INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student’s Name: Jax Miller

INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

Student’s Name: Jax Miller

IEP Team Meeting Date (mm/dd/yy): 11/24/20
IEP Implementation Date (Projected Date when Services and Programs Will Begin): 11/25/20
Anticipated Duration of Services and Programs: 11/25/20 - 6/14/21
Date of Birth: 10/11/13
Age: Seven
Grade: Second Grade
Anticipated Year of Graduation: 2031
Local Education Agency (LEA): Steubenville City Schools
County of Residence: Jefferson County
Name and Address of Parent/Guardian/Surrogate: Phone (Home): (111) 111-1111
Joseph Miller Phone (Work): (444) 444-4444
10 Streetname Road
Steubenville, OH 43952

Other Information: Jax’s parents are together and he lives with them and his two siblings in Steubenville, Ohio.

The LEA and parents have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:
N/A

Date of Revision(s) Participants/Roles IEP Section(s) Amended

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Jax Miller

IEP TEAM/SIGNATURES

The Individualized Education Program team makes the decisions about the student’s program and placement. The student’s parent(s), the student’s special
education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not
agreement.

Role Printed Name Signature

Parent/Guardian/Surrogate Joseph Miller
Parent/Guardian/Surrogate Sandy Miller
Student* N/A
Regular Education Teacher** Steffanie Mamula
Special Education Teacher Tammy Till
Local Ed Agency Rep N/A
Career/Tech Ed Rep*** N/A
Community Agency Rep N/A
Teacher of the Gifted**** N/A
Speech and Language Pathologist Pamela Jordan
School Nurse N/A
Principal Lynnett Gorman

* The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.
** If the student is, or may be, participating in the regular education environment
*** As determined by the LEA as needed for transition services and other community services
**** A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.
One individual listed above must be able to interpret the instructional implications of any evaluation results.

Written input received from the following members:

N/A

Transfer of Rights at Age of Majority

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Student’s Name: Jax Miller

For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals
with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.

PROCEDURAL SAFEGUARDS NOTICE

I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights,
including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.

Signature of Parent/Guardian/Surrogate:

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical Assistance programs)

I understand that the school may charge the School-Based Access Program (“SBAP”)—or any program that replaces or supplements the SBAP—the cost of
certain special education and related services described in my child’s IEP.  To make these charges to the SBAP, the school will release to the administrator of that
program the name, age, and address of my child, verification of Medicaid eligibility for my child, a copy of my child’s IEP, a description of the services provided
and the times and dates during which such services were provided to my child, and the identity of the provider of such services.   I understand that such
information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have provided written consent to
disclose such information.

I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to write,
at any time.  My refusal to consent or my withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my family, any service
or program to which my child is entitled under the Individuals with Disabilities Education Act (“IDEA”) or that is necessary to enable my child to receive a free
appropriate public education as described in my child’s IEP. 

I understand that the school cannot—

Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a condition of receiving a free appropriate
public education for my child;

Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including co-payments and deductibles, unless
it agrees to pay such expenses on my or my family’s behalf;

Cause a decrease in available lifetime coverage or any other insured benefit;

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Student’s Name: Jax Miller

Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that are required for my child outside
the time that he or she is in school;

Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.

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Student’s Name: Jax Miller

I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS “YES” MUST BE ADDRESSED IN THE
IEP.

Is the student blind or visually impaired?

Yes The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an
evaluation of the student’s reading and writing skills, needs, and appropriate reading and writing media (including an evaluation
of the student’s future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of Braille is not
appropriate for the student.
X No

Is the student deaf or hard of hearing?

Yes The IEP must include a communication plan to address the following: language and communication needs; opportunities for
direct communications with peers and professional personnel in the student’s language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the student’s language and communication mode; and
assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The
Communication Plan must be completed and is available at www.pattan.net

X No

Does the student have communication needs?

X Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)

No

Does the student need assistive technology devices and/or services?

Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)

X No

Does the student have limited English proficiency?

Yes The IEP team must address the student’s language needs and how those needs relate to the IEP.

