Enter the appropriate grade designation.
16. District ID: Enter the student identification number issued by the student’s district of attendance.
17. SSID: Enter the SSID assigned by the State. Each student must have a SSID.
18. Student Address: Enter the student’s current address.
19. Ethnicity: Answer the two part question and then check the appropriate ethnicity(s). Note: Only four ethnicities can be
listed. This should be the ethnicity designated by the parent on the student enrollment form at the school site.
20. Migrant: Check Yes or No to reflect the student’s Migrant status.
21. Native Language: This field was previously known as home language. This is the student’s home language or birth
language.
22. EL: Check if the student is an English learner or has been redesignated.
23. Interpreter: Check if an interpreter is needed for the IEP meeting.
24. Responsible Adult: Enter first and last name of the individual who has educational rights and check the box indicating his/her
role.
25. Home Ph: Enter the home telephone number of the Responsible Adult here.
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26. Work Ph: Enter the work telephone number of the Responsible Adult here.
27. Cell Ph: Enter the cellular telephone number of the Responsible Adult here.
28. Email: Enter the email address of the Responsible Adult here.
29. Address: Enter the address of the Responsible Adult here if different from the student address.
30. Residential Status: Check the student’s residential status.
31. District of Residence: Enter the student’s district of residence.
32. District Providing Education: Enter the district providing the majority of the student’s services.
33. Residence School: Enter the student’s neighborhood school.
34. School of Attendance: Use the drop down menu to identify the school where the student is enrolled or receives the
majority of instructional services.
35. School Type: The school type is automatically entered and should not be changed.
36. If a student is served outside of residence district, explain: Use this area to explain why the student’s needs could not be
addressed by the district of residence.
For example: The presence of severe emotional/behavioral difficulties necessitates placement in a structured learning
environment with a small student staff ratio and a consistent behavior management system for the majority of the day.
37. SELPA placing student: This box will be filled in 3606 – West End SELPA.
38. Disability: Check the primary disability. The primary disability should be the one that has the most significant impact on
the student’s ability to access the general education environment.
39. Secondary Disability: Enter a secondary disability if applicable. This box cannot be left blank so if none so indicate.
Note:
• Multiple Disability is a primary disability ONLY and should not be listed as a secondary disability.
• Established Medical Disability is ONLY for 3 and 4 year olds.
• For funding purposes, low incidence disabilities marked as secondary will generate low incidence funding.
• If team determines the student has a specific learning disability, complete Specific Learning Disability Team Determination
of Eligibility.
40. Describe how student’s disability affects involvement and progress in the general curriculum (or for preschoolers,
participation in appropriate activities): Explain why the student’s disability necessitates instruction outside a regular
education environment and/or curriculum.
For example: “Due to the student’s inability to process auditory information, he/she has difficulty meeting academic content
standards in reading and writing,” or “Due to the student’s inability to understand and use age appropriate language, he/she
has difficulty communicating with peers and adults in the school setting.”
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41. Check Plan Type
• (10) IEP Individualized Education Program (IEP) or (IFSP) Individualized Family Service Plan.
• (20) ISP (Individual Service Plan) -Parentally placed in private school.
• (70) Eligible – no IEP/IFSP/ISP – Parentally place in private school.
• (80) Eligible – no IEP, IFSP, or ISP – Parent declines special education services.
• (90) Not eligible for special education or related services.
If parent(s) do not agree that the child is not eligible for special education services, note their concerns, discuss
options for resolving their concerns, and review Notice of Procedural Safeguards.
42. Exiting from Special Education (returned to general education/no longer eligible): Check this box if based on current
assessments the student no longer requires special education services, or parent has revoked consent for special
education services.
43. Date of Exit: Enter date the student left the district or exited special education services.
44. Reason: Use the drop down menu to identify the reason for leaving or exiting the special education program. Dropped out
can only be used at the high school level.
45. Other Agency Services: Identify any other agencies the family or student is working with that are not providing services listed
on the IEP. If other is checked, indicate the name of the agency.
46. Additional Cover Page Comments (if needed): Add referrals or any other comments you need to make. This is a good place
to note IEP was sent home for parent’s signature.
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SELPA: Enter West End SELPA, unless the student is on an inter SELPA permit. DISTRICT: District of service
Casemanager: Name of the individual responsible for affirming and attesting the IEP
Initial Annual Triennial Individual Transition Plan Other
IEP Date:Mtg Date
SPED Entry Date: Date the
student first received special
education services, including
IFSP (0-3 infant services).
Review by:
1. STUDENT INFORMATION
Last Name
Current Annual IEP: Date of Annual, same
as IEP date if meeting is an Annual Review
Next Annual IEP: Enter the next IEP date
that will be one year from the present
date in most cases
First Name ____ Middle:
DOB: Enter the exact birth date Age:student’s age at IEP meeting
Male Female Grade: Enter the appropriate grade designation
District ID No.
CSIS ID No.
Student Address:
State:
Zip:
City:
Ethnicity: Race 1. Race 2. Race 3.
Migrant: No Yes
Native Language:
Current Evaluation:Date of most recently completed
comprehensive assessment to determine or re-determine
eligibility for sp. Ed. & related services (triennial or initial
IEP date)
Next Evaluation (Tri):Date when the next triennial
evaluation is due
EL: No Yes English Proficiency: Fluent Limited Redesignated Interpreter: No Yes
Responsible Adult:
Purpose of Meeting: Select purpose of meeting.
•Initial: IEP to determine eligibility after initial
assessment.
•Annual IEP meeting to be held within 1 year of prior IEP.
•Triennial IEP meeting to be held after
reassessment. May also include the Annual IEP
Meeting.
•Transition means transition from infant to preschool,
preschool to kindergarten, elementary to middle, middle
to high school, high school to transition placements, from
public school setting to NPS or reverse, etc.
•Other : Specify the reason for the meeting, for
example: Parent request, 30 day review of interim
placement, review of assessment, pre-expulsion, etc.
Home Ph:
Cell:
Parent Guardian Conservator Surrogate Parent Other
Work Ph:
Email:
Address:
City: State: Zip:
(If different than student address)
Other Responsible Adult (state name, address, phone and relationship - include person holding educational rights if necessary):
2. RESIDENTIAL STATUS
Parent or legal guardian
Hospital (except state hospital)
State hospital
Licensed children's institution
Residential Facility
Developmental Center
If the child has been placed into an LCI or FFH provide name of Agency and Contact Person:
Foster family home
Incarcerated Institution
Other
District of Residence:
District Providing Education:
District Assigned Home Residence School:
School of Attendance:
School Type:
If student is served outside of resident district, explain:
SELPA Placing Student:
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Last Name First Name DOB 1/1/2008 IEP Date:
3. DISABILITY
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Intellectual Disability
Speech or Language Impairment
Orthopedic Impairment*
Specific Learning Disability
Autism
* Low Incidence Disability
Hard of Hearing*
Visual Impairment*
Other Health Impairment
Deaf-Blindness*
Traumatic Brain Injury
Deafness*
Established Medical Disability
Emotional Disturbance
Multiple Disability
Secondary Disability (if applicable):
Describe how student's disability affects involvement and progress in the general curriculum (or for preschoolers, participation in
appropriate activities):
Plan Type:
IEP or IFSP
Individual Service Plan (ISP)
(Initial Only) Eligible – no IEP, IFSP, or ISP – Parentally placed in a private school
(Initial Only) Eligible – No IEP, IFSP, or ISP – Other reasons
(Initial Only) Not eligible for special education or related services
Exiting from Special Education (returned to general education/no longer eligible)
Date of Exit:
Reason:
4. OTHER AGENCY SERVICES
Regional Center
CCS
Dept of Rehabilitation Other
County Mental Health Dept of Social Services
Probation
If your child has Medi-Cal; health insurance benefits may be accessed by the District for applicable services such as OT, Speech
and Language, etc.
