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Individual Education Program (IEP)

Student’s Full Name: SSID:

Date of Birth: Grade:
School: Disability:
Age:

Education Present Levels of Academic Achievement and Functional Performance, including how the
Performance disability affects the student’s involvement and progress in the general curriculum
(For preschool children include the effect on participation in appropriate activities; Beginning in the child’s
Areas Assessed 8th grade year or when the child has reached the age of 14, a statement of transition needs is included.)
Communication Performance commensurate with similar age peers
Status
Academic Performance commensurate with similar age peers
Performance
Health, Vision, Not an area of concern at this time
Hearing, Motor
Abilities
Social and Emotional Performance commensurate with similar age peers
Status
Performance commensurate with similar age peers
General Intelligence

Not an area of concern at this time (Checking this box is not an option when the student is in the 8th Grade or 14 years or older
because transition must be addressed for these students)
Check all areas of need as identified by the Admissions and Release Committee (More than one area may be checked.)
Instruction
Related services
Transition Needs Community experiences
Employment
Daily Living Skills
Post School Adult Living Objectives
Functional Vocational Evaluation

Functional Not an area of concern at this time

Vision/Learning
Media Assessment

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Kentucky Individual Education Program

Revised 03/20/2012
 Student’s Full Name: SSID:
Date of Birth: Meeting Date:

Consideration of Special Factors for IEP Development: (The ARC MUST address each question below and consider these issues in the
review and revision of the IEP.)
 Does the child’s behavior impede his/her learning or that of others? No Yes If Yes, include appropriate strategies,
such as positive behavioral interventions
and supports in the ‘Statement of Devices /
Services’ below.
 Does the child have limited English proficiency? No Yes. If Yes, what is the relationship of
language needs to the IEP?

 Is the child blind or visually impaired? No Yes If Yes, the IEP Team must consider:
o Is instruction in Braille needed? No Yes
o Is use of Braille needed? No Yes
o Will Braille be the student’s primary mode of communication? No Yes
(See evaluation data for supporting evidence.)

 Does the child have communication needs? No Yes. If Yes, specify below

See Present Levels for Communication Status

Other (Specify):

 Is the child deaf or hard of hearing? No Yes. If Yes, the IEP Team must consider:
o The child’s language and communication needs; Describe:

See Present Levels for Communication Status

Other (Specify):

o Opportunities for direct communications with peers and professional personnel in the child’s language and communication mode, academic
level and full range of needs; Describe:

o Any necessary opportunities for direct instruction in the child’s language and communication mode; Describe:

 Are assistive technology devices and services necessary in order to implement the child’s IEP?
No Yes If Yes, include appropriate devices,
in the ‘Statement of Devices /Services below.
Statement of Devices/Services: If the ARC answers ‘Yes’ to any of the questions above, include a statement of services and or devices to be
provided to address the above special factors.

See Specially Designed Instruction See Supplemental Aids and Services See Behavior Intervention Plan
Other (Specify)

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Kentucky Individual Education Program

Revised 03/20/2012
Student’s Full Name: SSID:
Date of Birth: Meeting Date:

Measurable Annual Goals and Benchmarks

Annual Goal

For the IEP to be in effect by the child’s 16th birthday and thereafter: This annual goal will reasonably enable
the student to meet the student’s postsecondary goal in the area(s) of:
Education/Training Employment Independent Living

Specially Designed Instruction

Date Progress Report Sent to

Review of Progress of Annual Goal Parent
1st reporting period:
Reporting Period 1st 2nd 3rd 4th 5th 6th 7th 8th

2nd reporting period:

Methods of Evaluation*

3rd reporting period:

*Methods of Measure/Evaluation
4th reporting period:
1. Curriculum Based Measures 2. Direct Measures
3. Indirect Measures 4. Authentic Assessments
5. Other: 6. Other: 5th reporting period:

Schedule for Reporting Progress 6th reporting period:

Concurrent with the issuance of Report Cards

Other (specify below) 7th reporting period:

8th reporting period:

Benchmarks/Short-Term Objectives
1

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Kentucky Individual Education Program