X No

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Student’s Name: Jax Miller

Does the student exhibit behaviors that impede his/her learning or that of others?
Yes The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that
utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels
section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction sections
of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A Positive Behavior
Support Plan and a Functional Behavioral Assessment form are available at www.pattan.net
X No
✔

Other (specify):

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:

● Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based
assessments, transition assessments, progress toward current goals)
● Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
● Present levels related to current postsecondary transition goals if the student’s age is 14 or younger if determined appropriate by the IEP team
(e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)
● Parental concerns for enhancing the education of the student
● How the student’s disability affects involvement and progress in the general education curriculum
● Strengths
● Academic, developmental, and functional needs related to student’s disability

Present levels of Performance:

Academics:
Jax’s current grade report is as follows; a B in Language Arts, a C in Spelling, a Satisfactory in Handwriting, a B in Math, a C in Reading,
a B in Science, and an A in Social Studies. Jax’s academic performance is in the B-C range, and he is also struggling with core skills that
he should have in the second grade. An area of academic improvement that should be focused on is writing fluency, as it affects all
areas of his academics. Jax has a hard time focusing when he is asked to complete writing prompts independently. He is unable to
start writing and often forgets or gets distracted while he is in the middle of completing the work. Jax also struggles to remain
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Student’s Name: Jax Miller

organized and loses his spelling sheet almost every week. This is directly affecting his ability to succeed in spelling. Jax would benefit
from receiving extra supports and tips to help him remain organized. Jax struggles to focus on the task at hand which is directly
affecting his handwriting skills. His motor skills are developed and when he focuses and puts in some extra effort he can write legibly
and space his words. Jax has little to no reaction to completing assignments and does not communicate he has completed them to
the teacher. Jax is not enthusiastic about the work that he is asked to complete in the classroom which is the reason he does not feel
accomplished when he is finished. When Jax works one-on-one with an aide in the classroom he can focus and can complete mental
math appropriate for his grade level. Jax understands math and is good at it, however, he struggles to focus and complete the
problems. When he is taken through the work step by step he can complete the work well. Jax can read fluently and comprehend
what he is reading well enough to answer basic questions about the content. Jax is currently performing at a first grade level in
writing and reading. Jax took the second-grade reading scanner assessment on September twentieth, 2020. The assessment is a
diagnostic assessment that is administered to learn more about the students reading ability at the beginning of the school year,
typically September. Jax struggled to comprehend the reading segment Balloon Fun and answer the comprehension question about
what the weather was like in the passage. He was then able to answer two of the three multiple-choice questions correctly for the
same reading passage. In the next reading passage, How to Make a Bookmark, Jax was able to answer two of the four
comprehension questions correctly. Jax got one of the three questions correct on the third reading passage, A Little Rain. Jax
struggled to comprehend the theme of each of the reading passages and got the question about the main topic incorrect for each of
the passages. Jax was able to figure out a minimum of one of the multiple-choice questions for each passage. When asked questions
Jax gives the correct answer but he struggles to expand or explain the answer he has come to for a given problem or question. Jax
struggles to focus on the current topic and does not do work unless he wants to or it is interesting to him at the time. When Jax is
given an assignment he struggles to focus and complete the work. Jax is doing well in social studies as it is one of his favorite topics.
Jax struggles to find his schoolwork due to disorganization. Providing Jax with the support and tools that he needs to organize will
help to improve his academic performance and motivation.

Behavior:
Jax is a quiet student who remains to himself and prefers not to interact with his peers or teacher. Jax struggles to communicate how
he feels and becomes frustrated with the teacher when she does not know how he is feeling. Jax struggles to engage and make eye
contact when in conversation. If Jax were to be given tools and strategies for communicating the struggle he experiences would
decrease and there would be a great improvement in his confidence and ability to complete coursework. Jax struggles to remain in
his seat when he is working on assignments or listening to the teacher. Jax should receive accommodations that help him to remain
in his seat while being stimulated to decrease distraction and frustration. Jax is easily engaged in lessons that center around topics
that interest him and he loves to share the knowledge that he has about his favorite topics. When his engagement increases his
movement and distraction decreases. Jax remains to himself and does not intentionally distract his peers. Jax struggles to focus in
the classroom when he is disinterested in the topic. When he is disinterested he becomes distracted and inadvertently distracts his
peers. When Jax is frustrated or disinterested he flaps his arms and moves around in his seat. Receiving feedback from the teacher
frustrates Jax and he yells about not wanting to hear about what he did wrong. Jax struggles to follow directions when he does not
want to complete the work or task. Jax is motivated by his interest in animals and he enjoys explaining his hobbies and interests. Jax
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Student’s Name: Jax Miller

loves to talk about his interests and using that as a motivator is extremely effective. Jax is reinforced by behavior-specific praise and
personal encouragement. Jax appreciates when his success is reinforced with one-on-one recognition such as a great job or a high
five. Jax is motivated by the potential for receiving attention from the teacher.

