DATE: 10/12/2018 Page 1 of 14

STATE OF NEVADA INDIVIDUALIZED EDUCATIONAL PROGRAM (IEP)

INFORMATION
STUDENT/PARENT INFORMATION ELIGIBILITY CATEGORY MEETING INFORMATION
Student: Rita G. Sex: F DATE OF MEETING 10/12/18
Autism Spectrum Disorder DATE OF LAST IEP MEETING N/A
Birthdate: October 7, 2009 Grade: 3 Student ID # 123456
Student Primary Language English Deaf/Blind PURPOSE OF MEETING
Student English Proficiency Status: Select LEP Status Developmental Delay Interim IEP

Federal Placement Code: Select Placement Code Emotional Disturbance X Initial IEP

Federal Student Ethnicity Code: Select Ethnicity Code Health Impairment Annual IEP
Address: 1234 Street Lane, Las Vegas, NV 89149 Hearing Impairment/Deaf IEP Following 3-Yr Reevaluation
Student Phone: 702-123-4567 Intellectual Disability Revision To IEP Dated

Multiple Impairment Exit Select Exit Code

Parent/Guardian/Surrogate: Mother G.
Parent Phone (Home) 702-123-4567 (Work) 702-765-4321 Orthopedic Impairment IEP Revision Without A Meeting:

Optional: Cell 702-456-7890 Email ritasmom@gmail.com X Specific Learning Disability At the request of : Parent or School District

Primary Language Spoken at Home English Speech/Language Impairment X Other Teacher

Interpreter or Other Accommodations Needed: N Traumatic Brain Injury IEP SERVICES WILL BEGIN 10/13/18
Emergency Contact/Phone Number 911 Visual Impairment/Blind ANTICIPATED
DURATION OF SERVICES 1 year
Current School Rita G's Elementary School Zoned School Rita G's ELIGIBILITY DATE: 10/12/18
Elementary School IEP REVIEW DATE 8/1/19
ANTICIPATED 3-YR COMMENTS
REEVALUATION 10/12/21

IEP PARTICIPATION
Parent/Guardian/Surrogate* Mother G Speech/Language Therapist/Pathologist/Specialist: N/A
Student** Rita G. School Nurse: N/A
LEA Representative* Mr. Medium Interpreter: N/A
Special Education Teacher* Mrs. Hot Other (name and role): Ms. Salsa, Resource Teacher
Regular Education Teacher*** Mr. Mild Other (name and role)
School Psychologist Mrs. Guacamole Other (name and role)
*Required participant.
** Student must be invited when transition is discussed (beginning at age 14 or younger if appropriate).
***The IEP team must include at least one regular education teacher of the student (if the student is, or may be, participating in the regular education environment).

PROCEDURAL SAFEGUARDS
X I have received a statement of procedural safeguards under the Individuals with Disabilities Education Act (IDEA) and these rights have been explained to me in my primary language.

Parent Signature Mother G

AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, STUDENTS MUST BE INFORMED OF THEIR RIGHTS UNDER IDEA AND ADVISED THAT THESE RIGHTS WILL TRANSFER TO THEM AT AGE 18.

X Not applicable. Student will not be 18 within one year, and the student's next annual IEP meeting will occur no later than the student's 17th birthday.

The student has been informed of his/her rights under IDEA and advised of the transfer of these rights at age 18.

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PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Consider results of the initial evaluation or most recent reevaluation, and the academic, developmental, and functional needs of the student, which may include the following areas:
academic achievement, language/communication skills, social/emotional/behavior skills, cognitive abilities, health, motor skills, adaptive skills, pre-vocational skills, vocational skills, and other skills as
appropriate. For students who are 16 or older, or will turn 16 when this IEP is in effect, also consider the results of age appropriate transition assessments related to training/education, employment,
and independent living skills (as appropriate).

ASSESSMENTS CONDUCTED ASSESSMENT RESULTS EFFECT ON STUDENT'S INVOLVEMENT AND PROGRESS IN GENERAL EDUCATION
CURRICULUM OR, FOR EARLY CHILDHOOD STUDENTS, INVOLVEMENT IN
DEVELOPMENTAL ACTIVITIES

Goldman-Fistroe Woodcock Rita's auditory discrimination scores were adequate Rita is clearly behind her grade level in both reading comprehension and arithmatic. She
Test of Hearing on this test. also has poor social skills and an inability to do things for herself. Because of this Rita
should participate in pull out classes and be given a speech-to-text device in order to help
Keystone Visual-Screening No difficulties in vision were noted her write papers.
Service for School She should still participate with her classmates in the general classroom for most of the
day. She should be placed in groups in order to learn to participate in a team setting.
Wechsler Intelligence Scale for Full Scale IQ: 109 Group participation will help her learn better social skills that are more appropriate for a
Children-Third Edition (WISC- Verbal IQ: 128 child of her age.
111) Performance IQ: 87 With pull-out programs, a teacher aide, and assistive technology devices, Rita should be
(Mean: 100) able to participate with her general education class.