Additional Cover Page Comments (if needed):
Educational Benefit Reminder
Is all of the information complete and correct
How will the manager of the school MIS system be informed of any changes
Does the IEP clearly specify the child’s disability(s)
Did the IEP Team identify how the child’s disability affects his or her involvement and
progress in the general curriculum or participation in appropriate activities for the preschool
child
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Last Name First Name DOB IEP Date:
5. STRENGTHS/INTERESTS/LEARNING PREFERENCES AS IDENTIFIED BY PARENTS, STAFF AND STUDENTS
Identify the student’s strengths, preferences, and interests.
Concerns of parent relevant to educational progress:
This information should be discussed at the IEP Team meeting.
6. PRESENT LEVELS OF PERFORMANCE
PRE-ACADEMIC/ACADEMIC/COGNITIVE/FUNCTIONAL SKILLS (including recent STAR Assessment Results)
Not an area of unique need
Summarize Pre-academic/Academic/ Functional skills, including the student’s performance in
the classroom, levels of mastery of the California content standards, progress in the
curriculum, etc. Pre- academic and Functional skills should address the student’s development of
readiness concepts for continued academic progress in the general education curriculum, as
appropriate. Include classroom performance in all academic areas.
COMMUNICATION DEVELOPMENT
Not an area of unique need
For the students with identified areas of need in communication, describe the student’s
articulation, voice, fluency, and language needs. If none, check not an area of unique need.
MOTOR DEVELOPMENT
Not an area of unique need
Fine
For a student, who has been identified with motor development concerns, describe his or her
specific skills and/or needs. If none, check not an area of unique need.
Gross
SOCIAL/EMOTIONAL DEVELOPMENT
Not an area of unique need
Describe the student’s social/emotional/ behavioral strengths and needs. If the student’s
behavior is appropriate in the educational setting check not an area of unique need.
ADAPTIVE/DAILY LIVING SKILLS
Not an area of unique need
For those students with needs in self-help, specify skills such as dressing, toileting, feeding, etc.
If none, check not an area of unique need.
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VOCATIONAL
Not an area of unique need
Include strengths, interests, and needs related to pre-vocational/ vocational skills. Address
traits, such as work habits, initiative, completion of classroom or school site jobs, etc.
Except for the Concerns of the Parent, a draft of this portion of the IEP may be prepared prior to the meeting. Each section
should be discussed at the meeting and changes made as appropriate based on input by members of the IEP team.
o Educational Benefit Reminder
Are the student’s strengths, preferences, and interests clearly identified
Are the concerns of the parent identified
Does this clearly reflect the student’s performance in the educational setting
When compared to the Present Levels from the previous IEP is the progress made by student noted
Do the Present Levels of Academic Achievement and Functional Performance reflect all needs identified in the assessments
7. HEALTH
Enter the results of the most recent hearing and vision screening. Check yes or no to document
whether the student has health concerns. If yes, describe pertinent medical information that relates
to the student’s educational progress. Check yes or no to indicate if there is a specialized health care
plan in place, if yes identify the procedure which the health care plan addresses.
Vision and Hearing Screenings must be completed for each triennial review
Hearing Screening: (R) (L) Vision Screening: (R) (L)
Date
Health Alert No Yes
If yes,special health condition is:
Date
Specialized Health Care Procedure No Yes
If yes, identify:
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8. SPECIAL FACTORS
1. Behavior: Does student's behavior impede his/her learning or that of others No Yes
BSP BIP Behavior Goal Other:
Does the student’s behavior impede learning Check yes or no. If yes, describe how the behavior
impedes learning in the box below. Specify positive behavior interventions, strategies, and supports to
address the behaviors. Check if there is a Behavior Support Plan or Behavior Intervention Plan and
attach a copy. If there is a behavior goal check the box to indicate a goal is in the IEP.
2.Communication: Is the student Deaf or Hard of Hearing No Yes
If the student is deaf or hard of hearing: Check yes or no. If yes specify the student’s language
and communication needs, opportunities for direct communications with peers and professional
personnel in the student’s language and communication mode, in the box below.
3. Vision: Is the student Blind or Visually Impaired No Yes
Is the student blind or visually impaired Check yes or no. If the student is visually impaired,
indicate whether instruction in Braille will be provided, and if not, why in the box below.
4. Assistive Technology: Does the student require assistive technology devices or services No Yes
Does the student require assistive technology devices and services to meet educational goals and
objectives Check yes or no. If yes, specify the type of devices, services, equipment, and/or materials
needed in the box below.
Note: Best practice – assistive technology should be addressed in the Supplemental Aids and Services
section and/or in a goal.
5. Low Incidence: Does the student require low incidence services, equipment and/or materials to
meet educational goals
No
Yes
This applies only to the students with the following eligibility categories: DB, VI, OI, HH, and Deaf.
Does the student require or low incidence services, equipment and materials to meet specific educational
needs. Check yes or no. If yes, specify in the box below.
6. English Learner: Is the student an English learner No Yes
If yes, English Proficiency Level: ----
Is the student is an English Learner Check yes or no. If yes, in the box below,
Indicate what the language of instruction will be. It must be English unless the IEP team has
designated otherwise. Indicate who by title (such as general education teacher, special education
teacher, etc.) will provide the student’s ELD services. All EL students MUST receive ELD services
unless a parental exception waiver has been submitted. EL students get either English language
Mainstream (ELM) or Structured English Immersion (SEI) services depending on their CELDT scores
or proficiency in English. A student must get SEI if they score at the beginning or early intermediate
level on CELDT or have “less than reasonable fluency” in English.
If yes to any special factors, clarify and describe:
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Classroom and or Curricular Accommodations/Modifications: Select the statement that describes how the student will participate in the
general education curriculum.
If the student does not require any accommodations or modifications check the first box.
If the student only requires accommodations, check the second box and specify which accommodations are needed and for
which classes they are needed.
If the student requires a modified or alternate curriculum, check the third box and specify the curriculum modifications or alternate
curriculum (CAPA) and the classes for which they are needed.
If the student will be participating in the general education curriculum for social reasons and will not receive a grade, check the
fourth box and indicate the classes.
Program Modifications or Supports for School Personnel on behalf of the Student: Note supplementary aids and services and/or supports
for school personnel. This would include such things as consultation to teachers, preferential seating, enlarged text, additional classroom
staff, etc. If none, indicate none needed at this time.
9. CLASSROOM and/or CURRICULAR ACCOMMODATIONS/MODIFICATIONS
Evaluation of the student in the general education curriculum:
Student is expected to meet the same standards of curriculum content mastery as non-special education students within
the classroom -WITHOUT ACCOMMODATIONS.