Revised 03/20/2012
Student’s Full Name: SSID:
Date of Birth: Meeting Date:

Statement of Supplementary Aids and Services, to be provided to the child or on behalf of the child:

Accommodations for Administration of State Assessments and Assessments in the Classroom

ARC determined no accommodations needed

In order to justify appropriateness of accommodations for any state mandated tests, the testing accommodations must be used
consistently as part of routine instruction and classroom assessment as well as meet all additional requirements established by the
Inclusion of Special Populations in the State-Required Assessment and Accountability Programs,703 KAR 5:070 document.
NOTE: The Kentucky Administrative Regulations regarding accommodations on state testing dictate whether a student may use a
particular accommodation during the administration of state tests. Any IEP test accommodation that the regulations determine
will invalidate a particular test or type of test shall not be utilized in administration of such tests to the student.

Readers Scribes Paraphrasing Reinforcement and behavior modification strategies

Prompting/cueing Use of technology Manipulatives Braille Interpreters

Extended time Other: specify

Student has been determined eligible for participation in the Alternate Assessment Program. Complete the Participation Guidelines for the KY
Alternate Assessment form if selecting this checkbox. If determined eligible for the Alternate Assessment, the ARC must also determine if the
student is Dimension A or Dimension B.
Dimension A
Dimension B

Program Modifications/Supports for School Personnel that will be provided:

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Kentucky Individual Education Program

Revised 03/20/2012
Student’s Full Name: SSID:
Date of Birth: Meeting Date:
Least Restrictive Environment (LRE) and General Education: Explain the extent, if any, to which the student will not participate in
general education (content area):

Anticipated Frequency and Duration Of Service

Service Service Service Service Provider Location

(e.g., Regular Classroom,
Minutes (Per Frequency Period Start End (by Position)
Resource Room, Separate Class)
Service (Number of times (Daily, Weekly,
Frequency) provided per Monthly,
Service Period) Annually)
Special
Education Minutes
Times
Per

Times
Minutes
Per

Times
Minutes
Per

Related Services

Anticipated Frequency and Duration Of Service

Type of Service Service Service Service Provider Location

(e.g., Regular Classroom,
Service Minutes (Per Frequency Period Start End (by Position)
Resource Room, Separate Class)
Service (Number of times (Daily, Weekly,
Frequency) provided per Monthly,
Service Period) Annually)

Times
Minutes
Per

Times
Minutes
Per

Times
Minutes
Per

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Kentucky Individual Education Program

Revised 03/20/2012
 Student’s Full Name: SSID:
Date of Birth: Meeting Date:

Extended School Year: Yes No More Data Needed

If the ARC determines ESY services are to be provided, describe the service and indicate to which annual goal or goals the
service is related. If the ARC determines no ESY services are to be provided, please document the reason(s) for this decision.

What transition assessments were used to determine the child’s preferences and interests? (Check all that apply)
Student Interview Student Survey Student Portfolio Vocational Assessments Interest Inventory
Parent Interview Career Awareness Career Aptitude ILP Other:

Transition Services Needs (Beginning in the child’s 8th grade year or when the child has reached the age of 14 and thereafter)
Does the student’s Individual Learning Plan (ILP) include the student’s course of study?
No. If No, do not proceed with development of IEP until ILP is initiated, including the child’s course of study.
Yes. (See student’s attached course of study to include current year through graduation or exiting year)
Do transition service needs focus on the child’s course of study and are they addressed in the Present Levels?
No Yes

Postsecondary Goal(s) (By age 16, or younger if appropriate, and thereafter)

Postsecondary Goal(s) Related to Education/Training, Employment, and if needed, Independent Living:

Transition Services and Agency Responsible (By age 16, or younger if appropriate, and thereafter)
Transition Service Agency Responsible

If applicable, One year before the student reaches age 18 the student and parent have been informed of the student’s rights under Part B
of the Individuals with Disabilities Education Act, if any, that will transfer on reaching the age of majority. Date Informed:

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Kentucky Individual Education Program

Revised 03/20/2012