Social Skills:
Jax does not interact with his peers in the classroom and regularly stays to himself for the majority of the day. He does not enjoy
speaking to others and will not initiate a conversation even when he is prompted to in the classroom. Jax takes time when getting to
know people and mainly enjoys talking about his interests. Jax does not show affection toward any of his peers or his teacher. He
plays by himself and is entertained by his thoughts and imagination. Jax does not show companionship with his peers or adults. Jax is
closed off and does not often share himself or show care for others. Jax struggles to maintain eye contact and does not begin
interactions with a greeting. He waits for whomever he is speaking to in order to initiate the conversation and relies on them to keep
the conversation going. When Jax disagrees with the teacher or peer he becomes frustrated and ceases to engage in the
conversation.

Gross and Fine Motor Skills:

Jax’s gross and fine motor skills are developed at an age-appropriate level. Jax walks and runs often and does not struggle with those
gross motor skills. He is active and enjoys engaging in activities such as running and walking. He struggles with hand-eye coordination
and does not enjoy playing games with balls. Jax’s fine motor skills are well developed, however, he struggles to focus on what he is
doing for an extended time and that affects his ability to perform tasks. Jax struggles to tie his shoes and does not typically notice
when his shoes are untied. Jax should be given more support and introduced to skills that help him focus to improve his fine motor
skills.

Adaptive Skills:
Jax does not show interest in completing the task he is assigned and does not know how to approach a challenge. Jax struggles to
complete tasks that are challenging or new and remain motivated when the work becomes hard. Jax does not organize his
belongings or schoolwork; he puts everything into a bucket and does not touch it again. When asked to organize his belongings Jax
throws out his papers and places his pens and markers at the bottom of his bucket. Jax is unable to produce his planning paper when
asked to at the end of each day. Jax struggles to complete his online work because he does not know where his classes and
assignments are on the computer. Jax struggles to follow school rules as it is hard for him to focus or know when he is being spoken
to.

Present level related to current post secondary transition goals:

Transition services are not appropriate at this time.

Parental concerns for enhancing the education of the student:

Jax’s parents have no concerns about enhancing Jax’s education.
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Student’s Name: Jax Miller

How the student’s disability affect involvement in the general education curriculum:
Jax is performing at the academic level appropriate for his age and grade. Jax struggles with organization and communication which
both directly affect his involvement in the general education curriculum. Jax would benefit from receiving accommodations for the
general education curriculum.

Strengths (per information above):

● Jax can read fluently and comprehend what he is reading well enough to answer questions about the content.
● When Jax works one-on-one with an aide in the classroom he can focus and complete mental math appropriate for his grade
level.
● Jax is easily engaged in lessons that center around topics that interest him and he loves to share the knowledge that he has
about his favorite topic.
● Jax remains to himself and does not intentionally distract his peers.

Academic, developmental, and functional needs related to student’s disability:

Academic:
Jax is performing below grade level in reading according to his second-grade reading scanner assessment. Jax struggles to
comprehend what he has read, however, he can fluently read the text. He struggles to focus on the task at hand and this impacts his
reading and writing. When Jax is asked questions and encouraged to discuss the story as he reads he can remember more of what he
has read. Intermittent breaks while reading and writing have proven to increase Jax’s understanding and information retention.

Developmental:
Jax struggles to follow directions given to him by the teacher and needs help in improving his interpersonal skills. Jax’s struggle to
focus and listen to the teacher when she is addressing him is impacting his academics and social development. Jax struggles to create
a relationship with his teacher which is affecting his ability to form relationships with his peers. Jax needs support and he should be
taught skills for listening and interacting with his teacher and peers.

Functional:
Jax struggles to maintain an organizational level that allows him to complete his coursework and follow what is happening in the
classroom. Jax does not organize his belongings and struggles to keep track of important documents, including his planner paper. Jax
would benefit from having his planner paper and being able to maintain organization with his homework. Jax has a hard time keeping
track of his completed work, writing utensils, and online work. Due to COVID-19 all of the coursework is online in google classrooms.
This is hard for Jax to remain organized and follow along with coursework. Jax works better with hands-on assignments and working
on the computer is harder for him to organize.