Student is expected to meet the same standards of curriculum content mastery as non-special education students within
the classroom -WITH ACCOMMODATIONS:
The student will be exposed to the general education curriculum in order to develop positive social skills, and/or gain
academic competence in the curriculum. Student will require accommodations and will receive MODIFIED curriculum for the
following classes:
The student will be exposed to the general education curriculum in order to develop positive peer interaction, improve
social skills, and/or gain academic competence in the curriculum. Student will require accommodations and modifications and
will NOT receive a grade for the following classes:
Program modifications or supports for school personnel on behalf of the student:
10. PARTICIPATION IN STATE and/or DISTRICT ASSESSMENTS
NOTE: THE IEP TEAM MAY NOT WAIVE STATE ASSESSMENTS: Do not put
parent exemption on the IEP form as a reason that the student will not participate in statewide assessment. The
IEP Team must address how the student would participate even if there is a parent exemption. The parent must
file the exemption with the school site according to the district procedures for all students.
Student will participate in the following assessments during the school year(check all that apply):
Preschool
DRDP-R
DRDP-A
NOTE: A student may take a test in an area on the CST/CAT‐6 and in another area on the CMA. If the student is
taking CAPA he/she must take it in all areas. (Refer to http://www.cde.ca.gov/sp/se/fp/ for the Test Variation Matrix).
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California Standard Tests (CST) and/or CMA, or CAPA:
English Language Arts (ELA) (Grades 2 through 11; CMA only applies to grades 3 through 8)
Math (Grades 2 through 11; CMA only applies to grades 3 through 7)
Science (Grades 5 and 8 only; Grades 9 through 11, end-of-course)
History/SOCIAL SCIENCE (Grade 8; Grade 11 for U.S. History; Grades 9 through 11 World History)
Writing (Grades 4 and 7 only)
If participating in the CAPA, select Level:
The student will not participate in the CST or CMA and CAPA is appropriate because:
California English Language Development Test (CELDT)(For English Learners only)
California English Language Development Test (CELDT) (For English Learners Only): All EL students must take the
CELDT annually until they are redesignated as fluent in English. Identify if the student requires accommodations,
modifications or an alternate assessment.
Standards based Tests in Spanish STS(For English Learners only)
Standards based Tests in Spanish (STS) (For English Learners Only): This test is required for English learners
who will have been enrolled in a school in the United States less than 12 months on the first day of testing or who
are receiving instruction in Spanish regardless of the length of time he she has been enrolled in school in the
United States.
California High School Exit Examination (CAHSEE)
Document if the student will be taking CAHSEE with or without accommodations. If the student will participate in
CAHSEE using modifications a waiver is required after the student takes CAHSEE with modifications and passes. If
the student is outside the testing range check the appropriate box.
CAHSEE/ELA Passed Date: Score:
CAHSEE/Math Passed Date: Score:
Physical Fitness (5th,7th,9th Grades Only)
District Wide Assessments
Additional Notes (if needed):
Educational Benefit Reminder
Is participation on state and district wide assessments, including accommodations and modifications, in accordance with state
guidelines
Are accommodations used for state and district wide testing also used in the classroom
Are alternate assessment(s), including the reasons, clearly noted if required
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INDIVIDUAL TRANSITION PLAN
This form must be completed in time to be in effect when the student reaches 16 years of age (i.e. at the annual
review or via an addendum before the student’s 16 th birthday).The IEP Team may determine that consideration
is appropriate for younger students.
Name: Birthdate: IEP Date:
The student is required to be invited on the IEP meeting notification. If the student was invited mark YES. Keep the
documentation in the student’s file
Student Invited: Yes No If Appropriate, and agreed upon, agencies invited: Yes No Not Applicable
When appropriate support agencies need to be invited on the IEP meeting notification, with the parent/guardian/students
permission. If an agency was invited mark YES. Keep the documentation in the student’s file. At this time if it is not
appropriate to invite an agency please note that in the meeting notes.
Describe how the student participated in the process: Attended IEP Meeting Interview Inventory Questionnaire
Check all applicable options.
Age-appropriate transition assessments/instruments were used: Yes No Describe the results of the assessments:
Age-appropriate transition assessments/instruments are to be used and drive the ITP portion of the IEP. Select Yes or No.
If no, complete required transition assessments. Record the transition assessment information/results used to identify the
student’s preferences and interests for transition planning as they relate to the student’s post-secondary goals. Include
information gathered over time and from multiple sources
Example: Results from career interest inventories completed by Alex in the 9 th and 11 th grades suggest a career in business would be suitable,
particularly a job that works with computers. A formal observation completed by Workability staff indicated that at his work experience placement at Office Depot,
he demonstrated the ability to stay on task and perform to expected work standards. Alex reported to work on time, cooperates with his boss. In class he is
most attentive with tasks that use computers. He is a diligent student and has good attendance. Alex scored below basic in reading, math and writing. His
results on the WISC indicate he has average intelligence. The results of the adaptive behavior scales suggest he is functioning below average in the area of
communication and socialization and above average in the areas of daily living and motor skills.
Student's Post Secondary Goal Training or Education (Required):
Upon completion of school I will
Transition Service Code as Appropriate:
Document what the student plans on doing upon exiting school in each
Activities to Support Post Secondary Goal:
area. The post-secondary goals will be based on the results of the ageappropriate
transition assessments and the student’s desired Community outcomes. Experiences as Appropriate:
Linked to Annual Goal #
Person/Agency Responsible:
Related Services as Appropriate:
Student's Post Secondary Goal Employment (Required):
Upon completion of school I will
Transition Service Code as Appropriate:
Identify the specific areas of need to be addressed Select the code that will be used to support the student’s post-secondary
Activities to Support Post Secondary Goal:
within the next year by the annual goals to assist the goal. While it is not necessary to have a transition service associated with
student in meeting his/her post- secondary goals. Community each area, at Experiences least one 800 transition as Appropriate:
service should be included in the ITP.
Linked to Annual Goal #
Person/Agency Responsible:
Related Services as Appropriate:
Person (student or parent) or agency that will be responsible for the student meeting the post-secondary goal.
Student's Post Secondary Goal Independent Living (As appropriate):
Upon completion of school I will
Transition Service Code as Appropriate:
Indicate the annual goal number on the goal page of the
IEP that is linked to the post-secondary goal.
Linked to Annual Goal #
Identify the transition activities that will be provided to help the
student achieve their post-secondary goal.
Activities to Support Post Secondary Goal:
Community Experiences as Appropriate:
Related Services as Appropriate:Person/Agency Responsible:
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Name Birthdate IEP Date:
INDIVIDUAL TRANSITION PLAN
District Graduation Requirements:
Course of Study
A multi-year description of student’s coursework from current year to anticipated exit year, in order to enable the student to meet
their post secondary goal. Yes No
Describe the student’s course of study. Identify which courses are required for graduation. Identify the additional courses related
to goals and/or vocational interests. Attach student transcript and select Yes or No. If no, indicate why there is no transcript.
Units/Credits Completed
\
Units/Credits Pending:
Diploma: Yes No
Certificate of Completion: Yes No Anticipated Completion Date:
Update the units/credits the student has completed up to this meeting and then the units/credits the student still has to
complete or has pending for a diploma/certificate including the units/credits the student will take in the next IEP cycle.
