Sample Individualized Education Plan (IEP)

Sample Individualized Education Program
Appendix A
Sample Individualized Education Plan (IEP)

The following IEP sample reflects but one way to present an IEP and contains components that have worked well for some systems. It is critical to remember that each IEP must be individualized and based on the needs of the particular student. For a complete description of IEP content required by IDEA 97, please refer to the Final Regulations 300.347. In addition, be sure to check with your district and/or state for recommended or required IEP forms or processes.
IDEA 97 Transition Requirements: A Guide
75
Appendix A
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Appendix A
Individualized Education Program

A. Student Name (Last, First, MI) Schooler, Maureen H.
Current Grade Student's Primary Language or Communication Mode Birthdate (month/day/year) Sex
12/27/83 English
City State Zip
[ ]M
[X] F
9
Current Address
Phone Number
1234 West Here Street

Serving School
Nice Town
City
ND
State
12345
Zip
555-222-3333
Phone Number
Desert Valley Senior High

Resident School (If different from serving school)
Nice Town 123-45-6789

Check items that apply.
ND
12345
555-123-4567
Student Social Security Number (Optional)
Same
School District of Residence (If different from serving district)
Same B. Name of Parent(s) Teddy and Matilda Schooler

Address (if other than Student's Current Address)
[X] Open Enrolled in same district [ ] Open Enrolled in another district

Home Telephone Number
[ ] Agency Placed [ ] Home Education

Other Telephone Number
555-222-3333
None
Primary Language at Home
Same
Is there a Guardian/Educational Surrogate/Foster Parent
English
[ ] Guardian
Address
[ ] Educational Surrogate
[ ] Yes [X] No [ ] Foster Parent

City
Name:
State
Zip
N/A C. IEP Case Manager Henrietta Harvey

IEP Type
N/A
Telephone Number
N/A
N/A
555-999-8888
Date of Last Comprehensive Individual Assessment Report (month/day/year)
[ ] Initial
D. Date of IEP Meeting
(month/day/year)
[X] Annual
5/23/98
List Names of All Team Members Check Attendance
5/16/99
*Parent Parent Student Administrator/Designee Special Ed Teacher General Ed Teacher Representative of district of residence Vocational Rehabilitation Counselor
Teddy Schooler Matilda Schooler Maureen Schooler Joe Smith Jane Lakeman Ellie Math Carol Burkett, Special Education Christine Fullerton
[X] Yes [ ] No [X] Yes [ ] No [X] Yes [ ] No [X] Yes [ ] No [X] Yes [ ] No [X] Yes [ ] No [X] Yes [ ] No [X] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
* If the parent did not attend the IEP meeting, describe effort to arrange a mutually agreed upon time and place. Include date, contact, and outcome of each effort. Adapted and used with permission of the North Dakota Department of Public Instruction, Office of Special Education.
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Appendix A
E. Students Desired Post School Outcomes, ages 14-21 (or younger, if appropriate)
Employment: I would like to work with or teach children who have disabilities; no job supports are anticipated. Community Participation: I intend to remain independently involved in church and may volunteer with various community activities of interest. Recreation & Leisure: I will stay active in group activities (bowling, music, sport events) and independent activities (sewing, reading, roller-blading) with no need for supports. Post Secondary Training & Learning Opportunities: I will attend a liberal arts college program to work with children; funding & academic supports may be appropriate. Independent Living: I will be capable of living independently in a dorm, apartment or alone.
F. Present Levels of Educational Performance

The statement of present levels of educational performance is an integrated summary of information from all sources including the student's family. Summarize and discuss parent information and student progress toward previous goals and objectives. Include the parents perspectives and insights about their child's learning strategies, social skills, interests, and any existing medical diagnoses that are important contributions to creating a description of the whole child. The statement should include current information about the student's specific strengths and weaknesses, progress in the general education curriculum, unique patterns of functioning, and implications of the problem areas on the student's total functioning. Performance areas to be considered include the following: Cognitive functioning Academic performance Communicative status Motor ability Sensory status Health/physical status Emotional and social development, behavior skills (including adaptive behavior, if applicable), and ecological factors
Maureen is currently functioning in the average range of intelligence according to the WISC III administered on 5-23-98. Her strengths are in the area of short and long-term memory and problem solving. Her learning disability in the areas of reading comprehension and written expression require accommodations in her general education classes described in Section G. Maureen's oral expression skills are a strength for her as are her interpersonal skills. Academically, she has maintained Bs with a C in Biology for the second semester of her 9th grade year. She met her IEP goals for the 98-99 academic year.
Address the present levels of performance in each of the following domains with documentation of student needs, preferences and interests and identified by what method this information was obtained. Jobs and Job Training
Maureen volunteered at the Busy Bee Child Development Center during her 9th grade year. She worked primarily with the three-year-olds. Her supervisor reported that she was dependable and reliable and related very well with the students. Based on the California Occupational Preference Survey (COPS), her goal of working in child care appears to be an appropriate choice.
By what method was this obtained: Interview Recreation and Leisure
with job supervisor
Maureen is athletic; she is on a junior bowling league and enjoys rollerblading.

