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Running head: INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Individualized Education Program (IEP)
SEDP 533
Meera Mehtaji
Virginia Commonwealth University
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
COVER PAGE
Student Name Marty Brown_____________________________________________ Date 1/31/2011Page 1of ___
Student ID Number 007
Grade7
DOB 09/22/1999 Age* 12 years and 3 months Disability(ies) (if identified) Specific Learning Disability
Parent/Guardian Name Mr. Jack Brown and Ms. Jane Green.
Home Address: 1921 Browning street, Barrett town, Poetry, IN. Phone # (H) (232)334-3434.
_________________________________________________________ Phone # (W) (232) 0900-9900
Most recent eligibility date…………………………….…………………………………….………….
Most recent re-evaluation date …………………………………………...….……………………………3/8/2011
Next re-evaluation must occur before this date ………………………………………..…..……………..1/10/2012
Date of IEP meeting…………………...………………………………………………..……..………….. 2/14/2011
This IEP will be reviewed no later than this date…………………………………………….……………3/30/2011
Date parent notified of IEP meeting…………………………………………….………………………….1/20/2011
Date student notified of IEP meeting (if secondary transition will be discussed)...………………………
Copy of IEP given to parent/student by (Name)
IEP Teacher/Manager
Mrs. M&M
Mrs. M&M
On (Date) 1/31/2011
Phone Number (232)5577-8866
PARTICIPANTS INVOLVED:
The list below indicates that the individual participated in the development of this IEP and the placement decision;
it does not authorize consent. Parent or student (age 18 or older) consent is indicated on the “Prior Notice/Consent”
page.
NAME OF PARTICIPANT
Mr. Jack Brown and Ms. Jane Green
POSITION
Parents of the student Marty Brown
Mrs. M&M
Special Educator and Marty’s case manager
Mrs. Humpty Dumpty
Marty’s class teacher, General education classroom
Mr. Peeping Tom
School Principle
Miss. Jill
School Psychologist
_____________________________________________________
____________________________________
_____________________________________________________
____________________________________
* The student must be informed at least one year prior to turning 18 that the IDEA procedural safeguards (rights) transfer to
him/her at age 18 and be provided with an explanation of those procedural safeguards.
Date informed _____/_____/_____
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
FACTORS FOR IEP TEAM CONSIDERATION
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 2of _____
Student ID Number 007
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 each. The factors are addressed in other sections of the IEP if not
documented on this page. (for example: see Present Level of Performance)
1.
The strengths of the student and the concerns of the parents for enhancing the education of their child;
_____ see Present Level of Performance
___________________________________________________________________________________________________
_______________________________________________________________________________________
2.
The results of the initial evaluation or most recent evaluation of the student including state and district-wide assessments:
_______ see Present Level of Performance
___________________________________________________________________________________________________
___________________________________________________________________________________________________
3.
The communication needs of the student;
__________NA______________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
4.
The student’s assistive technology devices and services needs;
___________NA_____________________________________________________________________________________
___________________________________________________________________________________________________
5.
In the case of a student whose behavior impedes his or her learning or that of others, consider, when appropriate,
strategies, including the use of positive behavioral interventions and supports, and other strategies to address that behavior;
_________NA_______________________________________________________________________________________
__________________________________________________________________________________________
6.
In the case of a student with limited English proficiency, consider the language needs of the child as such needs relate to the
child’s IEP;
_________________NA_______________________________________________________________________________
_________________________________________________________________________________________________
7.
In the case of a student who is blind or has a visual impairment, provide for instruction in Braille and the use of Braille
unless the IEP team determines, after an evaluation of the student’s reading and writing skills, needs, and appropriate reading
and writing media (including an evaluation of the student’s future needs for instruction in Braille or the use of Braille), that
instruction in Braille or the use of Braille is not appropriate for the student; and
____________________NA____________________________________________________________________________
___________________________________________________________________________________________________
8.
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 instruction in the student’s language and
communication mode.