Check if student is working toward a Diploma or Certificate. Include the projected date for Diploma or Certificate
CAHSEE (High School Exit Exam)
CAHSEE/ELA date: Score: Passed Did not pass
CAHSEE/Math date: Score: Passed Did not pass
CAHSEE Other:
Age of Majority:
On or before the student's 17th birthday, he/she has been advised of rights at age of majority(age18)
By whom:
Date:
On or before the student’s 17 th birthday, explain that he and/or she will assume all special education rights and protections upon turning 18 (unless a
conservator has been appointed by the court). Review the Notice of Procedural Safeguards with the student. Have the student and parent sign this
section.
When you reach the age of 18, the age of majority, you have the right to receive all information about your educational program
and make all decisions related to your education. This includes the right to represent yourself at an IEP meeting and sign the IEP
in place of your parent or guardian.
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Enter the date and score on the ELA and Math section of the CAHSEE and indicate if the student passed or failed. In the
CAHSEE Other section you can indicate if the student is getting an exemption, waiver, or taking the CAPA
The student’s IEP includes appropriate measurable postsecondary goal or goals that covers the education or training,
employment, and as needed independent living Yes No
Is (are) the postsecondary goal(s) updated annually Yes No
Are there transition services in the IEP that will reasonably enable the student to meet his or her postsecondary goal(s)
Yes No
Is (are) there annual IEP goal(s) related to the student’s transition services
Yes No
Educational Benefit Reminder
Is the transition plan developed in accordance with the student’s post-school preferences, interests, and goals
Are there appropriate, measurable post-secondary goals in education or training, employment, and as needed, independent living
Are additional vocational and/or transition assessments required
Are the post-secondary goals updated annually
Are the post-secondary goals based on age appropriate transition assessments
Are there transition services in the IEP that will reasonably enable the student to meet the post-secondary goals
Does the course of study reasonably enable the student to meet their post-secondary goals
Is there an annual IEP goal related to the student’s transition services needs
Was the student invited and involved in their transition planning
Was a representative of any participating agency invited to the IEP Team meeting with prior consent from parent, guardian, or
student
When the invited agency representative(s) cannot attend the meeting, is there evidence in the student record that the LEA
used alternative methods to include the agency (e.g., phone conference or written input)
If appropriate, does the LEA reconvene the IEP team if the transition services were not provided as stated in the IEP
Is the transition plan designed to facilitate the student’s movement from school to post school activities, including
postsecondary education, vocational education, integrated employment, continuing and adult education, adult services,
independent living and/or community participation
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Last Name First Name DOB IEP Date:
Goal No: Proposed Goal Adopted By IEP Team No Yes Date Adopted:
11. ANNUAL GOAL (Form A)
Area of Need: Area of Need: Indicate the area of need for each goal These areas of need must match the “areas of need” on the PLOPs. (i.e., math,
Goal Baseline:: Specify the student’s baseline performance. The baseline should describe the child’s current performance on the skills identified in
the goal. The baseline should be a quantifiable description of classroom performance in the specified area. (i.e., reads 20 sight words, writes a simple
paragraph of 2-4 sentences, etc.)
Measurable Annual Goal:
Enables student to be involved/progress in general curriculum
Addresses other educational needs resulting from the disability
Linguistically appropriate (addresses EL Students)
Supports the following Post-Secondary Goals
Education/Training Employment Independent Living
Person(s) Responsible:
a-f
See next
page
Annual Goal Met
No Yes
Date Annual Goal Met:
Assistive Technology and/or Supplementary Aids to support the goal:
Short Term Objective: Date Met: Progress Report:
Enter the date met for each short term objective as it is met.
Making appropriate progress to meet
annual goal
No Yes
Recommend modifying goal
No Yes
Short Term Objective: Date Met: Progress Report:
Making appropriate progress to meet
While IDEA 2004 no longer requires short term objectives or benchmarks for
students participating in the general education curriculum, due to the need to
annual goal
No Yes
Recommend modifying goal
monitor progress throughout the year, the West End SELPA recommends
No Yes
Short including Term Objective: short term objectives or benchmarks in every students Date Met: IEP. Draft
goals may be developed prior to the meeting and reviewed with the IEP team
Progress Report:
Making appropriate progress to meet
annual goal
for changes. Annual goals must be measureable and at least one annual goal
No Yes
must be written for each area of identified need.
Recommend modifying goal
No Yes
Additional Comments:
g
Measurable Annual Goal: Annual goals must be measurable and relate to the baseline data. First consider
standards at the student’s chronological grade level. Also consider pre-requisite skills, levels of the cognitive
domain, accommodations, modifications, and assistive technology. Goals must include:
• Who student
• Does What observable behavior (will add single digit numbers)
• When by reporting date
• Given What conditions (when given a paragraph to read)
• How Much mastery, criteria (90% accuracy, 3 consecutive days)
• How Will It Be Measured performance criteria (as measured by teacher data)
NOTE: When determining dates by which short term objectives will be met, consider school breaks such as summer.
NOTE: If the student is taking CMA there must be a grade level standards based goal for each area where the student is taking
the CMA
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a) Enables the student to be Involved / Progress in the General Curriculum: Select if student is working
on the goal written to California content standards.
b) Addresses other Educational Needs Resulting from Disability: Select if the student is working on other
educational needs (i.e., behavior, social skills, self help, etc.).
c) Linguistically Appropriate: To be linguistically appropriate, the goals should align to the student’s
assessed level on the CELDT (if appropriate) and the CDE English Language Standards.
d) Supports the following Post-Secondary Goal: If the goal is related to secondary transition, check the
box and then check the appropriate area: Education/Training, Employment, or Independent Living.
e) Person(s) Responsible: Identify which person(s) are responsible for implementing the goals.
f) Assistive Technology and/or Supplementary Aids to support the goal: Document any assistive
technology or supplementary aids the student will require to meet the annual goal.
Best Practice: Goals for related services should be integrated into the classroom routine,
related service providers, should not solely be responsible for implementation of goals, especially
non public agencies.
g) Progress Report: To create a progress report, go to the Future IEP – edit goal.
Check yes or no, to indicate if student is making appropriate progress to meet the annual goal. Check yes
or no, to indicate if modifying the annual goal is recommended. If yes, an IEP meeting should be scheduled
to discuss modifying the annual goal. Comments may be entered on the left for each progress report; all
comments should be dated for clarity.
Educational Benefit Reminder
Are there goals and objectives/benchmarks for each area of need
Are the goals and objectives/benchmarks measurable
Do the goals and objectives/benchmarks enable the student to be involved/progress in the curriculum
Are all other educational needs resulting from the disability addressed
If the student is an English Learner, are the goals and objective/benchmarks linguistically appropriate
Has progress toward goals and objectives been documented on the IEP throughout the year
If there is a lack of progress was an IEP held to discuss student progress and revise goals and/or services
Sept. 2012 21

SERVICES OFFER OF FAPE
12. Service Considered by the IEP team: Discuss and document service delivery options considered. The
team must first consider placement in the general education classroom with supports prior to
recommending a more restrictive setting all or part of the day.
Follow the continuum of services below as a guide to determining LRE:
General Education Class.
General Education Class – Supplemental aids or services.
General Education Class – Some direct instruction by special education staff. Less than 21% of time
out of the classroom for special education services.
General Education Class – 21% to 60% of instructional day in a separate classroom.
Some/or no instruction in General Education Class – 60% or more of the instructional day in a
separate classroom (intensive services).