By what method was this obtained: Home/Independent Living
Interview with Maureen and her parents
Maureen is independent at home now and intends to pursue living on her own after graduation.
By what method was this obtained: Community Participation
Interview with Maureen and her parents
Woodcock-Johnson Scale of Independent Behavior
Maureen is quite active in church activities at this time.

By what method was this obtained: Interview
with Maureen
Post-Secondary Training and Learning Opportunities
Maureen wishes to attend a post-secondary liberal arts college, majoring in Child Development. She is exploring both 2year and 4-year institutions at this time and considering earning an AA + certificate first.
By what method was this obtained: Related Services
Interview with Maureen
Maureen has not received related services since the elementary grades (K-3) when she received Speech and Language therapy for 2x/week for 30 minutes. She was discharged at the end of third grade.
By what method was this obtained:
Review of school records
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Appendix A
(F. Present Levels of Educational Performance, continued) Considerations the IEP team must address A. Does the student exhibit behaviors that impede his or her learning or that of others? [X] No [ ] Yes - Consider strategies including positive behavior interventions, strategies, and supports in the IEP. If yes, what are recommendations to address these needs?
B. Does the student have limited English proficiency? [X] No [ ] Yes If yes, what are recommendations to address these needs?
C. Is the student blind or visually impaired? [X] No [ ] Yes - but the student does not need Braille/Braille instruction based on the students current and future reading and writing skills and needs. [ ] Yes - and the student needs Braille/Braille instruction based on the students current and future reading and writing skills and needs. If yes, what are recommendations to address these needs?
D. Is the student deaf or hearing impaired? [X] No [ ] Yes - Consider the childs language and communication needs, opportunities for direct communication with peers and professionals in the childs language and communication mode, academic level, and full range of needs including opportunities for direct instruction in the childs language and communication mode. If yes, what are recommendations to address these needs?
E. Does the student have other communication needs? [X] No [ ] Yes - Consider the strategies to address communication needs of the student. If yes, what are recommendations to address these needs?
F. Does the student require assistive technology devices and services? [ ] No [X] Yes - Consider the assistive technology needs of the student. If yes, what are recommendations to address these needs? Algebra: calculator for completion of assignments, quizzes and tests. Child Development, English, Advanced Biology: tape recorder to record class lectures and demonstrations.
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Appendix A
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G. Statement of Transition Service Needs (ages 14-21, or younger if appropriate)
List Courses to be taken each year Credits Earned
School Year
Grade Level Grade 8
Grade 9 Child Development (1/2), English 10 (1), Band (1), Phy Ed (1/2), Spanish I (1), Algebra (1), Adv. Biology (1), Resource Room (1) English 11 (1), Spanish II (1), Geometry (1), Band (1), Phy Ed (1/2), Family & Consumer Science I (1/2), Chemistry (1), Resource Room (1) Psychology (1/2), English 12 (1), Algebra II (1), Band (1), Cooperative Work Experience (11/2), Phy Ed (1/2), US History (1/2), Resource Room (1)
6 7 (13) 7 (19) 6 (24)
99-00
Grade 10
00-01
Grade 11
01-02
Grade 12
Ages 18-21
Total number of credits required by this district for graduation:
21
Anticipated month and year of graduation: May 2002 [ ] Yes [X] No
Will this student graduate with fewer credits than required of all students by the district?
If yes, identify graduation adaptations
H. Statement of Needed Transition Services (ages 16-21, or younger if appropriate) Needs & Activities Agency(ies) & Responsibilities Provider & Payer
School district will provide identified supports School district College of choice School district School district College of choice & Maureen Sp Ed supports in identified classes Modified ACT testing Post secondary supports (academic)
Transition Services

Instruction:
Community Experiences:
Visit three colleges which offer program of interest Maureen & parents Maureen & parents Coordinated by case manager and Maureen Maureen & Job Service Counselor Open a checking/saving account at bank Job preparation skills & review Part time employment by personal job search and/or with assistance from Job Service if necessary
Three job shadow experiences with children Coordinated by Case Manager and Maureen
School District will provide services Maureen and her parents will be responsible for any expenses incurred to visit colleges Maureen and her parents will be responsible for any expenses incurred. School district will provide services Maureen will incur any expenses to locate and find part time employment