____________NA____________________________________________________________________________________
_____________________________________________________________________________________________
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF PERFORMANCE
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 3of___
Student ID Number______007________________________________
The Present Level of Performance describes the effect of the student’s disability on the student’s involvement and progress
in the general education curriculum and area(s) of need. This includes the student’s performance in academic areas
(reading, math, science, history/social sciences, etc.) and functional areas (socialization, communication, behavior, personal
management, self-determination, etc.). Test scores should include an explanation. For preschool age students this section
should include how the student’s disability affects the student’s participation in appropriate activities. There should be a
direct relationship between the present level of performance and the other components of the IEP.
___________________________________________________________________________________________________
Marty is a seventh grade student. He lives with him mother and elder brother. His parents are divorced for the past
one and a half years. However, both his parents are collaborating to support Marty with his educational program. According
to Marty’s mother, he has good health. He has no sensory difficulties, and has not had any major illnesses or surgeries, and
is not taking any medication. His parents describe him as a very outgoing and energetic individual who is sociable and has
lots of friends. His parents reported that Marty loves to make things, and is often asked by others to fix things for them.
According to Marty’s teacher, he is highly verbal, very knowledgeable about a variety of subjects, and appears to learn best
when he sees something explained or makes something. He enjoys working on the computer and performs better on writing
tasks when he uses a talking processor.
Marty’s parents and his teacher are both concerned about his academic progress. His parents feel that Marty
compares himself to his older brother who is very bright and feels that he is “stupid”. They feel that he will be demotivated
and decided to drop out of school. His parents want to take steps to prevent that from happening. Marty’s classroom teacher
is concerned about Marty’s inconsistent performance. She is concerned about his reading, math, and writing skills, and his
inability to complete assignments on time as he jumps from one assignment to another. Marty’s teacher had referred him o
to the Student Improvement Team (SIT) after several weeks of strategies suggested by SIT members and no change in
performance, the team referred Marty for a comprehensive evaluation.
Marty’s classroom observation during independent study class indicated that he is frequently off-task and has
difficulty completing his assignments. He often works on one assignment for a short period of time and then works on
another assignment, engages in an off-task activity such as playing with objects, leaves his work area, or seeks attention
from his teacher or his peers. His behavior also appears to be affected by other activities in the classroom, the placement of
his work area near certain students, and the type and difficulty level of the activity. He however, enjoyed working on the
computer and finished his journal on it.
Observations during testing indicated that Marty has a difficult time attending to task, he will easily disengage
from tasks that are difficult. He is also self – conscious and has was distracted and anxious throughout the testing process.
The tester observed that Marty played with his pencil, fidgeted in his seat, and frequently needed to be redirected back to
the task. When he encountered items that were difficult for him, he would begin to talk about the Boy Scouts and his family
or tell jokes. Several times during the testing, he said, “I’m not good at this” and “I’m dumb at some things.”
Marty was administered the following tests: the Wechsler Intelligence Scale for Children-Fourth Edition (WISCIV), the Brigance Diagnostic Inventory of Basic Skills (Brigance), and the KeyMath-Revised (KeyMath).
Marty was administered the WISC-IV. His full scale IQ was 113, which places him in the high average range. His
Verbal Comprehension Index score was 102 and a Perceptual Reasoning Index Score of 124. The difference between his
verbal and perceptual index is 22-point discrepancy and is considered significant. The results indicate that Mary is better at
working on paper-and-pencil than his working memory. Marty did extremely well on subtests requiring the ability to
analyze and synthesize abstract visual stimuli and in categorical reasoning. His fluid intelligence skills, visual-motor
coordination, cognitive flexibility, and capacity for concentration are strengths. Verbal reasoning and concept formation
and expression, auditory short-term memory, and sequencing skills and his capacity to attend closely to and remember
verbal information are less well developed
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRESENT LEVEL OF PERFORMANCE, Continued
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 4of___
Student ID Number_____007_____________________________
PRESENT LEVEL OF PERFORMANCE, continued.