Special day school – Separate facility (public or nonpublic) with no general education students
on campus.
Residential School.
Hospital Program.
Home Instruction.
12a. Free and Appropriate Public Education: The team needs to determine the special education and
related services that will provide educational benefit and facilitate progress on the goals for the
student (e.g. specialized academic instruction, health and nursing, language and speech, etc).
12b. Service: Using the CASEMIS codes for services, identify the services that constitute the
district’s offer of FAPE. The primary service should be listed first. If the student receives the same
service, but with a different delivery model, frequency, provider or location, the service must be
duplicated for each specific condition. See CASEMIS codes in Appendix:
For duplicate services, check DNR in the left column to avoid CASEMIS errors.
Duplicate services that have “from” dates in different fiscal years will not create CASEMIS
errors.
Delivery: Identify how the service will be delivered.
Class Type: Identify the type of classroom where the service will be delivered.
From/To: Identify the specific dates when the service will start and end.
Duration /Frequency: Indicate the number of times a service will be provided, the number of
minutes each time, and the frequency such as daily, weekly, monthly, yearly, or any other frequency.
Provider: Identify the district or agency that will provide of the service.
See List of Location Codes in Appendix
Notes: Use the notes section to clarify the offer of services.

Parent will be informed of Progress: Indicate the frequency and manner in which
progress reports will be provided.
Requires Special Education Transportation: Check yes or no, if yes indicate needs, use
other to document the type of special transportation, (e.g. door to door, wheel chair bus)
Data Collection for Mental Health: Effective July 1, 2011 this program became inoperative.
Until the field is removed, check no.
12c. Due to the student’s unique needs identified in the present levels and goals, the student
will not participate in the general education environment: Document the regular education
environments where the student will not participate with typically developing peers using
the check boxes and space for information.
12d. Activities to support transition: Identify appropriate transitions and enter any
activities to support the transition that may be required.
For example:
• An IEP meeting will be held by 5/12/2013 to discuss the student’s transition from
preschool to kindergarten.
• A representative from Los Osos High School participated in the IEP to facilitate the
student’s transition from 8 th grade to 9 th grade.
13. Extended School Year (ESY): Discuss if the student needs ESY to receive FAPE.
Check yes or no. If yes, specify in the grid the services the student will receive, the start and
end date, provider, frequency, duration, and location.
NOTE: ESY shall be provided to a student with a disability who the IEP deems requires special
education and related services in excess of the regular academic year. Such students shall have
disabilities which are likely to continue indefinitely or for a prolonged period of time, and interruption
of the student’s educational programming may cause regression, when coupled with limited recoupment
capacity, rendering it impossible or unlikely that the student will attain the level of self‐sufficiency
and independence that would otherwise be expected in view of his or her disability. (5 CCR 3043)
Educational Benefit Reminder
Was the determination of the appropriate supplementary aids and services, and
special education and related services completed after the goals were finalized
Are the appropriate services identified to support progress toward all goals including:
progress in the general curriculum, participation in extracurricular activities, and other
nonacademic activities
Are the special education, related services, and supplementary aids and services based on
peer-reviewed research to the extent practicable
Are the start/end dates, provider, frequency, duration, and location specified for
supplementary aids and services as well as special education and related services
If appropriate, are the activities clearly identified to support transition from
preschool to kindergarten, from special education and/or NPS to general education,
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12. INSTRUCTIONAL SETTINGS/SERVICES
Programs and services will be provided according to when student is in attendance and consistent with the public
school calendar and scheduled services, excluding holidays, vacations and non-instructional days unless otherwise
specified.
12a. Services considered by the IEP Team based on the student's educational needs and adopted goals:
General Education
Specialized Academic Instruction in General Education
Specialized Academic Instruction outside General Education
Related Services:
Other:
12b. Free Appropriate Public Education (FAPE) based on the student's unique educational needs and adopted goals.
Parent will be informed of Progress: Quarterly Trimester Semester Other
How Progress Summary Report Other
Data Collection for Transportation:
Requires Special Education Transportation No Yes
Consideration for wheelchair and/or other medical equipment
Requires Child Safety Restraint System (CSRS)
Other:
Eligible for transportation, however parent declined offer and will transport student
12c. Due to the student's unique needs identified in the present levels and goals, the student will not participate in the general
education environment:
for general education academic curriculum:
in non-academic and/or extracurricular activities:
for related services:
at school of residence; educational placement will be provided at:
12d. Activities to support transition (e.g., preschool to kindergarten, special education and/or NPS to general education class, 8th
-9th grade):
13. EXTENDED SCHOOL YEAR (ESY)
The student demonstrates a handicapping condition which is likely to continue indefinitely or for a prolonged period; interruption of
service for a prolonged period may cause regression based on the student's limited capacity to recoup skills; and specific area of
need has been identified through the student's goal and objectives. Yes No
Special education and related services are determined at the IEP meeting only after goals have been finalized. Placement decisions must
be made in conformity with the least restrictive environment (LRE) provisions. These provisions direct that to the maximum extent
appropriate, students with disabilities be educated` with typically developing peers, and that special classes, separate schooling or other
removal of students from the general education environment occurs only if the nature or severity of the disability is such that education in
general education classes with the use of supplementary aids and services cannot be achieved satisfactorily. The placement must be
made in the school that the student would attend if the student did not have a disability unless unique circumstances prevent this
placement. Special education and related services and supplementary aids and services, should be based on peer-reviewed research to
the extent practicable.
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IEP TEAM MEETING COMMENTS
Notetaker's Initials:
Notes:
IEP Form – IEP TEAM MEETING NOTES
Use this page for summarizing pertinent information regarding the student’s Individualized
Education Program Meeting. This is an opportunity to memorialize the discussion that took
place during the meeting. Examples of the content appropriate to this page include:
• Statement regarding the purpose of the meeting.
• Statement regarding the review of parents’ rights as contained in the Procedural
Safeguards.
• Statement(s) summarizing evaluations reviewed including independent evaluations.
• Statement(s) regarding parents’ input into the IEP including requests, concerns and areas of
agreement or disagreement
• Statement(s) regarding any changes in services and reasons for decisions.
• Statement(s) of the placement and/or services offered by the district, even if the
parent does not agree.
• When documenting statements, use names and position. When offering services use
position only.
• If the meeting is a triennial review, eligibility for special education.
Note taker’s initials – Write the initials and date of the note taker in this space.
Educational Benefit Reminder
Is this information a summary of the meeting
Does the information accurately reflect what was discussed and the agreements that were made
Has the district made a single, clear offer of placement and services
Are next steps clearly identified, including individuals responsible, if needed
Sept. 2012 25

Name BLANK FORM Birthdate 1/1/2008
School West School
IEP Date:
WEST END TRAINING SELPA
SPECIFIC LEARNING DISABILITY TEAM
DETERMINATION OF ELIGIBILITY
Initial Evaluation
3-Year Re-evaluation
I. Presence of Severe Discrepancy. (Select either A or B and then complete items II through IV.)
A. The IEP Team finds a severe discrepancy between measures of intellectual ability and one or more of the
following areas of achievement:
Oral Expression
Mathematics Calculation
Reading Comprehension
Written Expression
Basic Reading Skills
Reading Fluency
Page
Listening Comprehension
Mathematics Reasoning
B. Standard measures do not reveal a severe discrepancy, but the IEP Team finds that a severe discrepancy
does exist based upon the additional documentation provided in the attached report. (Complete and attach
Specific Learning Disability Discrepancy documentation form)
II. The discrepancy identified in Item I. (above) is directly related to a processing disorder. Yes No
Check appropriate area(s): Sensory Motor Skills Visual Processing Auditory Processing
Attention Cognitive Abilities,(including association, conceptualization and expression)
III. If any of the items below(A-G) are checked "Yes", the student may not be identified as having a specific learning
disability.
