Pleasants County Schools
Verification of Dissemination of I.E.P.
House Bill 4384
Student_______________________
WVEIS#____________________
As a non-participant in the development of this student’s I.E.P., I acknowledge that I have
read and understand the student’s I.E.P. I agree to help the student succeed in class by
making any needed or identified accommodations and modifications as listed on the IEP. The
legislation (H.B.4384) requires that ALL teachers, including but not limited to, teachers of
Music, Music Education, Drivers Education, Health, Art, and Physical Education must certify
by signature that they have fulfilled this requirement prior to implementation of the IEP.
This document must be completed at least annually or each semester according to the
student’s schedule. Place a copy in the student’s file when completed.
PRINT/SIGNATURE/DATE
CASE MANAGERS SIGN AND DATE
PRINT/SIGNATURE/DATE
CASE MANAGERS SIGN AND DATE
Sent to Central Office Date_________
Received by Central Office Date_____
(Original Copy)
(Original Copy)