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Student’s Name: Jax Miller

III. TRANSITION SERVICES – This is required for students age 14 or younger if determined appropriate by the IEP team. If the student does not attend the IEP
meeting, the school must take other steps to ensure that the student’s preferences and interests are considered. Transition services are a coordinated set of
activities for a student with a disability that is designed to be within a results oriented process, that is focused on improving the academic and functional
achievement of the student with a disability to facilitate the student’s movement from school to post school activities, including postsecondary education,
vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent living, or
community participation that is based on the individual student’s needs taking into account the student’s strengths, preferences, and interests.

POST SCHOOL GOALS – Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education
and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal.
Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.

For students in Career and Technology Centers, CIP Code:

N/A

Postsecondary Education and Training Goal: Measurable Annual Goal

N/A Yes/No
(Document in Section V)
Courses of Study:
N/A

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible

Employment Goal: Measurable Annual Goal

N/A Yes/No
(Document in Section V)
Courses of Study:
N/A

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Student’s Name: Jax Miller

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible

Independent Living Goal, if appropriate: Measurable Annual Goal

N/A Yes/No
(Document in Section V)
Courses of Study:
N/A

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Instructions for IEP Teams:
Please select the appropriate assessment option. Information on available testing accommodations may be found in the Accommodations Guidelines
available on www.education.state.pa.us.

State Assessments

Not Assessed
X No statewide assessment is administered at this student’s grade level.
No English proficiency assessment administered because the student is not an English Language Learner.

PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5
and 8; and ELA*)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Math

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Student’s Name: Jax Miller

Science
Reading
Writing
ELA*
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11 th grade)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1
Literature
Biology

Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam module.)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1
Literature
Biology

Validated Local Assessment (Available when selected as option by LEA)

Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1
Literature
Biology

PASA (Administered in grades 3-8, 11 for Reading and Math; Grades 4, 8, 11 for Science)
X Student will participate in the PASA.

Explain why the student cannot participate in the PSSA or the Keystone Exam for Reading/Literature, Math/Algebra 1,
Science/Biology, and Composition (The Composition exam will be available for the 2016-17 school year):

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Student’s Name: Jax Miller

Explain why the PASA is appropriate:

Choose how the student’s performance on the PASA will be documented.

Videotape (preferred method)

Written narrative notes (requires prior approval in accordance with PDE

guidance)

ACCESS for ELLs (Administered in grades K-12)

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to
Accommodations Accommodations Participate Participate in Selected Domains
Listening N/A
Reading N/A
Writing N/A
Speaking N/A

Alternate ACCESS for ELLs (Administered in grades 1-12)

Student will participate in the Alternate ACCESS for ELLs.

Explain why the student cannot participate in the ACCESS for ELLs:

Explain why the Alternate ACCESS for ELLs is appropriate:

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to

Accommodations Accommodations Participate Participate in Selected Domains
Listening
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Student’s Name: Jax Miller

Reading
Writing
Speaking

Local Assessments

Local assessment is not administered at this student’s grade level; OR

X Student will participate in local assessments without accommodations; OR

Student will participate in local assessments with the following accommodations; OR

The student will take a local alternate assessment.

Explain why the student cannot participate in the local regular assessment:
N/A

Explain why the local alternate assessment is appropriate:

N/A

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V. GOALS AND OBJECTIVES – Include, as appropriate, academic and functional goals. Use as many copies of this page as needed to plan appropriately. Specially
designed instruction may be listed with each goal/objective or listed in Section VI.

Short term learning outcomes are required for students who are gifted. The short term learning outcomes related to the student’s gifted program may be listed
under Goals or Short Term Objectives.