Apply for all possible college financial aid Maureen, parents, school guidance office Maureen, parents and VR staff Maureen and parents School will provide services within limits of building, and Maureen/parents will incur expenses for mailings, etc. There is no expense to apply for VR services Maureen and her parents will be responsible for any expense of this activity Maureen and parents Maureen and parents Vocational Rehabilitation referral to determine eligibility for tuition assistance for college Participate in home skills (make clothing & misc. purchases, cook 1 meal/week, help with laundry & misc. household chores) Apply for college/DSS no later than 12/01. Maureen, Guidance office, Case Manager School district will provide this service there is no expense There is no expense for this activity for the district. Review CHOICES to reaffirm vocational goal and review college information Complete community & Independent living assessment
Employment:
Related Services:
Maureens IEP team identified no long-term needs in related services at this time.
Adult Living & Post School:
Daily Living: (if appropriate)
Appendix A
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Functional Vocational Assessment: (if appropriate)
Appendix A
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Agency Collaboration & Responsibilities* (ages 16-21, or younger if appropriate) Needed Service(s) Agency & Contact Person Who will contact & when Timeline for delivery of service(s)
Summer 1999 to Spring 2000 December 2000 Maureen, June 99 Job service Counselor John Olson Maureen & parents Job seeking/placement assistance
School Year
Grade Level
Results & Outcomes
99-00
10
00-02 Referral to Independent Living Center Case Manager, Maureen May 2001
11-12
Eligibility determination Vocational Rehabilitation Counselor Sue Smith ILC Counselor Mary Jones
Part time employment for summer 1999 & possibly to continue through school year Possible eligibility for services (tuition for college)
00-01
11
Maureen & parents
March 2002
01-02
12
Post-secondary academic supports College Disability Support Services Staff
Independent Living and Community assessment to determine strengths and prepare for college/advocacy Classroom & testing accommodations in college
* If any agency identified by the IEP team fails to provide services, the IEP team must reconvene as soon as possible to identify alternate strategies and amend the IEP as necessary. Document date of reconvened IEP meeting and results.
Appendix A
I. Annual Goals, Short-Term Objectives, and Characteristics of Services

Use one page for each annual goal. Thoroughly state the annual goal. Annual goals should be reasonably achieved in one year and should be unique to the student. Related Services should appear ONLY as objectives that are integrated into the student's instructional program. Annual Goal (behavior or skill, desired ending level of achievement, intent or purpose of the behavior): Goal # of 1 goals
Maureen will fully participate in her Child Development course during her sophomore year, attaining the prescribed competencies with 80% accuracy or better. Short-Term Instructional Objectives and Characteristics of Services: List objectives for each goal including conditions under which the behavior is performed, the specific behavior, measurable criteria, evaluation procedures, and schedules for determining if objectives are being achieved (initiation date, dates for progress checks). The person responsible for monitoring progress will be added upon completion of Section J. For each objective, consider and document the following characteristics of services information: Does the performance specified in the objective(s) promote the child's involvement and progress in the general education curriculum? How might services be modified to enable greater involvement and progress in the curriculum? Describe the needed modifications or adaptations. If the child will not participate in the general education curriculum, provide a justification for the alternative selected. Describe the specially designed instruction (e.g., specially designed driver education) or supportive training related to the disability (e.g., braille instruction/occupational therapy). Who will provide the modifications/adaptations OR the specially designed instruction/supportive training related to the disability described above? Given each district-prescribed competency, Maureen will complete the competency with 80% accuracy or better. Data will be collected via classroom observation work samples, teacher and practicum supervisor, anecdotal records, portfolio, and teacher-made tests. Biweekly progress checks will be conducted and written reports sent to Maureen's parents based on the district's competency list for child development.
Progress reporting to parents will occur at least as often as reporting in general education (report cards). Written reports will be provided every:
[ ] 6 weeks
[X] 9 weeks
[ ] Other schedule (specify: Biweekly
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Appendix A
J. Adaptation of Educational Services