Sub Tests on WISC
Verbal Comprehension Index:
Similarities
Vocabulary
Comprehension
Perceptual Reasoning Index
Block Design
Picture Concepts
Matrix Reasoning
Working Memory Index
Digit Span
Letter-Number Sequencing
Processing Speed Index
Coding
Symbol Search
Standard Scores
102
8
9
10
124
15
12
14
97
9
9
120
13
14
To assess Marty’s mathematics performance, the examiner administered the KeyMath. Marty’s overall grade
equivalent was 3.1. His strongest areas included geometry, measurement, time, and money. Marty had difficulty with the
Multiplication, Division, Fractions, and Word Problem subtests. He was unable to multiply more than one-digit numbers,
fractions, and decimals. He could not perform multistep division tasks. He had difficulty identifying fractions, putting
fractions in order, and converting fractions to percentages. His word-problem solving skills were poor. He had the most
difficulty solving problems that contained nonessential information.
Marty’s reading skills were assessed by administering the Brigance. Marty’s reading is characterized by
weaknesses in word recognition, oral reading, and comprehension. On the Word Recognition subtest, he was able to read
one- and two-syllable words, but could not read any words that had three or more syllables. On the Word Analysis subtest,
he correctly read words with single initial consonant sounds and words with short vowel sounds. He had difficulty reading
words that contained the long vowel and silent “e.” He also had difficulty reading the “ai,” “ea,” “ie,” and “ou” vowel
blends in certain words.
On the Reading Comprehension subtest, Marty had difficulty with the passages that were written at a third grade
level. His oral reading of the passage revealed difficulties sounding out multisyllabic words and a reliance on semantic or
syntactic cues. He had particular problems with comprehension questions that related to large amounts of information and
interpreting abstractions.
Marty completed an interest inventory to identify his viewpoint regarding his strengths, needs, interests, goals,
and learning style. He indicated that he had difficulty reading and writing and would like to improve in these areas. He
indicated that he learns best when he works with others and uses computers. He dislikes taking tests and would prefer to do
some type of project instead. He loves to work with his hands and to take things apart and fix them. He likes to be with
people and is interested in teaching others how to fix things.
The results indicate that Mary has average- to above-average intellectual ability whose perceptual
reasoning skills are superior to his verbal comprehension skills. He struggles in math, reading, and writing and prefers
hands-on activities and projects to demonstrate his mastery of the curriculum. He sometimes has difficulty completing tasks
and organizing his work. Marty is well aware of his academic problems and his self-esteem is beginning to be affected by
his lack of success in the classroom
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PARTICIPATION IN THE STATE ACCOUNTABILITY/ASSESSMENT SYSTEM,
DIPLOMA, AND TRANSITION STATUS
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 5of___
Student ID Number___007_______________________________

PARTICIPATION IN THE STATE ACCOUNTABILITY/ASSESSMENT SYSTEM: Discuss annually. If this is a
testing year, based on the present level of performance, is this student being considered for participation in the Virginia
Alternate Assessment Program (VAAP), which is based on Aligned Standards of Learning? ___No ___Yes
If yes, complete the “VAAP Participation Criteria” prior to making this decision.
Does the student meet the VAAP participation criteria? ___No ___Yes
If yes, refer to the Aligned Standards of Learning for developing annual goals and short-term objectives or benchmarks.

DIPLOMA STATUS: Discuss annually. This student is a candidate for a:
[ ] Advanced Studies Diploma
[ ] Modified Standard Diploma*
[ ] Standard Diploma
[ ] Special Diploma
[ ] GED Certificate (General Educational Development - only for those who meet requirements of the
GED program)
[ ] Certificate of Program Completion
[ ] Not discussed at this time
Projected Graduation/Exit Date: ________________
Is the student projected to graduate/exit school this year? ___No ___Yes
If yes, inform the student and parents that a Summary of Performance will be provided prior to graduating/exiting school.
*Selecting the Modified Standard Diploma option is determined by the IEP team and the student, where appropriate, at any
point after the student’s eighth grade year. In pursuing a Modified Standard Diploma, the IEP team shall consider the
student’s need for occupational readiness upon school completion, including consideration of courses to prepare the student
as a career and technical education program completer.
NOTE:
Special education and related services end upon receiving an Advanced Studies Diploma or Standard Diploma. If the
student receives a Modified Standard Diploma, Special Diploma, Certificate of Program Completion, or a GED Certificate,
the student remains entitled to a free appropriate public education through age 21.

