2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
District:
Student’s Name:
Date of Review:
School:
Age:
Grade:
Eligibility:
Monitor’s Name:
Eligibility Date:
NOTES:
Revised September 2015
Record Review Form
Page 1 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
DELIVERY OF SERVICES/LRE/FAPE
Record
Review
Item
DS-1
Regulation
34 CFR or
SBP 7219
300.116
Record Review Question
Compliant
Does the public agency ensure
when determining the
educational placement of a child
with a disability that the
placement decision is made by a
group of person, including the
parents, and other persons
knowledgeable about the child,
the meaning of the evaluation
data, and the placement options.
Record Review Form
Potential Sources of
Documentation
Placement decisions are
made by a group of
persons including the
parent(s), who are
knowledgeable of the
student.
IEP – Signature page
Evidence indicates that
placement decisions
were not made by a
group of persons
including the parent,
who are knowledgeable
about the child, the
meaning of the
evaluation data, and the
placement options.
IEP – Signature page
YES
NO
Revised September 2015
Evidence
LRE Determinations
Page 2 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
Regulation
34 CFR or
SBP 7219
300.320(a)(1)
300.324(a)(1)
DELIVERY OF SERVICES/LRE/FAPE
Record
Review
Item
DS-2
Revised September 2015
Record Review
Question
Compliant
Evidence
YES
School-age (PLAAFP)
PLAAFP must include the following
information as it relates to each goal:
 Summary of current daily
academic/behavior and/or
functional performance (strengths
and needs);
 Baseline data provided for
developing a measurable goal.
(e.g. ATR results, if current;
formative, curriculum-based,
transition, functional behavior
assessments).
Preschool
IEP describes how the disability affects
the child’s participation in appropriate
activities to access, participate, and
progress in the general curriculum
and/or participation in developmentally
appropriate activities.
Additional for Preschool
PLAAFP relate to the child’s
developmental domains, functional
performance and pre-academic skills.
Functional skills are: integration of
cognitive, language, and motor skills for
the child to demonstrate positive socialemotional skills, acquisition and use of
knowledge and skills; and to take care
of personal needs (self-help).
Does the IEP include
Present Levels of
Academic Achievement
and Functional
Performance (PLAAFP)
that address the needs
of the student?
Record Review Form
Potential Source(s) of
Documentation
IEP - Present Levels of
Academic Achievement
and Functional
Performance (PLAAFP)
Page 3 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
DS-2
(cont.)
300.320(a)(1)
300.324(a)(1)
NO
DS-3
DS-4
DS-5
300.320(A)(1)(i)
300.324(a)(1)(i)
(ii)(iii)(iv)
300.320(a)(2)(i)
300.324(b)(i)
Revised September 2015
Does the IEP include a
statement of how the
student’s disability
affects the child’s
involvement and
progress in general
education?
Does the IEP have
student strengths,
concerns of parents and
results of the initial or
most recent evaluation,
academic,
developmental and
functional needs?
Do annual goals
address the child’s
academic area(s) of
need?
YES
NO
YES
NO
YES
Present levels of performance do not
provide detailed and targeted summary
of current daily academic/behavior
and/or functional performance related to
the development of EACH measurable
goal.
(i.e. Do behavior goals have detailed
description of behavior, do math goals
have specific descriptions of math
performance)?
Impact statement explains how the
disability affects performance
IEP - PLAAFP
No impact statement. OR
Statement does not address all areas of
involvement and progress in the
general curriculum.
IEP contains strengths of student.
IEP contains concerns of parents.
IEP does not contain strengths of
student.
IEP does not contain concerns of the
parents.
There is alignment between the
academic needs identified in the IEP
and the annual goals or evidence in the
IEP that the IEP Committee, based on
the severity of needs, decided to
prioritize addressing the needs. i.e. If
student is in 9th grade reading on the 3rd
grade level there should be a
Record Review Form
IEP – PLAAFP
IEP – Measureable
Annual Goals
IEP - PLAAFP
IEP - Annual Goals
Page 4 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
reading/decoding goal, not just identify
the main idea, etc.
NO
There must be a direct relationship
between each measurable annual goal
and the present levels of academic
achievement and functional
performance that precede it.
Annual goals fail to address the child’s
academic needs identified in the IEP.
Academic needs were not identified at
this time.
NA
Revised September 2015
Record Review Form
Page 5 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
Record
Review
Item
DS-6
Regulation
34 CFR or
SBP 7219
300.320(a)(2)(i)
300.324(b)
Record Review
Question
Compliant
Do annual goals
address the child’s
functional area(s) of
need?
There is alignment between the
functional needs identified in the IEP
and the annual goals.
Functional means nonacademic, as in
“routine activities of everyday living.”
YES
DELIVERY OF SERVICES/LRE/FAPE
Evidence
NO
Potential Source(s) of
Documentation
Annual Goals
There must be a direct relationship
between each measurable annual goal
and the present levels of academic
achievement and functional
performance that precede it.
The annual goals fail to reasonably
address functional area(s) of need
identified in the IEP.
