Individualized Education Program

Student's Name: __________________ IEP Date: ______________ Grade: ____Age* :_____

Disability (if identified): ..____________ Parent/Guardian/Adult Student: ______________

_Primary language at home: __________ Parent interpreter needed? 0 Yes 0 No

Single parent: 0 Yes 0 No If yes, name: _______________

Home Address: Phone # (H): ___________ Phone # (W): ----------- Attending School: ______

Is this student's neighborhood school? 0 Yes 0 No

Most recent evaluation date:_________________ Plan date _________

Next re-evaluation must occur before this date ______________ Plan end date ____________

Date of Plan meeting _______________ Date parent notified of Plan meeting __________

Date student notified of Plan meeting (if transition will be discussed)

Primary Staff Contact: -___________________ Teacher Phone Number:________________

The list below indicates that the individual participated in the development of this Plan and the
placement decision; it does not authorize consent.

Excused Name of Participant Title

 _______________________________________ _____________________
 _______________________________________ _____________________
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 _______________________________________ _____________________
 _______________________________________ _____________________
 _______________________________________ _____________________
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 Team Considerations
Meeting Date__________________

PURPOSE: During the IEP meeting the following factors must be considered by the IEP team.
Best practice suggests that the IEP team document that the factors were considered and any
decision made relative to ea.ch. The factors are addressed in other sections of the IEP if not
documented on this page, (for example: see Present Levels of Academic and Functional
Performance)

 The strengths of the student and the concerns of the parents for enhancing the
education of the child.
_____________________________________________________________________
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 The results of the student's performance on any general state or district-wide

assessments.
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 The communication needs of the student.

(In the case of a student who is deaf or hard of hearing, consider the student's
language and communication needs, opportunities for direct communications with
peers and professional personnel in the student's language and communication
mode, academic level, and full range of needs, including opportunities for direct
instiu ction in the student's language and communication mode. )

 The student's assistive technology devices and services needs.

______________________________________________________________________
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Present Level of Educational Performance

A. Social/Emotional

B. Academic
Math
 Reading
Writing
Work Habits/Study Skills

Measurable Annual Goals

Meeting Date:_____________

PURPOSE: IEPs must include a statement of measurable annual goals, including academic and
functional goals, designed to meet each of the student's educational needs that result from the
student's disability to enable the student to be involved and make progress in the general
education curriculum. In order to be measurable, the goal should include a baseline ("from"), a
target ("to"), and a unit of measure

I. Social/Emotional
II. Math
III. Reading
IV. Writing
V. Working habits

Special Education Programs and Related Services/Program Modifications

A. Special Education Initiation Date Frequency Duration

Programs/Related Services

_____________________ ________________ _________ __________

_____________________ ________________ _________ __________

_____________________ ________________ _________ __________

Describe any assistive technology devices or services needed:

_________________________________________________________________________________

_________________________________________________________________________________

Describe the program modifications or supports for school personnel that will be provided on
behalf of the students to address the annual goals and participation in general education
curriculum and activities.

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Explain how the student will be assesses:

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Reporting Progress to Parents

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