SECONDARY TRANSITION STATUS: Discuss annually beginning the year prior to entering high school course work,
or younger. This must be discussed beginning not later than the first IEP to be in effect when the student is age 16.
Is secondary transition being addressed? ___No ___Yes
If yes, complete the “Secondary Transition” pages before developing measurable annual goals.
Will the student be graduating or exceeding the age of eligibility this year? ___No ___Yes
If yes, a Summary of Performance must be provided to the student prior to graduating or exceeding the age of eligibility. 

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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 6of___
Student ID Number___007__________________________ Area of Need:-Language Arts and Math. On task Behavior
# _____ MEASURABLE ANNUAL GOAL:
1.
On task Behavior: - At the end of the 35 week period Marty will be able to be on task with 95% of his class work,
with less than two verbal prompt from the teacher thought the day.
2.
Language Arts: - At the end of the 35 week period Marty’s write an essay, to or a letter, using a computer with
90% accuracy. He will use pre writing tools like a mind maps, and incorporate punctuations and edit his own
writing 9 out of 10 times.
3.
Math: - At the end of the 35 week period Marty will be able to solve multi digit multiplication and division word
problems with 90% accuracy.
How will progress toward this annual goal be measured? (check all that apply)
____ Classroom Participation
____ Observation
____ Checklist
____ Special Projects
____ Criterion-referenced test:_________________________
____ Classwork
____ Tests and Quizzes
____ Norm-referenced test: ___________________________
____ Homework
____ Written Reports
____ Other: _______________________________________
Progress on this goal will be reported using the following codes. Comments may be attached using optional progress report
comment form.
IP -The student has demonstrated Insufficient Progress to meet
SP -The student is making Sufficient Progress to achieve this
this annual goal and may not achieve this goal within the
annual goal within the duration of this IEP.
duration of this IEP.
ES - The student demonstrates Emerging Skill but may not achieve
this goal within the duration of this IEP.
NI -The student has Not been provided Instruction on this goal.
M -The student has Mastered this annual goal.
Anticipated Date of Progress Report
Actual Date of Progress Report
Progress Code
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SHORT TERM OBJECTIVES / BENCHMARKS
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 7of___
Student ID Number__007_________________________ Goal # _____ Area of Need: ___________________________
Short Term Objectives or Benchmarks, as needed
Objective/Benchmark # September – October.
1. On task Behavior: - At the end of the two month period Marty will be able to be on task with 50% of his class
work, with less than six verbal prompt from the teacher thought the day.
2.
Language Arts: - At the end of the two month period Marty’s will be able to use a mind map with 40% accuracy.
He will edit his work 3 out 10 times.
3.
Math: - At the end of the two month period Marty’s will be able to solve two digit multiplication and division
problems with 80% accuracy.
Objective/Benchmark # November- December
1.
On task Behavior: - At the end of the two month period Marty will be able to be on task with 65% of his class
work, with less than five verbal prompt from the teacher thought the day.
2.
Language Arts: - At the end of the two month period Marty’s will be able to use a mind map with 60% accuracy.
He will edit his work 5 out of 10 times.
3.
Math: - At the end of the two month period Marty’s will be able to solve three digit multiplication and division
problems with 80% accuracy.
Objective/Benchmark # January - February
1.
On task Behavior: - At the end of the two month period Marty will be able to be on task with 75% of his class
work, with less than four verbal prompt from the teacher thought the day.
2.
Language Arts: - At the end of the two month period Marty’s will be able to use a mind map with 70% accuracy.
He will edit his work 7out of 10 times.
3.
Math: - At the end of the two month period Marty’s will be able to solve multi digit word problems with 60%
accuracy.
Objective/Benchmark # March - April
1. On task Behavior: - At the end of the two month period Marty will be able to be on task with 85% of his class
work, with less than three verbal prompt from the teacher thought the day.
2.
Language Arts: - At the end of the two month period Marty’s will be able to use a mind map with 80% accuracy.
He will edit his work 8 out of 10 times.
3.
Math: - At the end of the two month period Marty’s will be able to solve multi digit problems word problems with
75% accuracy.
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IEP
Short Term Objectives or Benchmarks, as needed
Objective/Benchmark #May - June
1.