Functional needs were not identified at
this time.
NA
Revised September 2015
Record Review Form
Page 6 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
DELIVERY OF SERVICES/LRE/FAPE
Record
Review
Item
DS-7
Regulation
34 CFR or
SBP 7219
300.320(a)(2)(i)
300.324(b)(1)
Record Review
Question
Compliant
Are annual goals stated
in measurable terms?
(Performance criteria
desired: the level the
child must demonstrate
for mastery and the
number of times the
child must demonstrate
the skill or behavior.)
YES
NO
DS-8
300.320(a)(2)
Revised September 2015
Does the IEP include a
description of how the
child’s progress toward
meeting the annual
goals will be measured
and a Current Level of
Performance (CLP) for
Report of Progress
describing the child’s
current performance on
the annual goals based
on progress on STIO/Bs
using the identified
method of measurement
OBS, CRT, CBM, WS,
D/P, etc)
Evidence
Potential Source(s) of
Documentation
Measurable annual goals are
statements in measurable terms that
describe what can be taught to the child
using specially-designed instruction
within a twelve-month period. A
measurable annual goal must contain
the following:
 Clearly defined behavior: the
specific action the child will be
expected to perform.
 The condition (situation, setting
or given material) under which
the behavior is to be performed.
The annual goals do not describe what
can be taught to the child using
specially-designed instruction, and do
not contain the above
IEP (Measurable Annual
Goals)
There is evident to determine sufficient
and/or insufficient progress was made.
IEP – Current level of
performance (CLP)
for report of
progress
YES
The IEP does not have
evidence of sufficient
and/or insufficient
progress reported
appropriately or the areas
are left blank.
The IEP does not have evidence or
documentation of sufficient and/or
insufficient progress reported
appropriately or the areas are left blank.
NO
Record Review Form
Page 7 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
Record
Review
Item
DS-9
Regulation
34 CFR or
SBP 7219
300.324(a)(2)
300.324(b)(2)
Record Review
Question
Compliant
Does the IEP address
Special Considerations?
YES
Evidence
Potential Source(s) of
Documentation
The IEP specifically identifies the
provision of Special Considerations that
aligns with the needs of the child and
supports achievement of annual goals.
IEP - Special
Considerations section
Special Considerations: Communication
and assistive technology needs, special
needs of children who are blind, deaf,
and visually and/or hearing impaired,
who need behavior interventions, and
who have limited proficiency in English
Communication and assistive
technology must be addressed in every
situation. If L/S is primary or a related
service, communication must be
marked “yes”.
The IEP does not specify special
considerations that align with the needs
of the child or support annual goals.
NO
The IEP contains the provision of some
special considerations but they do not
address all the needs of the student.
Basis for decision not included for
communication and assistive
technology
Revised September 2015
Record Review Form
Page 8 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
Record
Review
Item
DS-10
Regulation
34 CFR or
SBP 7219
300.320(a)(4)
300.39(b)(3)
Record Review
Question
Does the IEP contain a
statement of speciallydesigned instruction that
addresses the needs of
the child and supports
annual goals to enable
the child –
i.
ii.
To advance
appropriately
toward attaining
the annual goals;
The IEP specifically identifies the
provision of specially-designed
instruction and describes the nature of
the instruction that aligns with the needs
of the child and supports the
achievement of annual goals.
YES
To be involved in
and make progress
in the general
education
curriculum.
NO
Revised September 2015
Evidence
Compliant
Potential Source(s) of
Documentation
IEP - Description(s) of
Specially-Designed
Instruction
(Accommodations and
Modifications)
Definition 300.39 (b)(3)
Specially-designed instruction means
adapting, as appropriate to the needs of
an eligible child under this part, the
content, methodology, or delivery of
instruction or the child is receiving
related services that the IEP Committee
has determined is specially-designed
instruction; i.e. only related services
listed on the IEP.
(e.g. Instruction in organization skills to
include use of daily checklists and
academic subject organizers)
The IEP does not specifically identify
the provision of specially-designed
instruction and does not describe the
nature of the instruction that aligns with
the needs of the child and supports the
achievement of annual goals.
Record Review Form
Page 9 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
Record
Review
Item
DELIVERY OF SERVICES/LRE/FAPE
DS-11
Regulation
34 CFR or
SBP 7219
300.320(a)(7)
Record Review
Question
Compliant
Does the statement of
specially-designed
instruction indicate the
location where it will be
provided?
The IEP specifically identifies the
location of services.
YES
NO
DS-12
300.320(a)(7)
Does the statement of
specially-designed
instruction indicate
duration and frequency
of services?
YES
NO
Revised September 2015
Evidence
Potential Source(s) of
Documentation
IEP - Description(s) of
Specially Designed
Instruction
If more than one location, each location
must show the specially designed
instruction that will be provided in that
location.
The IEP does NOT specify where
specially-designed instruction will be
provided.
The statement of specially-designed
instruction specifically identifies the
amount of time and frequency of
services the child will receive.