Describe changes in educational services that will be made to permit successful accommodation and education of this student (e.g. credits, staff, transportation, facilities, materials, braille, equipment, technology, adaptive devices, curriculum, methods and other services). Include procedures for monitoring equipment, if applicable.
Maureen will be provided with extended time on tests in her Child Development, Algebra and Advanced Biology classes. She will be provided with preferential seating in Spanish I. She will be provided with taped texts for English 10 and multiple choice or short answer tests rather than essay. She may tape record lectures in Child Development, English 10, and Advanced Biology and use a calculator for Algebra. She may also have syllabi in advance and guided notes if desired.
Assistive Technology MUST be considered for each student with a disability. Does the student need assistive technology devices and services to access the general education curriculum (or FAPE)? [ ] No [X] Yes If "Yes" is checked, explain.
Algebra: calculator for completion of assignments, quizzes and tests. Child Development, English, Advanced Biology: tape recorder to record class lectures and demonstrations.
Describe the student's participation in district-wide and statewide assessment. [ ] Student will participate without accommodations.
[X] Student will participate with accommodations specified below: [Note: Some students may participate in portions of district/statewide assessments.]
Scheduling: extended time only
[ ] Student will participate in alternate assessment. Justification for not participating in district or statewide assessments and the
description of alternate assessment must be provided. Positive Behavior Interventions and Strategies. Do the Present Levels of Educational Performance include a description of problem behavior that [ ] Yes impedes the student's learning or the learning of others? Does the student's disability limit his/her understanding of school rules and consequences?[ Does the student's disability limit or influence his/her ability to follow school rules?
[X] No ] Yes [X] No [ ] Yes [X] No
If "Yes" is checked for any of the above questions, then the components of a Behavior Intervention Plan must be documented. Documentation of Behavior Intervention Plan can be found: [ ] in goals and objectives [ ] in adaptations section [ ] in an attachment.
K. Description of Activities with Students Who Are Not Disabled

Physical Education. Indicate type of physical education program that the student receives: [X] regular P.E. [ ] adaptive/specially designed P.E. (include specific goals and objectives in Section I) Participation in Academic and Nonacademic Activities: Check any program options in the boxes below in which the student will be participating with students who do not have disabilities. Program Options. [ ] Art. Comments:
[X] Music (Band) [ ] Home Economics
[ ] Industrial Arts [X] Vocational Education (Child Development) [X] Other (English 10, Algebra, Advanced Biology, Spanish I)
Comments:
Nonacademic and Extracurricular Services and Activities. [ ] Counseling [ ] Meals
[X] Employment Referrals [X] Athletics (Tennis Team) [ ] School Sponsored Clubs [ ] Transportation
[ [ [ [
] Recess ] Recreation ] Special Interest Groups ] Other_______________
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Appendix A
L. Least Restrictive Environment Justification

This page is intended as a SUMMARY for all Goals, Objectives, Characteristics of Services, Adaptations, and Special Education and Related Services information included in sections I, J & L. Check all settings in which the special education and related services will be provided. SETTING: Percent of time/week 6 periods
[X] A. [ ] B. [X] C. [ ] D. [ ] E. [ ] F. [ ] G. [ ] H. [ ] I. [ ] J.
Regular Education Classroom Limited special services in Regular Education classroom Resource Room Separate Class Public separate school (day) facilities Private separate school (day) facilities Public residential facilities Private residential facilities Correction facilities Homebound/hospital environments
86% 14%
1 period
TOTAL: 100% Before a disabled child can be placed outside of the regular educational environment, the full range of supplementary aids and services that if provided would facilitate the students placement in the regular classroom setting must be considered. In all cases, placement decisions must be individually determined on the basis of each child1s abilities and needs, and not solely on factors such as category of disability, significance of disability, availability of special education and related services, configuration of the service delivery system, availability of space or administrative convenience. Explain why options selected above are the most appropriate and the least restrictive. Describe other options considered and provide reasons those options were rejected.
Maureen will participate in one period per day of Special Education Services in the resource room for the purpose of academic support in her regular education classes. Given her current course load this period of support is necessary. Removal from the regular education setting during this time will not be harmful.
Is there a potential harmful effect to the student with this placement?
[ ] Yes [X] No
Is there a potential harmful effect to the students peers with this placement? [ ] Yes [X] No If yes to either question, make sure the explanation for the selection of the placement option documents this concern for potential harmful effect.
M. Special Education and Related Services

*Services Min./ Week Starting Date Ending Date Service Provider and Telephone Location of Services Building Name AND Room (if another school district, provide district name)
Resource Room Rehabilitation Counseling
45 Minutes 1 x/mo 45 Minutes
5/16/995/16/00 9/16/995/16/00
Jane Lakeman
Desert Valley High School Room C 25 ND Rehabilitation Services
Christine Fullerton
* The duration of these services may not exceed one year (12 months) from the date of this IEP. Length of school day:
[X] The student will attend for the full school day. [ ] The student will attend for a shorter or longer school day than peers. (Explain why this is necessary.)
Extended school year MUST be considered for each student with a disability. Justification for the decision made MUST BE STATED BELOW.
[ ] The review of each goal indicates that an extended school year is needed. [X] The review of each goal indicates that services will be in effect for the normal school year. [ ] The team needs to collect further data before making this determination and will meet again by __________________________________.
Justification for the above decision:
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Appendix A
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