Verbal Subtest Scaled Scores:

Information: 13
Similarities: 14
Arithmetic: 8
Vocabulary: 14
Comprehension: 11
Digit Span: 13
(Mean: 10)

Performance Subtest Scaled Scores:

Picture Arrangement: 7
Coding: 6
Picture Completion: 8
Block Design: 8
Object Assembly: 7
Symbol Search: 7
Mazes: 5
(Mean 10)

Rita had strengths in areas of language, but struggled

to manipulate objects and visualize them in space. She
seemed to have no system for attacking challenging
problems and would simply give up.

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Mathematics
Peabody Individual Achievement Substantially below grade level. Her grade placement
Test-Revised (PIAT-R) was 3.8 at the time of the test and she scored from 1.8-
2.5 making her 1.5 to 2 years below her present grade.
Key Math-Revised Most serious issues were in areas of numerical
reasoning and word problems. However, she also did
Brigance Comprehensive poorly in addition, subtraction, and multiplication.
Inventory of Basic Skills-Revised

Reading
Brigance Comprehensive Rita scored satisfactorily in tests of word recognition,
Inventory of Basic Skills-Revised but her performance dropped when reading
comprehension was required. She seemed to lose her
PIAT-R place and struggle to concentrate on the material. She
had normal phonics and vocabulary skills, but
Woodcock Reading Mastery struggled when she had to conceptualize what she was
Tests-Revised reading.
She has second-grade level reading comprehension
Gray Oral Reading Tests, Third skills and fourth-grade level word recognition skills.
Addition

Handwriting
Brigance Comprehensive This is a major problem for Rita. She cannot write in
Inventory of Basic Skills-Revised cursive and writes very poorly in manuscript.
She writes from her letters from the bottom of the line
to the top of the line. Small letters an tall letters are the
same size. She has an odd pencil grip andis tense when
she writes. Her written expression could not be tested
because her extremely poor handwriting skills.
Spelling
PIAT-R
Brigance Comprehensice
Inventory of Basic Skills-Revised
Rita scored at a second-grade level for spelling. She
Woodcock- showed poor visual memory for irregularly spelled
Johnson Psychoeducational words.
Battery-111 (WJ-111)

Wide Range Achievement Test-

111 (WRAT-111)

Adaptive Behavior
Vineland Adaptive Behavior Low scores in areas of daily living skills and

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Skills socialization. She relies on people to tell her what to do.

Plays mainly with her younger sister. She lacks
motivation to organize herself.
Other
Developmental Test of Visual- Rita's score was equivalent to that of a six year old. She
Motor Integration struggled to draw more complex shapes such as
triangles and diamonds.

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STRENGTHS, CONCERNS, INTERESTS AND PREFERENCES

STATEMENT OF STUDENT STRENGTHS

Rita shows strengths in auditory discrimination.

STATEMENT OF PARENT EDUCATIONAL CONCERNS

Mother G. is concerned that Rita is failing the third grade and that she does not want to go to school.

STATEMENT OF STUDENT'S PREFERENCES AND INTERESTS (required if transition services will be discussed, beginning at age 14 or younger if appropriate)
Rita enjoys watching television and eating. She also only likes to play with her younger sister and her sister's friend.

If student was not in attendance, describe the steps taken to ensure that the student's preferences and interests were considered:
N/A

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CONSIDERATION OF SPECIAL FACTORS

1. Does the student's behavior impede the student's learning or the learning of others? X No. Yes.
If YES, IEP committee must provide positive behavioral strategies, supports and interventions, or other strategies, supports and interventions to address that
behavior.
Addressed in IEP.

2. Does the student require assistive technology devices and services? No. X Yes.
If YES, IEP committee must determine nature and extent of devices and services.
X Addressed in IEP.
3. Does the student have limited English proficiency? X No. Yes.
If YES, IEP committee must consider the following (check box if IEP committee considered the item):
Language needs of the student as those needs relate to the student's IEP.