MEASURABLE ANNUAL GOAL Describe HOW the

Describe WHEN periodic
Include: Condition, Name, Behavior, and Criteria student’s progress toward
reports on progress will be Report of Progress
(Refer to Annotated IEP for description of these meeting this goal will be
provided to parents
components) measured
When given a reading passage, Jax will be able to Once a week, when the Progress will be reported to
read fluently and upon completing it answer 2 out class completes a story Jax Jax’s parents every two
of 3 comprehension questions with an 80% will be removed from the weeks or as his teacher
accuracy for 5 consecutive progress monitoring classroom by the special deems it necessary.
sessions. education teacher. He will
be asked to read the story
and then answer a series
of comprehension
questions. The special
education teacher will
come prepared with three
comprehension questions
and the ideal answers
they would like to hear.
The number of correct
answers will be recorded
out of three and the
accuracy will be assessed
in comparison to the ideal
answers.
When given verbal directions by an adult in the Twice a week the general Progress will be reported to
classroom, Jax will follow the directions in 30 education teacher will parents at the end of each
seconds after making eye contact with the adult in intentionally give Jax the month to ensure progress is
3 out of 5 trials for 6 sessions in a row. opportunity to listen to, occurring in the classroom.
make eye contact, and
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follow directions
presented to him. Jax’s
progress will be recorded
and his progress will be
graphed to visually
represent the results.
When asked to produce his planner sheet to Jax’s general education Progress will be reported to
record his homework, Jax will be able to locate it teacher will give him the parents at the end of each
and fill in his homework with 90% accuracy, 4 out opportunity to produce month to show them how
of the 5 days of the week. his planner paper daily. Jax’s organizational skills are
The progress will be improving.
recorded by date and will
then be reported through
line graphs to view the
progress being made
throughout the year.

SHORT TERM OBJECTIVES – Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).

Short term objectives / Benchmarks

N/A

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VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS – Include, as appropriate, for nonacademic
and extracurricular services and activities.

A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)

● SDI may be listed with each goal or as part of the table below.
● Include supplementary aids and services as appropriate.
● For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or modifications to the general
education curriculum, as appropriate for a student with a disability.

Modifications and SDI Location Frequency Projected Beginning Date Anticipated Duration
SDI for Goal 1:
The special education
teacher will provide direct
and explicit individual
instruction on how to read 2 times per week
The special education 11/25/20 11/25/20 - 6/14/21
a short story with pauses to 20 minutes
classroom
discuss the plot of the story
and prepare to answer
possible comprehension
questions.
SDI for Goal 1:
Following direct and explicit
individual instruction, Jax
and the special education
The special education 2 times per week
teacher will create potential 11/25/20 11/25/20 - 6/14/21
classroom 10 minutes
comprehension questions
for their story and answer
them verbally through
think-alouds.

SDI for Goal 2: The general education 2 times per week 11/25/20 11/25/20 - 6/14/21
The general education classroom 20 minutes
teacher, tutor, or
paraeducator will role play

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with Jax to teach him what

he should do when
directions are given in the
classroom.
SDI for Goal 2:
The general education
teacher will read Jax stories
about how best to follow The general education 1 time per week
11/25/20 11/25/20 - 6/14/21
directions and show him classroom 20 minutes
step-by-step how to engage
in eye contact through the
example of others.
SDI for Goal 3:
The special education
teacher, paraeducator, or
tutor will spend time with
Jax and help him to The special education 1 time per week
11/25/20 11/25/20 - 6/14/21
organize his belongings and classroom 15 minutes
show him through direct
instruction how to remain
organized throughout the
week.
SDI for Goal 3:
The general education
teacher will observe Jax as
he goes through the week
and organizes himself. At The general education 1 time per week
11/25/20 11/25/20 - 6/14/21
the end of the week she will classroom 10 minutes
provide feedback that is
constructive and helps Jax
improve his organizational
skills.

B. RELATED SERVICES – List the services that the student needs in order to benefit from his/her special education program.
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Service Location Frequency Projected Beginning Date Anticipated Duration

Special Education 5 times per week for
Special Education 11/25/20 11/25/20 - 6/14/21
CLassroom 10-20 minutes per session

C. SUPPORTS FOR SCHOOL PERSONNEL – List the staff to receive the supports and the supports needed to implement the student’s IEP.

School Personnel to Projected Beginning

Support Location Frequency Anticipated Duration
Receive Support Date
N/A

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D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS IDENTIFIED AS A STUDENT WITH A DISABILITY – Support services are
required to assist a gifted student to benefit from gifted education (e.g., psychological services, parent counseling and education, counseling services,
transportation to and from gifted programs to classrooms in buildings operated by the school district).

Support Service N/A

Support Service N/A
Support Service N/A

E. EXTENDED SCHOOL YEAR (ESY) – The IEP team has considered and discussed ESY services, and determined that:

Student IS eligible for ESY based on the following information or data reviewed by the IEP team:

OR

X As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:

Jax will be assessed for ESY Services using the 2020-2021 winter holiday break. Regression and recoupment data will be taken 10 days
prior to the break and the 10 days after the student’s return to school. Data will be analyzed to determine if a successive interruption
in school and impacts his academic, social, and/or functional performance, per his current IEP goals. A decision regarding ESY
placement will be determined by February of 2021.