On task Behavior: - At the end of the two month period Marty will be able to be on task with 95% of his class
work, with less than two verbal prompt from the teacher thought the day.
2.
Language Arts: - At the end of the two month period Marty’s will be able to use a mind map with 90% accuracy.
He will edit his work 9 out of 10 times.
3.
Math: - At the end of the two month period Marty’s will be able to solve multi digit problems word problems with
90% accuracy.
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 9of___
Student ID Number __007_________________________________
Least Restrictive Environment (LRE)
When discussing the least restrictive environment and placement options, the following must be considered:
 To the maximum extent appropriate, the student is educated with children without disabilities.
 Special classes, separate schooling or other removal of the student from the regular educational environment occurs only
when the nature or severity of the disability is such that education in regular classes with the use of supplementary aids
and services cannot be achieved satisfactorily.
 The student’s placement should be as close as possible to the child’s home and unless the IEP of the student with a
disability requires some other arrangement, the student is educated in the school that he or she would attend if he or she
did not have a disability.
 In selecting the LRE, consideration is given to any potential harmful effect on the student or on the quality of services
that he/she needs.
 The student with a disability is not removed from education in age-appropriate regular classrooms solely because of
needed modifications in the general curriculum.
Free Appropriate Public Education (FAPE)
When discussing FAPE for this student, it is important for the IEP team to remember that FAPE may include, as
appropriate:




Educational Programs and Services
Proper Functioning of Hearing Aids
Assistive Technology
Transportation




Nonacademic and Extracurricular Services and Activities
Physical Education
Extended School Year Services
Length of School Day
SERVICES: Identify the service(s), including frequency, duration and location, that will be provided to or on behalf of the student in
order for the student to receive a free appropriate public education. These services are the special education services and as necessary, the
related services, supplementary aids and services based on peer-reviewed research to the extent practicable, assistive technology,
supports for personnel, accommodations and/or modifications* and extended school year services* the student will receive that will
address area(s) of need as identified by the IEP team. Address any needed transportation and physical education services including
accommodations and/or modifications.
Service(s)
Reading Remediation
Language Arts
Computer
Frequency
Location
5 times a week. One
Special Education
Duration
m/d/y to m/d/y
9/15/2011 to
hour every day
Classroom
6/15/2012
5 times a week. One
Special Education
9/15/2011 to
hour every day
Classroom
6/15/2012
To complete all
Classroom
9/15/2011 to
written assignments
6/15/2012
*These services are listed on the “Accommodations/Modifications” page and “Extended School Year Services” page, as needed.
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
ACCOMMODATIONS/MODIFICATIONS
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 10 of___
Student ID Number___007____________________________
This student will be provided access to general education classes, special education classes, other school services and
activities including nonacademic activities and extracurricular activities, and education related settings:
___ with no accommodations/modifications
___ with the following accommodations/modifications
Accommodations/modifications provided as part of the instructional and testing/assessment process will allow the student
equal opportunity to access the curriculum and demonstrate achievement. Accommodations/modifications also provide
access to nonacademic and extracurricular activities and educationally related settings. Accommodations/modifications
based solely on the potential to enhance performance beyond providing equal access are inappropriate.
Accommodations may be in, but not limited to, the areas of time, scheduling, setting, presentation and response. The impact
of any modifications listed should be discussed, including the earning of credits for graduation.
ACCOMMODATIONS/MODIFICATIONS (list, as appropriate)
Accommodation(s)/Modification(s)
Extra Time to complete tests
Frequency
All tests
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Location
Classroom
Duration
30 minutes extra
time
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
PARTICIPATION IN STATE AND DISTRICT-WIDE ASSESSMENTS
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 11 of___
Student ID Number_007______________________________
STATE AND DISTRICT-WIDE ASSESSMENTS
This student’s participation in state or district-wide assessments must be considered and discussed. During the duration of
this IEP:
Will the student be at an age or a grade level for which the student is eligible to participate in a state
or district-wide assessment?
___No ___Yes
Will the student be enrolled in a course for which there is a SOL End-of-Course test
or district-wide assessment?
___No ___Yes
Will the student be participating in a SOL remediation recovery program?