4. Is the student blind or visually impaired? X No. Yes.

If YES, IEP committee must evaluate reading and writing skills, needs, and appropriate reading and writing media (including an evaluation of the child’s future needs for
instruction in Braille or use of Braille) and must provide for instruction in Braille and use of Braille unless determined not appropriate for the student.
Braille instruction and use of Braille is not appropriate for student. Braille instruction and use of Braille is addressed in IEP.

5. Is the student deaf or hard of hearing? X No. Yes.

If YES, IEP committee must consider the student’s language and communication needs and consider the following (check box if IEP committee considered the
item):

The related services and program options that provide the student with an appropriate and equal opportunity for communication access.
The student’s primary communication mode.
The availability to the student of a sufficient number of age, cognitive, academic and language peers of similar abilities.
The availability to the student of adult models who are deaf or hearing impaired and who use the student’s primary communication mode.
The availability of special education teachers, interpreters and other special education personnel who are proficient in the student’s primary communication mode.
The provision of academic instruction, school services and direct access to all components of the educational process, including, without limitation, advanced
placement courses, career and technical education courses, recess, lunch, extracurricular activities and athletic activities.
The preferences of the parent or guardian of the student concerning the best feasible services, placement and content of the student’s IEP.
The appropriate assistive technology necessary to provide the student with an appropriate and equal opportunity for communica tion access.

6. Does the student have a Specific Learning Disability and Dyslexia? No. X Yes.
If YES, the IEP committee must consider the following instructional approaches (check box if IEP committee considered the item):

X Explicit, direct instruction that is systematic, sequential and cumulative and follows a logical plan of presenting the alphabetic principle that targets the specific needs of
the student.
X Individualized instruction to meet the specific needs of the student in an appropriate setting that uses intensive, highly-concentrated instruction methods and materials
that maximize student engagement.
X Meaning-based instruction directed at purposeful reading and writing, with an emphasis on comprehension and composition.
X Multisensory instruction that incorporates the simultaneous use of two or more sensory pathways during teacher presentations and student practice.

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TRANSITION

DIPLOMA OPTION SELECTED FOR GRADUATION (Diploma option must be declared at age 14 and reviewed annually.)
Standard or Advanced High School Diploma. Must complete all applicable credit Adjusted High School Diploma. Must complete IEP requirements.
requirements and pass the High School Proficiency Examination (with permissible accommodations as needed).

STUDENT'S VISION FOR THE FUTURE

A short statement that directly quotes what the student wants for the future.

STATEMENT OF TRANSITION SERVICES: COURSE OF STUDY

Beginning at age 14 or younger if determined appropriate by the IEP team, describe the focus of the student's course of study.

STATEMENT OF MEASURABLE POSTSECONDARY GOALS

Beginning not later than the first IEP to be in effect when the student is 16, describe measurable postsecondary goals in the following areas:

Training/Education

Employment

Independent Living Skills (As Appropriate)

Other

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TRANSITION (continued)
STATEMENT OF TRANSITION SERVICES: COORDINATED ACTIVITIES
Beginning not later than the first IEP to be in effect when the student is 16, develop a statement of needed transition services, including strategies or activities, for the student.

Instruction

Any Other Agency Involvement (Optional):

Related Services

Any Other Agency Involvement (Optional):

Community Experiences

Any Other Agency Involvement (Optional):

Employment and Other Post-School Adult Living Objectives

Any Other Agency Involvement (Optional):

Acquisition of Daily Living Skills and Functional Vocational Evaluation (if appropriate)

Any Other Agency Involvement (Optional):

Other

Any Other Agency Involvement (Optional):

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IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS, AND BENCHMARKS OR SHORT-TERM OBJECTIVES

MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress Being Made (continue)

Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)

Training/Education Employment Independent Living Skills Other 3. Goal Met (note date)

Date: Date: Date: Date:

Check here if this goal will be addressed during Extended School Year Services (ESY) 12/1/18 2/1/19 4/1/19 6/1/19

Progress Progress Progress Progress

# 1 ) Improve social skills by adding more group work and group assignments to the general curriculum.

# 2 ) Observe Rita and encourage her to help with the group assignments.

# 3 ) Observe Rita to see if she is talking to other students during free periods, recess, and lunch time. Encourage her to engage with other children.

# 4 ) Observe her behavior towards other students after one month of increased group assignments. If she still seems to stuggle to socialize, the plan should be revised.

MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
2. Satisfactory Progress Being Made (continue)

Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)

Training/Education Employment Independent Living Skills Other 3. Goal Met (note date)

Date: Date: Date: Date:

Check here if this goal will be addressed during Extended School Year Services (ESY) 12/1/18 2/1/19 4/1/19 6/1/19

Progress Progress Progress Progress

# 1 ) Provide Rita with individualized mathematical instruction 3 times per week.

# 2 ) Use relevant concepts that will help her understand objects in space and mathematical story problems.

# 3 ) Test her once per quarter with the PIAT-R math test to see if her skills have improved.

# 4 ) If scores have not improved by at least one point per quarter, then her individual instuction time should increase and instruction style should be revised.

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MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
3. Satisfactory Progress Being Made (continue)

Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)

Training/Education Employment Independent Living Skills Other 3. Goal Met (note date)

Date: Date: Date: Date:

Check here if this goal will be addressed during Extended School Year Services (ESY) 12/1/18 2/1/19 4/1/19 6/1/19

Progress Progress Progress Progress

# 1 ) Provide Rita with individualized spelling and writing instruction for one hour, 2 times/week. Pencil grips should be given to Rita to help her have a better hold of her pencil. To
understand her writing abilities, Rita should either be able to speak her story while someone writes it, or be given a speech-to-text device.

# 2 ) Handwriting samples should be analyzed quarterly. She also should be provided a text-to-speech option during written expression examinations.

# 3 ) Assess Rita quarterly with the Brigance Basic Skills-Revised writing assessment and through observation.

# 4 ) If her writing test scores have not improved by at least 1 point per quarter, then her inividualized instruction time should be increased and instruction style should be
revised.

IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS, AND BENCHMARKS OR SHORT-TERM OBJECTIVES

MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
4. Satisfactory Progress Being Made (continue)

Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)

Training/Education Employment Independent Living Skills Other 3. Goal Met (note date)

Date: Date: Date: Date:

Check here if this goal will be addressed during Extended School Year Services (ESY) 12/1/18 2/1/19 4/1/19 6/1/19

Progress Progress Progress Progress

# 1 ) Rita should be provided with extra class time for writing and spelling assignments. She should also receive additional phonics instuction in class.

# 2 ) Rita should be given the PIAT-R and the WRAT-111 to test here spelling scores quarterly.

# 3 ) If her spelling skills have not improved by at least one point per quarter, then her individualized instruction time should be increased and instruction style should be revised.

# )

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METHOD FOR REPORTING PROGRESS

METHOD FOR REPORTING THE STUDENT'S PROGRESS TOWARD MEETING ANNUAL GOALS (check all PROJECTED FREQUENCY OF REPORTS
methods that will be used)
X IEP Goals Pages X District Report Card X Quarterly Semester
X Specialized Progress Report X Parent Conferences Trimester Other
Other

SPECIAL EDUCATION SERVICES

SPECIALLY DESIGNED INSTRUCTION BEGINNING FREQUENCY LOCATION
AND OF SERVICES OF
ENDING SERVICES
DATES

Writing Skills practice with resource teacher. Individualized instruction to help improve physical writing skills and writing 10/2018 - 2 hours/week Resource Room
concepts 06/2019
Mathematical skills. 3 hours/week of individualized instruction. Emphasis on improving concepts of spatial orientation. 10/2018 - 3 hours/week Resource Room
06/2019
Move student to front of room. Only call on her when she is ready. 10/2018 - Daily General
06/2019 Classroom
Implement more group activities in the class room 10/2018 - Daily General
06/2019 Classroom
-
-

SUPPLEMENTARY AIDS AND SERVICES

Includes aids, services, and other supports provided in regular education classes, other education-related settings, and in extracurricular and nonacademic settings to enable
students with disabilities to be educated with nondisabled students to the maximum extent appropriate.