The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the student’s ESY Program are:

If the IEP team has determined ESY is appropriate, complete the following:
ESY Service to be Provided Location Frequency Projected Beginning Date Anticipated Duration

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Jax Miller

VII. EDUCATIONAL PLACEMENT

A. QUESTIONS FOR IEP TEAM – The following questions must be reviewed and discussed by the IEP team prior to providing the explanations regarding
participation with students without disabilities.

It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public or
private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal of
students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education in
general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily.

● What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the
supplementary aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the
general education class.

● What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?

● What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the class,
even with supplementary aids and services?

● To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:
Jax will spend the majority of his time in the general education classroom with his typically developing
peers. Jax is performing at the same level of his peers and would benefit from remaining in the general
education classroom. Jax will spend a portion of his day in the special education classroom to gain the
support that he needs.

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
The only time that Jax will not participate in the general education classroom will be the 45 minutes per
week he will be gaining support in the special education classroom. Jax is benefiting from the general
education curriculum but requires some support in the special education classroom.

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Jax Miller

B. Type of Support

1. Amount of special education supports

X Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day

Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than
80% of the school day

Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day

2. Type of special education supports

Autistic Support

Blind-Visually Impaired Support

Deaf and Hard of Hearing Support

Emotional Support

X Learning Support

X Life Skills Support

Multiple Disabilities Support

Physical Support

Speech and Language Support

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Jax Miller

C. Location of student’s program

Name of School District where the IEP will be implemented: Steubenville City Schools

Name of School Building where the IEP will be implemented: Pugliese West Elementary School

Is this school the student’s neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
X Yes

No. If the answer is “no,” select the reason why not.

Special education supports and services required in the student’s IEP cannot be provided in the neighborhood school

Other. Please explain:

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Jax Miller
VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one Educational Environment)

To calculate the percentage of time inside the regular classroom, divide the number of hours the student spends inside the regular classroom by the total
number of hours in the school day (including lunch, recess, study periods). The result is then multiplied by 100.

SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers – Indicate the Percentage of time INSIDE the regular classroom for
this student:

Time spent outside the regular classroom receiving services unrelated to the student’s disability (e.g., time receiving ESL services) should be considered time
inside the regular classroom. Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as
college campuses or vocational sites, should be counted as time spent inside the regular classroom.
Calculation for this Student:
Column 1 Column 2 Calculation Indicate Percentage Percentage Category
Total hours the student Total hours in a (Hours inside Section A: The percentage
spends in the regular typical school day regular classroom ÷ of time student spends
classroom per day hours in school inside the regular Using the calculation result – select the appropriate
(including lunch, day) x 100 = % classroom: percentage category
recess & study
periods) (Column 1 ÷
Column 2) x 100 =
%
6 6.5 6÷ 6.5 x 100 = 92% 92% of the day Inside the Regular Classroom 80% or More of the Day

SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day – select and indicate the Name
of School or Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP
team must do the calculation in Section A)
☐Approved Private School (Non Residential) _________________________ ☐Other Public Facility (Non Residential) _________________________
☐Approved Private School (Residential) _________________________ ☐Hospital/Homebound _________________________
☐Other Private Facility (Non Residential) _________________________ ☐Correctional Facility _________________________
☐Other Private Facility (Residential) ________________________ ☐Out of State Facility _________________________
☐Other Public Facility (Residential) ________________________ ☐Instruction Conducted in the Home _________________________

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Jax Miller

EXAMPLES for Section A: How to Calculate PennData–Educational Environment Percentages

Column 1 Column 2 Calculation Indicate Percentage
Total hours the student Total hours in a typical (Hours inside regular classroom ÷ hours in Section A: The percentage of time
spends in the regular school day (including lunch, school day) x 100 = % student spends inside the regular
classroom per day recess & study periods) classroom:
(Column 1 ÷ Column 2) x 100 = %
Example 1 5.5 6.5 (5.5 ÷ 6.5) x 100 = 85% 85% of the day
(Inside 80% or More of Day)
Example 2 3 5 (3 ÷5) x 100 = 60% 60% of the day
(Inside 79-40% of Day)
Example 3 1 5 (1÷ 5) x 100 = 20% 20% of the day
(Inside less than 40% of Day)
For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on
the website. If you do not have access to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.

Page 25 of 25 April 2014