A. The discrepancy is due primarily to limited school experience or poor school attendance. Yes No
B. The discrepancy is a result of environmental, cultural difference or economic disadvantage. Yes No
C. The discrepancy is due primarily to intellectual disability or emotional disturbance. Yes No
D. The discrepancy is due primarily to a visual, hearing, or motor disability. Yes No
E. This discrepancy can be corrected through other regular or categorical services offered within the regular
Instructional program.
Yes No
F. The discrepancy is due to limited English proficiency. Yes No
G. The discrepancy is due to lack of appropriate instruction in reading and math. Yes No
IV. The Student has a specific learning disability. Yes No
V. Basis for determination of eligibility
Psycho educational Evaluation utilizing multiple measures. See attached psycho educational report.
Other (specify)
VI. Relevant behavior related to academic functioning, noted during observation
of
VII.
See attached Psycho educational report.
Educationally relevant medical findings, if any (describe)
I agree with the conclusions stated above:
School Psychologist/Date
Special Ed. Admin./Designee/Date
Special Education Teacher/Date
General Education Teacher/Date
Speech Language Pathologist/Date
Reading Teacher/Date
Parent/Guardian/Date
Other/Date
My assessment of this student differs from the above report as follows: Statement (attach additional pages as
necessary)
Signature and Title/Date
Sept. 2012 26

WEST END TRAINING SELPA
SPECIFIC LEARNING DISABILITY DISCREPANCY DOCUMENTATION REPORT
(INDIVIDUALIZED EDUCATION PROGRAM TEAM CERTIFICATION)
Name BLANK FORM
This form is to be completed and attached to the IEP Team Certification identification of Specific Learning Disability Form
in order to document the presence of a Specific Learning Disability in instances when the student does not exhibit a
severe discrepancy between ability and achievement as measured by standardized test. (Ed. Code Section 3030j
Paragraph C)
Statement of the area, the degree, and the basis and method used in determining the discrepancy:
1. Data from assessment instruments (ability and achievement):
Page
of
2. Information provided by the parent:
3. Information provided by the pupil's present teacher:
4. Summary of the pupil's classroom performance:
a. Observations:
b. Work Samples:
c. Group Test Scores:
5. Consideration of the pupil's age:
6. Additional Relevant Information:
Sept. 2012 27

Page
WEST END TRAINING SELPA
English Language Development(ELD)for English Language Learners(ELL)
For any student whose native language is not English and who has not been re-designated as English proficient.
Name Birthdate 1/1/2008 Date of Meeting:
of
1. LANGUAGE ASSESSMENT: Section 1 will include input from the English Language Development (ELD) Staff.
Language Proficiency Assessment: CELDT Other Check CELDT if the language levels were determined by the
California English Language Development Test. Check Other if a different assessment was used.
Date Assessed: Enter date of assessment if other than the CELDT.English
English Language Development Level:
Beginning Early Intermediate Intermediate Early Advanced Advanced
Primary Language: List student's primary language based on the Home Language Survey.
Instrument: Identify the assessment used to determine English language levels if other than the CELDT. Date Assessed:
Results: Enter the results of the assessment.
Language of Instruction:Enter the language of instruction Language of Assessment for Eligibility: Identify the language
used by the assessors and the assessments to determine the student's eligibility for special education and related
services
2. COMPREHENSIBLE INPUT IN ENGLISH WILL BE PROVIDED THROUGH THE FOLLOWING STRATEGIES:
Check the boxes that identify the strategies used in the classroom to make the curriculum accessible to English Language
Learners. If the student is being taught using all English instruction, a statement regarding the rationale for all English
instruction should be made in supplemental information
TPR (Total Physical Response)
Natural Approach (Natural Acquisition)
3. CURRICULUM WILL INCLUDE:
ELD (English Language Instruction)
ELD and SDAIE
(Specially Designated Academic Instruction in English)
ELD, SDAIE, and L1 Support
LEA (Language Experience Approach)
English Reading/Writing at Appropriate Level
ELD and Primary Language (L1) Instruction-Academics
Other (specify)
4. L1 (PRIMARY LANGUAGE) SUPPORT/INSTRUCTION DETERMINED APPROPRIATE AND WILL BE PROVIDED BY:
Teacher
Instructional Assistant
Volunteer
Peer or cross-age tutors
Technologies (RETAC, ETN, MATS)
Other
Parent
Primary language materials
This area is filled out for students that are being taught in a classroom where their primary language is used for instruction.
Check appropriate boxes.
5. GOALS AND OBJECTIVES DEVELOPED IN
CROSS CULTURAL UNDERSTANDING PROVIDED THROUGH:
AREAS OF:
English Language Development (required)
Self Esteem
Classroom activities
Curriculum content
Textbook selection
Other
Check appropriate boxes. All students with score at a 1, 2, or 3 on any subtest on the CELDT
need a separate ELD goal and objective in the area of that subtest. The reference materials
section of SEIS contains an ELD Benchmark Matrix by grade level in the section labeled special
publications. The ELD matrix should be used to develop linguistically appropriate ELD goals.
Also, this needs to be address on the comments page as to what ELD support will be provided.
6. COMPREHENSIBLE INPUT ADDRESSED BY:
Check boxes as appropriate.
Teacher with Second Language Acquisition
Certificate
Instructional Staff
Parent
Other (specify)
Check the boxes to identify what curriculum is being utilized to
address English Language Learners in the classroom.
Check appropriate boxes.
Most classrooms utilize all
these areas.
7. COMPREHENSIBLE INPUT PROVIDED IN: E=English P=Primary
Language E=English P=Primary Language: Identify the language each
class will be taught in.
E P E P
Physical Education
Science
Music
Math
Art
Social Studies
Vocation
Language Arts
Recreation/Leisure
Other (specify)
8. SUPPLEMENTAL INFORMATION: Use to add any relevant additional information
Sept. 2012 28

Page of
Educational Benefit Reminder
WEST END TRAINING SELPA
Did all IEP Meeting participants
INDIVIDUALIZED EDUCATION PROGRAM SIGNATURE PAGE sign and date, if required
Do the parent(s) consent to all
components of the IEP
Student Name: DOB: Date:
If not, are areas of agreement
DOCUMENTED EFFORTS TO CONTACT PARENTS Date the IEP invitation was sent
and/or disagreement clearly
Invitation sent. Date:
and any follow up contacts.
