Individualized Education Program (IEP) (Form PR07) Each school ...

INDIVIDUALIZED EDUCATION PROGRAM (IEP)(Duplicate as needed)Annual Goals and Short­Term ObjectivesStep 3: Identify needs that require specially designed instructionGoal #Content area addressed:Step 4: Identify measurable annual goalsBenchmarks or short­term objectivesStatement of Student Progress(Include how the child’s progress towards annual goals will be measured and how the parents will be informed of the extent to which the child’s progress is sufficient to enablehim/her to achieve the goals by the end of the year)Step 5: Identify servicesService:__________________ Initiation date: ______________ Expected duration: ______________ Frequency: (how often) ______________(Identify all services needed for the child to attain the annual goal and progress in the general curriculum. Services may include specially designedinstruction, related services, supplementary aids, or, on behalf of the child, a statement of program modifications, testing accommodations, or supportsfor school personnel)Step 6: Determine least restrictive environmentDetermine where services will be provided(Include an explanation of the extent, if any, to which the child will not participate with nondisabled children in the regular classroom)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)Discuss and Document a Statement of Needed Transition ServicesName of Student Date Person(s) Responsible for Coordinating Transition ServicesWrite a statement of transition service needs that focus on the student’s courses of study during his/her secondary school experiences (beginning at age 14 or younger, ifappropriate).FOR 16 YEARS AND OLDERCOMPLETED AFTER IEP DEVELOPMENTEMPLOYMENT AND POSTSECONDARY LONG­TERM OUTCOME:_Current YearActivities and ServicesResponsiblePerson/ProviderInitiation/Duration(Specify Date)Goals/Objectives that SupportActivities/ServicesPOSTSCHOOL/ADULT LIVING LONG­TERM OUTCOME:Current YearActivities and ServicesResponsiblePerson/ProviderInitiation/Duration(Specify Date)Goals/Objectives that SupportActivities/ServicesCOMMUNITY PARTICIPATION LONG­TERM OUTCOME:Current YearActivities and ServicesResponsiblePerson/ProviderInitiation/Duration(Specify Date)Goals/Objectives that SupportActivities/ServicesFunctional Vocational Evaluation r Needed r Not Needed Date Completed ______________________

INDIVIDUALIZED EDUCATION PROGRAM (IEP)Statewide and Districtwide TestingStudent Name: Student Grade (when scheduled to take this test): Student ID:___________________School Year: IEP Meeting Date: _____STATEWIDE TESTINGDISTRICTWIDE TESTINGAreas of AssessmentGrade Level of Testto be AdministeredWill Take Test withoutIEP AccommodationsWill Take Test withIEP AccommodationsWill Participate in AlternateAssessmentGrade Level ofTest to beAdministeredWill Take TestwithoutAccommodationsWill Take TestwithAccommodationsWill Participate inAlternateAssessmentReadingWritingMathScienceCitizenshipTechnologyITACExcused from the consequences associated with not passing the test (Graduation Test) in the following area(s) of assessment:Met participation requirements Yes No Date ____________________________________(Graduation Tests)Area ofAssessmentList Accommodations to AssessmentArea ofAssessmentList AccommodationsReadingOther (Specify)WritingOther (Specify)MathOther (Specify)ScienceOther (Specify)CitizenshipOther (Specify)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)Name IEP summary for effective dates Date of next IEP reviewIEP Meeting Participants’ SignaturesParent Parent Child/Student’s Special Education Teacher/ProviderChild/Student’s Regular Education Teacher District Representative Child/StudentOther Titles Other Titles Other TitlesOther Titles Other Titles Other TitlesSummary of special education services:Consentq I give consent to initiate special education and related services specified in thisIEP.*q I give consent to initiate special education and related services specified in this IEPexcept for **q I do not give consent for special education services at this time.**q I give consent for a change of placement.Parent SignatureDate:* This IEP serves as prior written notice if there is agreement.**If there is not agreement, the district must provide prior written notice to the parents.Reevaluation (State and federal rules and regulations mandate that everychild/student with a disability be reevaluated at least every three years.)Your child’s last MFE wasParent Notice of Procedural Safeguardsq I have received a copy of the parent notice of procedural safeguards; orq I have a current copy of the parent notice of procedural safeguards.q I waive my right to notification of special education and related services by certifiedmail.Parent SignatureDate:Note: The student receives notice of procedural safeguards at least one year prior tohis/her 18 th birthday.Student SignatureDate:Reason for Placement in Separate Facility (If applicable)Having considered the continuum of services and the needs of the student, this IEPteam has decided that placement in a separate facility is appropriate because:The next MFE shall occur byYou will be invited to participate in this meeting as part of the team. Parent permissionis required for reevaluation if additional assessment is to be conducted.