The specially-designed instruction
statement does not specify the amount
of time and frequency of services
received.
Record Review Form
Specially-Designed
Instruction
(Duration and Frequency)
Page 10 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
Regulation
34 CFR or
SBP 7219
300.320(a)(4)
300.34
300.324(a)(2)
300.324(b)(2)
DELIVERY OF SERVICES/FAPE/LRE
Record
Review
Item
DS-13
Record Review
Question
Compliant
Does the IEP identify
related services that
address the needs of
the child and support
annual goals?
Evidence
Potential Source(s) of
Documentation
The IEP specifically identifies the provision
of related services that aligns with the needs
of the child and supports achievement of
annual goals.
YES
Related Services: Developmental, corrective
and other supportive services as are
required to assist a child with a disability to
benefit from special education and includes
the following services: speech-language
pathology and audiology, interpreting,
psychological, physical and occupational
therapy, recreation including therapeutic
recreation, early identification and
assessment of disabilities in children,
counseling including rehabilitation,
orientation and mobility, social work, health
and school nurse, parent counseling and
training, and medical services for diagnostic
or evaluation purposes.
The IEP does not specify related services
that align with the needs of the child or
support annual goals.
NO
The IEP contains the provision of some
related services but they do not address all
the related service needs of the student.
Based on the needs of the child, related
services were not identified at this time.
NA
Revised September 2015
Record Review Form
Page 11 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
Record
Review
Item
DS-14
DS-15
Regulation
34 CFR or
SBP 7219
300.320(a)(7)
300.320(a)(7)
Revised September 2015
Record Review
Question
Does the statement
of related services
indicate the location
where it will be
provided?
Does the statement
of related services
indicate duration and
frequency?
Compliant
YES
Evidence
The IEP specifically identifies where related
services will be provided.
NO
Location is not specified for each related
service.
NA
Based on the needs of the child, related
services were not identified at this time.
YES
The IEP specifically identifies the duration
and frequency of related services that will be
provided.
NO
Duration and frequency is not specified for
each related service.
NA
Based on the needs of the child, related
services were not identified at this time.
Record Review Form
Potential Source(s) of
Documentation
IEP
Description(s) of Specially
Designed Instruction
(Related Services)
IEP
Description(s) of Specially
Designed Instruction
(Related Services)
Page 12 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
Record
Review
Item
DS-16
Regulation
34 CFR or
SBP 7219
300.320(a)(7)
Record Review
Question
Compliant
Does the IEP correctly
identify the child as
SCD?
YES
DELIVERY OF SRVICES/LRRE/FAPE
NO
Evidence
All three SCD standards are marked as
YES.
Potential Source(s) of
Documentation
IEP – SCD section
The student is marked as SCD but all
three standards are not marked YES.
The student is not SCD
NA
DS-17
DS-18
300.115(a)(b)
300.320(b)
300.324(c)
Provide access to
general State-wide and
district-wide
assessment programs,
with appropriate
accommodations, where
necessary.
If the student is 14 or
older, are appropriate
transition services
provided?
YES
NO
YES
NO
NA
Revised September 2015
There is access to general State-wide
and district-wide assessment programs,
with appropriate accommodations
where necessary.
No access to general State-wide and
district wide assessments or
appropriate accommodations.
The transition planning elements of the
IEP are compliant with criteria
established on the National Secondary
Transition Technical Assistance Center
(NSTTAC) Indicator 13 Checklist (See
addendum).
Transition planning on the IEP is
noncompliant with one or more of the 8
required Federal elements outlined on
the checklist (See addendum).
The child is not 14 or above, or the IEP
reported in MSIS is the current IEP.
Record Review Form
IEP – State and district
testing page
IEP Indicator 13 Checklist
Page 13 of 14
2015 – 2016
MISSISSIPPI DEPARTMENT OF EDUCATION – OFFICE OF SPECIAL EDUCATION
ACCOUNTABILITY STANDARD 17.4
ON-SITE MONITORING RECORD REVIEW FORM
DELIVERY OF SERVICES/FAPE/LRE
DELIVERY OF SRVICES/LRE/FAPE
Record
Regulation
Review
34 CFR or
Item
SBP 7219
FAPE-1 300.106(a)(1)(2)
Record Review
Question
Compliant
Does the ESY
determination page
include documentation
of eligibility and criterion
used for determination?
YES
If the student is eligible,
are goals targeted?
If regression
/recoupment is the
criterion, is there
evidence of data
collection in the
student’s folder
Evidence
The ESY determination page has both
the documentation of eligibility and the
criterion used for determination.
If student is eligible, are there targeted
goals?
Potential Source(s) of
Documentation
IEP – ESY determination
page
If regression/ recoupment is the
criterion, there is evidence of
appropriate data collection for the
required amount of time.
NO
The ESY determination page is blank or
the following is missing:
- eligibility determination
- criterion used for determination
Regression/Recoupment data (if
applicable) is not present in student
records.
Student is eligible, but there are no
targeted goals identified on the IEP
Revised September 2015
Record Review Form
Page 14 of 14