specified
Follow-up contacts: Date(s):
Are the next steps identified for
reaching resolution, if
Parent unable to attend but requests copy of I.E.P. Including Special Education Procedural Safeguards. appropriate
PARTICIPANTS
The following participants were in attendance at this Individualized Education Program
All meeting participants sign and date that they were in attendance. Include titles of each participant
Name Parent/Guardian Name LEA Representative
Name Special Education Teacher Name General Education Teacher
Name Student Name Position
Name Position Name Position
Name
Position
Name
Position
Name
Position
Name
Position
Parent/Guardian/Surrogate Acknowledgements
Parent initials the appropriate lines, and insert dates. Ask parent to indicate their response to the question: as a means of
improving services and results for your child, did the school facilitate parent involvement
Please initial each applicable statement below:
Annual copy of Procedural Safeguards (Parent/Student Rights) provided:
As a means of improving services and results for your child, did the school facilitate parent involvement
Yes No No response given
I/we have received and understood a copy of the assessment report(s) dated:
I/we have reviewed and understood the goals and objectives for the IEP dated (IDEA)
Parent notification of transfer of rights one year prior to and at time of age of majority, 18 (parent initial or N/A)
Student Parent/Guardian/Surrogate N/A Date:
Student is progressing toward standard high school diploma. Yes No (parent initial)
Parent acknowledges that beginning in 2008 student must pass the California High School Exit Exam (CAHSEE) to receive a
high school diploma. (Parent Initial or N/A)
PRIMARY LANGUAGE OTHER THAN ENGLISH
If parent’s primary language isn;t English, have the parent initial the appropriate lines. Interpreter signs in the space provided.
I/we understand that a translation of this Individualized Education Program is available on request.
The Individualized Education Program has been interpreted orally (when applicable) by:
Interpreter's Signature
Have the parent initial, if they agree in-whole or in-part to the IEP. If they agree only in-part, ask them to document the
areas they are not in agreement with.
Please initial each applicable statement below: INFORMED CONSENT
I/we CONSENT to the goals and objectives/benchmarks of this Individualized Education Program.
I/we CONSENT to the placement, supports and services of this Individualized Education Program.
I/we CONSENT to this Individualized Education Program, EXCEPT for the following:
I/we DO NOT CONSENT to the Individualized Educational Program. REASONS:
I/we CONSENT to the review/access of Medi-Cal benefits/information for my child by the school district and/or IEP team for
services provided under this IEP, including if appropriate, the provision of Targeted Case Management Services.
MY SIGNATURE INDICATES CONSENT TO ABOVE
The parent(s)/guardian/surrogate/adult student signs and dates. If the parent asks to take a copy of the IEP to
review prior to signing have them initial to acknowledge taking the IEP to review. Enter date area to memorialize
when the IEP will be returned.
Parent/Guardian/Surrogate/Adult Student:
Date:
Parent/Guardian/Surrogate:
Date:
Parent took a copy of the IEP to review prior to signing. Parent will return the IEP by: Date:
Sept. 2012 29

APPENDIX
Sept. 2012 30

Sept. 2012 31

GLOSSARY OF TERMS
Associated with Special Education:
ADA
ADD
ADHD
APE
ATP
BIP
BMH
Americans with Disabilities Act
Attention Deficit Disorder
Attention Deficit Hyperactivity Disorder
Adapted Physical Education - Specialized physical education services designed and provided
by an Adapted Physical Education Specialist
Adult Transition Program
Behavior Intervention Plan
Behavioral Mental Health
CAC Community Advisory Committee - Advisory group to the governing board of the Local Plan
Area. Composed of parents of individuals with exceptional needs.
CAHSEE California High School Exit Exam
CAPA California Alternate Performance Assessment
CBI Community Based Instruction
CCS California Children Services - Provides medical care and rehabilitation for students with
physical handicaps
CDE California Department of Education
CEC Certificate of Educational Completion - For students who complete a course of study prescribed
by the IEP team.
CST California Standards Test
DD Developmentally Delayed (See MR)
DHH Deaf/Hard of Hearing
DIS Designated Instructional Services
DSM IV Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition
ED
FAPE
FBA
HH
ID
IDEIA
IEP
IQ
ITP
Emotionally Disturbed
Free and Appropriate Education
Functional Behavior Assessment
Hard of Hearing
Intellectual Disability (formerly Mental Retardation)
Individuals with Disabilities Education Improvement Act
Individual Education Plan
Intelligence Quotient
Individual Transition Plan
LD Learning Disability
LEA Local Education Agency - Refers to school districts providing special education service within
the SELPA
LCI Licensed Children’s Institution
LRE Least Restricted Environment
LSH Language, Speech and Hearing
MH
Multiple Handicaps
Sept. 2012 32

MR
NCLB
NPS
Mentally Retarded (See DD) Replaced with ID under Rosa’s Law
No Child Left Behind - Federal legislation for school accountability
Non-Public School
OCR Office of Civil Rights
OI Orthopedically Impaired
OHI Other Health Impaired
OSEP Office of Special Education Programs (Federal)
OCERS Office of Special education and Rehabilitative Services (Federal)
OT Occupational Therapy or Therapist
O&M Orientation and Mobility
PT
ROP
RSP
RtI
Physical Therapy or Therapist
Regional Occupation Program
Resource Specialist Program
Response to Intervention
SAI Specialized Academic Instruction
SARB School Attendance Review Board
SDC Special Day Class - Instructional settings in which the student receives special instruction more
than 50% of the day
SELPA Special Education Local Plan Area
SESR Special Education Self-Review
SLI Speech and Language Impairment
504 Section 504 of the Rehabilitation Act of 1973
SH Severely Handicapped
S&L Speech and Language Services
SLD Specific Learning Disability
SLP Speech/language Pathologist
SLPA Speech and Language Pathology Assistant
SPED Special Education
SSDI Social Security Disability Income
SSI Social Security income
SST Student Study Team
STAR Standardized Testing and Reporting Program (Statewide)
TBI
TPP
Traumatic Brain Injury
Transition Partnership Program
VH Visually Handicapped Services
WA1 WorkAbility 1 – A grant which allows special education students to receive job preparedness
skills and on the job (paid) experiences.
Sept. 2012 33

CASEMIS CODES
SPECIALIZED INSTRUCTION
330 Specialized academic instruction Adapting, as appropriate to the needs of the child with a disability the content,
methodology, or delivery of instruction to ensure access of the child to the
general curriculum, so that he or she can meet the educational standards within
the jurisdiction of the public agency that apply to all children. (RSP- school based,
RSP, SDC inclusion services, SDC-public integrated, SDC-public segregated,
SDC-non-public school.)
340 Intensive individual instruction IEP Team determination that student requires additional support for all or part
of the day to meet his or her IEP goals. (1-1 instructional assistant)
350 Individual & small group
instruction
Instruction delivered one-to-one or in a small group as specified in an IEP
enabling the individual(s) to participate effectively in the total school program.
(FOR PRESCHOOL ONLY)
RELATED SERVICES
415 Language and Speech Includes receptive and expressive language, articulation, voice, and fluency.
425 Adapted physical education Direct physical education services provided by an APE.
435 Health & nursing –specialized
physical health care services
Specialized physical health care services means those health services
prescribed by the child’s licensed physician and surgeon requiring medically
related training of the individual who performs the services and which are
necessary during the school day to enable the child to attend school. SPHCS
include but are not limited to suctioning, oxygen administration, catheterization,
nebulizer treatments, insulin administration, and glucose testing.
436 Health & nursing – other services This includes services that are provided to students by qualified personnel
pursuant to an IEP when a student has health problems which require nursing
intervention beyond basic school health services. Services include managing
the health problem, consulting with staff, group & individual counseling, making
appropriate referrals and maintaining communication with agencies and health
care providers.
