DEPARTMENT OF EDUCATION INDIVIDUALIZED EDUCATION PLAN (IEP)
Region X
Schools Division of Misamis Oriental Overview: This IEP has been designed in accordance with the World Health Organization International Classification of Functioning
District of Disability and Health. In accordance with this approach, Disability is defined as an impairment in interaction with a wide range of
_____________________ environmental barriers. In this IEP, teachers are asked to identify the learner’s impairment in combination with their school
environment. The learning barriers should be documented alongside accommodations designed to remove the participation barriers
and improve educational success.
SECTION A: PERSONAL INFORMATION
LEARNER/PARENT INFORMATION: DIFFICULTIES: MEETING INFORMATION
DATE OF MEETING _____________
Learner: __________________ Sex : ______________ ___ Difficulty in Seeing DATE OF LAST IEP ______________
Birth date: _________________ Grade/Level: _______________ PURPOSE OF MEETING:
LRN: _____________________ ___ Difficulty in Hearing ___ Interim IEP
___ Initial IEP
Current School: __________________________________
__ Annual IEP
Address of School: _______________________________ ___ Difficulty in Communicating ___ IEP Following 3-Yr Reevaluation
Mother Tongue Spoken: ___________________________ ___ Revision to IEP Date_________
Address: ____________________________________________ ___ Difficulty in Mobility / Walking ___ Exit/Graduation_____________
Learner’s Phone (if there is) ________________________ ___ IEP Revision Without a Meeting:
Parent/Guardian/Caregiver: ________________________ ___ Difficulty in Displaying Interpersonal Behavior At the request of ___Parent
Work & Workplace: _________________ ___School
____ Difficulty in Performing Adaptive Skills IEP Review Date: _________________
Landline/Mobile/Cell Phone No.____________ Email: __________ COMMENTS:
Mother Tongue Spoken: _____________________________
____ Difficulty in Basic Skills and Applying Knowledge
Interpreter or Other Accommodations Needed: __________________
______________________________
__ Difficulty in Remembering/ Understanding
___ Others (please specify) _______________
___ Medical Diagnosis (if yes, please specify)
IEP TEAM MEMBERS IN ATTENDANCE
Parent/Guardian/Caregiver: _____________________________ School Psychologist__________________________________________________
*Learner: ____________________________________________ Guidance Counselor /Designate:
Principal/School Head: ________________________________ School Nurse: ______________________________
Other (name and role) Therapist/Pathologist/Specialist_________________________________________
________________________________________________ Speech/Language ____________________________________________________
Special Education Teacher: ______________________________ Interpreter __________________________________________________________
**Regular Education /Receiving Teacher Other (name and role) _________________________________________________
____________________________________
Other (name and role):
*Learner must be invited when transition is discussed.
**The IEP team must include at least one regular education teacher of the learner (if the learner is or may be participating in the regular education environment)
Signature over Printed Name of Parent/Guardian/Caregiver:________________________________________
AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, LEARNER MUST BE INFORMED OF THEIR RIGHTS UNDER THE LAW AND ADVISED THAT THESE RIGHTS WILL BE
ENJOYED AT AGE 18.
___ Not Applicable (learner will not be 18 within one year ____The learner has been informed of his/her rights under law and advised of the transfer of rights at age 18
Distribution: __Learner’s Folder ___Parent/Guardian/Caregiver __Special Education teacher __Adviser (Regular Education/Receiving Teacher)
LEARNER: ____________________________________________ DATE: ___________________________
I. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Results of Initial or most recent evaluation and results of school and division assessments:
Description of academic, developmental and/or functional strengths
Description of academic, developmental and/or functional needs:
Parental concerns regarding their child’s education:
Impact of the disability on involvement and progress in the general education curriculum:
STRENGTHS, CONCERNS, INTERESTS AND PREFERENCES
STATEMENT OF THE LEARNER’ STRENGTH
STATEMENT OF PARENTS’ EDUCATIONAL CONCERNS
STATEMENT OF LEARNER’S PREFERENCES AND INTERESTS (required if transition services will be discussed)
II. CONSIDERATION OF SPECIAL FACTORS
a. Does the learner have difficulty relating with people which impedes his/her learning or learning of others? √ No Yes
b. If yes, consider the appropriateness of developing a Behavior Intervention Plan
Behavior Intervention Plan developed?
Refer to Behavior Intervention Plan for additional information.
Does the learner have difficulty in Moving/ Walking? No Yes
If yes, consider the mobility needs as related to the IEP and describe below.
Does the learner have difficulty in seeing with blindness/visual impairment? No Yes
If yes, provide for instruction in Braille and the use of Braille, unless the IEP Team determines that instruction in Braille is not appropriate for the learner after an evaluation of the learner’s reading and writing
skills, needs, and appropriate reading and writing media, including evaluation of needs for instruction in Braille or the use of Braille. Describe below.