___No ___Yes
Will the student need to take a state assessment as a requirement to earn an Advanced Studies
Diploma, Standard Diploma, or Modified Standard Diploma?
___No ___Yes
If Yes to any of the above, check the assessment(s) considered and attach the assessment page(s), which will
document the assessments and decisions made about participation and any needed accommodations and/or
modifications.
 State Assessments:
___ SOL Assessments and retake (SOL)
___ Virginia Grade Level Alternative (VGLA)*
___ Virginia Substitute Evaluation Program (VSEP)*
___ Virginia Alternate Assessment Program (VAAP)**
___ Other State Approved Substitute(s): ______________________________
 District-wide Assessment
(List):
___________________________
___________________________
___________________________
* Refer to Procedures for Determining Participation in the Assessment Component of Virginia’s Accountability System
and the Procedural Manuals for VGLA and VSEP.
**Refer to Virginia Alternate Assessment Program (VAAP) Participation Criteria and Procedural Manual.
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 12 of___
Student ID Number__007_____________________________
PLACEMENT
The team may consider placement options in conjunction with discussing any needed supplementary aids and services, accommodations/
modifications, assistive technology, and supports for school personnel. In considering the placement continuum options, check those the
team discussed. Then, describe the placement selected in the PLACEMENT DECISION section below. Determination of the Least
Restrictive Environment (LRE) and placement may be one or a combination of options along the continuum.
Placement Continuum Options Considered:
Services provided in:
___ general education class(es)
___ special class(es)
___ special education day school
___ state special education program / school
___ residential facility
___ home-based
___ hospital
___ other (describe):
PLACEMENT DECISION:
Based upon identified services and the consideration of least restrictive environment (LRE) and placement continuum options, describe
in the space below the placement. Additionally, summarize the discussions and decision around LRE and placement. This must include
an explanation of why the student will not be participating with students without disabilities in the general education class(es), programs,
and activities. Attach additional pages as needed.
Placement Description:
Marty will be in the general education classroom for most of the day except Language Arts and Math. During Language Arts
and Math Marty will go the special education classroom and work with the special education teacher on his IEP goals. For all the other
classes Marty will be in his general education classroom.
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IEP
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
PRIOR NOTICE/CONSENT
Student Name Marty Brown ____________________________________ Date 1/31/2011Page 13 of___
Student ID Number___007_______________________________
PRIOR NOTICE OF IEP AND PLACEMENT DECISION
The school division proposes to implement this IEP and the placement decision as written. This proposed IEP and
placement will allow the student to receive a free appropriate public education in the least restrictive environment. This
decision is based upon a review of current records, current assessments and the student’s performance as documented in the
Present Level of Performance. Other options considered, if any, and the reason for their rejection are attached, or can be
found in the Placement Decision section of this IEP. Additionally, other factors, if any, that are relevant to this proposal are
attached. Parent and adult student rights are explained in the Procedural Safeguards. If you, the parent(s) and adult student,
need another copy of the Procedural Safeguards or need assistance in understanding this information please contact
________________________________ at (___) ____________ or e-mail ________________________________ or
________________________________ at (___) ____________ or e-mail ________________________________ .
____ Parent(s) initials here indicate that the parent(s) has read the above prior notice and attachments, if any, before giving
permission to implement this IEP and the placement decision.
PARENT/ADULT STUDENT CONSENT: Indicate your response by checking the appropriate space and sign below.
___ I give permission to implement this IEP and the placement decision.
___ I do not give permission to implement this IEP and the placement decision.
________________________________________________________ ____/____/____
Parent Signature or Adult Student Signature (if appropriate) Date
TRANSFER OF RIGHTS AT THE AGE OF MAJORITY (age 18):
Indicate the date that the student and parent were informed of the transfer of parental rights under IDEA to the adult student
at the age of 18. This must occur at least one year prior to the age of 18.
_____________________
Date
___________________________________________________
School Official Signature
I was informed of the parental rights under IDEA and that these rights transfer to me at age 18.
_____________________
Date
___________________________________________________
Student Signature
I was informed of the parental rights under IDEA that transfer to my child at age 18.
_____________________
Date
___________________________________________________
Parent Signature
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IEP
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