BEGINNING AND FREQUENCY OF LOCATION OF

MODIFICATION, ACCOMMODATION, OR SUPPORT FOR STUDENT OR PERSONNEL ENDING DATES SERVICES SERVICES
Provide specific description(s) below.
Provide e-books or books on tape for student. She should be able to listen to what the rest of the class is 10/2018 - As needed General
reading. 06/2019 Classroom
Provide speech to text device for student so she can express what is difficult for her to physically write 10/2018 - As needed General
down 06/2019 Classroom
Provide pencil grips for the student so she can improve her writing and drawing skills. 10/2018 - As needed General
06/2019 Classroom
Provide an aide during in class instruction that will provide Rita with extra instruction in difficult subjects. 10/2018 - As needed General
06/2019 Classroom
Provide extra physical therapy for Rita during P.E. instruction that will help improve her fine motor skills. 10/2018 - 1/2 of the P.E. Physical
06/2019 class time Education
Setting

-
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RELATED SERVICES
RELATED SERVICE SERVICE TYPE AND/OR BEGINNING FREQUENCY LOCATION
DESCRIPTION AND ENDING OF SERVICES OF
A - Assessment DATES SERVICES
C - Consultative
D - Direct

Teacher’s Aide Description: Aide should provide Rita with additional help during regular 10/1/18 - Daily General
classtime. 6/1/19 Classroom
Special Education Teacher Description: Provided for individualized instruction time 10/1/18 - One hour per Resource
6/1/19 day, 5 days per room
week
Physical Therapist Description: Provided to help improve fine motor skills 10/1/18 - 20-30 minutes Physical
6/1/19 per day Education
Area
Select Related Service Select Service Type Description: -
Select Related Service Select Service Type Description: -
Select Related Service Select Service Type Description: -

PARTICIPATION IN STATEWIDE AND/OR DISTRICT-WIDE ASSESSMENTS

Indicate how the student will If the student will participate in an alternate assessment, explain why the If the student will participate in a
participate in statewide or district- student cannot participate in the regular assessment, and why the regular assessment, does the
wide assessments. particular alternate assessment selected is appropriate student require accommodations?

State Criterion-Referenced The regular assessment would not be No Yes

Test (CRT) Yes N/A If YES, list on "Accommodation(s) for the
appropriate for someone with a learning Nevada Proficiency Examination
XAlternate Program" (attach form).
disability. Since Rita has a learning disability
she will be assessed with the tests described
in her IEP.
End of Course Exams No Yes
Yes XN/A If YES, list on "Accommodation(s) for the
Nevada Proficiency Examination
Program" (attach form).
College and Career Readiness No Yes
Assessment If YES, list on "Accommodation(s) for the
Nevada Proficiency Examination
Yes XN/A Program" (attach form).

Other (List): No Yes List Accommodation(s):

YesXN/A
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EXTENDED SCHOOL YEAR SERVICES

Does the student require extended school year services?

X No Yes If YES, IEP goals and benchmarks/short-term objectives and/or related services to be implemented in ESY must be identified.
If need for ESY is to be determined at a later date, indicate date by which IEP decision will be made:

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PLACEMENT
PLACEMENT CONSIDERATIONS PERCENTAGE OF TIME
IN REGULAR EDUCATION ENVIRONMENT
Selected X Rejected Regular class with supplementary aids and services (no removal)
X Selected Rejected Regular class and special education class (e.g., resource) combination The student will spend 16 % of his or her school day in the
Selected X Rejected Self-contained program regular education environment.
Selected X Rejected Special School
Selected X Rejected Residential
Selected X Rejected Hospital
Selected X Rejected Home
Selected X Rejected Other

JUSTIFICATION FOR PLACEMENT INVOLVING REMOVAL FROM REGULAR EDUCATION ENVIRONMENTS*

Explain why the IEP goals and objectives cannot be implemented in regular education environments, including the reasons why the team rejected a less restrictive placement.
Include an explanation of any harmful effects on the learning of this or other students which affected the placement selection.
The IEP goals can not be implemented in the regular classroom for 100% of the day because Rita is very far behind her
classmates. Because of this, it is necessary to pull her out for a period of the day so she can be taught independently. She will still
be in the classroom for the majority of the day with instructional accomodations being made. She will still be taught in the Least
Restrictive Environment possible for her. She may not need to be pulled out of the classroom if AYP is met.

*Regular education environments include academic classes (which might include field trips linked to the curriculum), nonacademic settings (such as recess), and extracurricular activities (for
example, sports, after-school clubs, band, etc.).

IEP IMPLEMENTATION

X As the parent, I agree with the components of this IEP. I understand that its provisions will be implemented as soon as possible after the IEP goes into effect.

As the parent, I disagree with all or part of this IEP. I understand that the school district must provide me with written notice of any intent to implement this IEP. If I wish to prevent the implementation of this IEP, I must
submit a written request for a due process hearing to the local school district superintendent.

Parent Signature

X A copy of this IEP was provided to the student’s parent on : _____October 12, 2018 ____by_ Mr. Souercreme __________ Principal _____________
(date) (name) (title)
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