Does the learner have difficulty in communicating? No Yes
If yes, consider the communication need and describe below.
Does the learner have difficulty in concentrating/ paying attention? No Yes
If yes, consider the attention span needs and describe below.
Does the learner have difficulty in hearing or is the learner deaf or hard of hearing? No Yes
If yes, consider and describe the learner’s language and communication needs, opportunities for direct communication with peers and professional personnel in the learner’s language and communication
mode, academic level and full range of needs, including opportunities for direct instruction in the learner’s language and communication mode. Describe communication needs below.
Does the learner need assistive technology devices or services?
No Yes
If yes, describe the type of assistive technology and how it is used. If no, describe how the learner’s needs are being met in deficit areas.
Does the learner require alternative format for instructional materials? No Yes
If yes, specify format(s) of materials required below.
Braille Large Type Auditory Electronic Text
SECTION B: DIFFICULTIES, BARRIERS AND ENABLING SUPPORTS
DIFFICULTY ENVIRONMENTAL BARRIERS ENVIRONMENTAL FACILITATORS ACCOMMODATIONS
(enter all areas of difficulty) (describe each factor restricting (describe each factor enabling (list items, staff resources and
participation) participation in response to barriers) infrastructure changes required to
enable participation)
SECTION C: LEARNER GOALS
To support Identification of learner goals, also confirm:
What opportunities are available at the school to support learner goals?
What are the student interest areas?
What disability-specific skills does the learner need to develop to support their participation / attainment of goals?
Goals – (e.g. skills to improve participation in education or daily living skills? Goals should be SMART.
INTEREST GOAL INTERVENTIONS TIMELINE INDIVIDUALS REMARKS PROGRESS /
RESPONSIBLE NEXT STEPS
METHOD FOR REPORTING PROGRESS
METHOD FOR REPORTING THE STUDENT’S PROGRESS TOWARD MEETING ANNUAL PROJECTED FREQUENCY OF REPORTS
GOALS (Check all methods that will be used)
___IEP Goals Per Domain ____ Report Card ___ Quarterly ____Semester
___Specialized Progress Report _ __ Parent Conferences
___Other (please specify):___________________________________________________ ____ Trimester ____Other
SPECIAL EDUCATION SERVICES
SPECIALLY DESIGNED INSTRUCTION BEGINNING AND FREQUENCY OF LOCATION OF
ENDING DATES SERVICES SERVICES
SUPPLEMENTARY AIDS AND SERVICES
Includes aids, services and other supports provided in regular education classes or other education-related settings to enable participation with
non-disabled learner
MODIFICATION, ACCOMODATION OR SUPPORT FOR LEARNER BEGINNING AND FREQUENCY OF LOCATION OF
OR PERSONNEL (Describe below or select from supplemental ENDING DATES SERVICES SERVICES
“Modifications, Accommodations and supports”
RELATED SERVICES
RELATED SERVICES SERVICES TYPE BEGINNING AND FREQUENCY OF LOCATION OF SERVICES
AND/OR DESCRIPTION ENDING DATES SERVICES
___Speech/Language Therapy
___Physical Therapy
___Occupational Therapy
___Transportation
___Counseling
___Psychological Services
___Orientation and Mobility
___School Health/Medical Services
___Recreation Therapy
___Parent Counseling & Training
___ Audiology /Interpreting Services
___Social Work Services
Other (specify)
EXTENDED SCHOOL YEAR SERVICES
Does the learner require extended School year services?
___No ___Yes If YES, IEP goals and 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:
PLACEMENT
PLACEMENT CONSIDERATIONS PERCENTAGE OF TIME IN REGULAR EDUCATION
ENVIRONMENT
___Selected ____Rejected Regular class w/ supplementary aides and services
___Selected ____Rejected Regular class and SPED class (i.e., resource) combination
___Selected ____Rejected Self-contained program
___Selected ____Rejected Special School
___Selected ____Rejected Community
___Selected ____Rejected Hospital
___Selected ____Rejected Home
___Selected ____Rejected Other
JUSTIFICATION FOR PLACEMENT INVOLVING REMOVAL FROM REGULAR EDUCATION ENVIRONMENTS
IEP IMPLEMENTATION
___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 will or part of this IEP. I understand that the school 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 school principal.
___________________________
Parent’s Signature
__________________________ _________________________
______________________________
Special Education Teacher Principal/School Head
Regular/Receiving Teacher (if LSEN is in inclusion)
_______________________ ________________________________ _______________________
Learner (if applicable) Guidance Counselor/SPED Coordinator Psychologist/Other Specialist