445 Assistive technology services Any specialized training or technical support for the incorporation of assistive
devices, adapted computer technology or specialized media with the
educational programs to improve access for students.
450 Occupational therapy OT includes services to improve student’s educational performance, postural
stability, self-help abilities, sensory processing and organization, environmental
adaptation and use of assistive devices, motor planning and coordination, visual
perception and integration, social play abilities and fine motor.
460 Physical therapy Services provided by a register PT pursuant to an IEP when assessment shows
discrepancy between gross motor performance and other educational skills.
Sept. 2012 34

MENTAL HEALTH SERVICES
510 Individual counseling One-to-one counseling, provided by a qualified individual pursuant to an IEP.
515 Counseling & guidance Counseling in a group setting, provided by a qualified individual pursuant to an
IEP.
520 Parent counseling Individual or group counseling provided by a qualified individual pursuant to an
IEP to assist the parent(s) of special education students in better understanding
and meeting their child’s needs.
525 Social work services Includes services provided pursuant to an IEP by a qualified individual.
530 Psychological services These services provided by a credentialed or licensed psychologist pursuant to
an IEP.
535 Behavior intervention services A systematic implementation of procedures designed to promote lasting, positive
changes in the student’s behavior resulting in greater access to a variety of
community settings, social contacts, public events, and placement in the LRE.
540 Day treatment services Structured education, training and support services to address the student’s
mental health needs.
545 Residential treatment services A 24 hour out-of-home placement that provides intensive therapeutic services to
support the educational program.
610 Specialized services for low
incidence disabilities
710 Specialized deaf and hard of hearing
services
LOW INCIDENCE SERVICES
Low incidence services are defined as those provided to the student population
of orthopedic impairment (OI), visual impairment (VI), deaf, hard of hearing (HH),
or deaf-blind (DB). Typically, services are provided in education settings by an
itinerant teacher or the itinerant teacher/specialist. Consultation is provided to the
teacher, staff and parents as needed.
These services include speech therapy, speech reading, auditory training, and/or
instruction in the student's mode of communication.
Rehabilitative and educational services; adapting curricula, methods, and the
learning environment; and special consultation to students, parents, teachers, and
other school personnel may also
be included.
715 Interpreter services Sign language interpretation of spoken language to individuals, whose
communication is normally sign language, by a qualified sign language
interpreter.
720 Audiological services These services include measurements of acuity, monitoring amplification,
and Frequency Modulation system use.
725 Specialized vision services This is a broad category of services provided to students with visual
impairments. It includes assessment of functional vision; curriculum
modifications necessary to meet the student's educational needs -- including
Braille, large type, aural media; instruction in areas of need; concept
development and academic skills; communication skills (including alternative
modes of reading and writing); social, emotional, career, vocational, and
independent living skills. It may include coordination of other personnel
providing services to the students (such as transcribers, readers, counselors,
orientation & mobility specialists, career/vocational staff, and others) and
collaboration with the student's classroom teacher.
Sept. 2012 35

730 Orientation and mobility Students with identified visual impairments are trained in body awareness and to
understand how to move. Students are trained to develop skills to enable them to
travel safely and independently around the school and in the community. It may
include consultation services to parents regarding their children requiring such
services according to an IEP.
735 Braille transcription Any transcription services to convert materials from print to Braille. It may include
textbooks, tests, worksheets, or anything necessary for instruction. The transcriber
should be qualified in English Braille as well as Nemeth Code (mathematics) and
be certified by appropriate agency.
740 Specialized orthopedic services Specially designed instruction related to the unique needs of students with
orthopedic disabilities, including specialized materials and equipment.
745 Reading Services
750 Note taking services Any specialized assistance given to the student for the purpose of taking notes
when the student is unable to do so independently. This may include, but is not
limited to, copies of notes taken by another student, transcription of taperecorded
information from a class, or aide designated to take notes.
755 Transcription Services Any transcription service to convert materials from print to a mode of
communication suitable for the student. This may also include dictation services as
it may pertain to textbooks, tests, worksheets, or anything necessary for
instruction.
760 Recreation Services Therapeutic recreation and specialized instructional programs designed to assist
pupils to become as independent as possible in leisure activities, and when
possible and appropriate, facilitate the pupil’s integration into general education
programs.
820 College Awareness
830 Vocational assessment, counseling,
guidance, and career assessment
TRANSITION SERVICES
Organized educational programs that are directly related to the preparation of
individuals for paid or unpaid employment and may include provision for work
experience, job coaching, development and/or placement, and situational
assessment. This includes career counseling to assist student in assessing
his/her aptitudes, abilities, and interests in order to make realistic career
decisions.
840 Career awareness Transition services include a provision for in self-advocacy, career planning, and
career guidance.
850 Work experience education Work experience education means organized educational programs that are
directly related to the preparation of individuals for paid or unpaid employment,
or for additional preparation for a career requiring other than a baccalaureate or
advanced degree.
855 Job Coaching Job coaching is a service that provides assistance and guidance to an employee
who may be experiencing difficulty with one or more aspects of the daily job tasks
and functions. The service is provided by a job coach who is highly successful,
skilled and trained on the job who can determine how the employee that is
experiencing difficulty learns best and formulate a training plan to improve job
performance.
Sept. 2012 36

860 Mentoring Mentoring is a sustained coaching relationship between a student and teacher
through on-going involvement and offers support, guidance, encouragement and
assistance as the learner encounters challenges with respect to a particular area
such as acquisition of job skills. Mentoring can be either formal as in planned,
structured instruction of informal that occurs naturally through friendship,
counseling and collegiality in a casual, unplanned way.
865 Agency linkages (referral and
placement)
870 Travel Training (includes mobility
training)
Service coordination and case management that facilitates the linkage of
individualized education programs.
890 Other transition services These services may include program coordination, case management and
meetings, and crafting linkages between schools and between schools and postsecondary
agencies.
900 Other Special Education/Related
Services
Location: Where the service is provided to the student:
Any other specialized service required for a student with a disability to receive
educational benefit.
210 Home instruction based on IEP team determination (not medical)
220 Hospital
310 Head Start center
320 Child development or childcare facility
330 Public preschool
340 Private preschool
350 Extended day care
360 Residential facility
510 Regular classroom/public day school. Includes students who are fully included in general education classrooms. Also
includes students who are seen under a “push in” model in the general education classroom and students who receive DIS
services in the general education classroom. Additionally, students who receive services in a setting that includes other
students with special needs are included here if there are general education students who are “reverse mainstream”
students in that class for that portion of the day.
520 Separate class in public integrated facility
Includes students receiving special education “pull-out” services, including RSP and DIS, or in a “special day class” model,”
etc.
530 State Special School
540 Separate school or special education center or facility
550 Public residential school
560 Other public school or facility
570 Charter school operated by an LEA/district
580 Charter school operated as an LEA/district
610 Continuation school
620 Alternative work education center/work study facility
630 Juvenile court school
640 Community school
650 Correctional institution or facility
710 Community college
720 Adult education facility
810 Nonpublic day school
820 Nonpublic residential school-in California
830 Nonpublic residential school-outside California
840 Private day school (not certified by CDE Special Education Division)
850 Private residential school (not certified by CDE Special Education Division)
860 Parochial school
890 Service provider location
900 Any other location or setting
Sept. 2012 37