Document date:
Individual Education Program (IEP)
Page
This IEP is an: ___Initial ___Annual Review ___Amended
Student’s Name:
Native Lang:
District:
of ___
Projected Triennial Re-evaluation Date: ____
District ID:
Ethnicity:
State ID:
Birthdate:
Grade:
Sex:
Age:
School:
Parent/Guardian Name:
Address:
Native Language:
Home Phone:
Parent/Guardian Name:
Address:
Native Language:
Home Phone:
Daytime Phone:
Daytime Phone:
IEP Information
Special Education Teacher Name:
Telephone Number:
Eligibility Category:
Medical Information:
Procedural Safeguards
I have been provided the special education procedural safeguards in my native language or other mode of
communication.
Yes
No
_____________________________________________________ ______________
Parent/Guardian Signature IDEA 300.504(a)
Date
A copy of the IEP has been provided to the parent(s) IDEA 300.322(f)
Yes
No
IEP Team Information
Position or Title
Names of All IEP Team Members
Invited to Attend
Student
IDEA 300.321(a)(7) and 300.321(b)(1)
Parent/Guardian
IDEA 300.321(b)(1)
Special Education Director or Designee
IEP Meeting Attendance
(Check DOES NOT
indicate agreement)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
IDEA 300.321.(a)(4)(i)-(iii)
General Education Teacher
IDEA 300.321(a)(2)
Special Education Teacher
IDEA 300.321(a)(3)
Draft 1/7/2016
Page 1
Document date:
Individual Education Program (IEP)
Page
This IEP is an: ___Initial ___Annual Review ___Amended
Student’s Name:
Native Lang:
District:
of ___
Projected Triennial Re-evaluation Date: ____
District ID:
Ethnicity:
State ID:
Birthdate:
Grade:
Sex:
Age:
School:
Annual Present Levels of Performance and Annual Goals
A. Skill Area:
B. Present Level of Performance:
How does the student’s disability affect his or her involvement in and progress in the general education curriculum?
1. Strengths of the child IDEA 300.324(a)(i);
2.
Student’s preferences and interests IDEA 300.321(b)(2);
3.
Present level of academic achievement and functional performance IDEA 300.320(a)(1);
4.
Baseline: (student’s most recent CBM, observation data, other special skill measurement that
addresses specific annual goal) IDEA 300.324(a)(iii);
5.
How the child’s disabilities affects the child’s involvement and progress in the general curriculum and
participation in appropriate activities IDEA 300.320(a)(1)(i);
6.
Parental concerns IDEA 300.324(a)(1)(ii);
C. General Education Content Standard(s): (Idaho Content Standards, Common Core, Idaho Work Place
Competencies, Idaho Extended Content Standards)
D. Annual Goal: Must list the condition or level of instruction, the behavior or skill, and the criteria (must be
aligned to baseline data identified in the Present Level of Performance) IDEA 300.320(a)(2)(i):
1. Condition
2. Performance
3. Criteria
4. Procedure IDEA 300.320(a)(3)(i) :
Observation
Assessment: _____________
5. Schedule IDEA 300.320(a)(3)(i):
Daily
Work Sampling
Weekly
Bi-Monthly
Data Collection
Rubric
Monthly
E. Progress Report (Describe how parents will be informed of the student’s progress toward goals and how
frequently will occur) IDEA 300.320(a)(3)(i)
Written progress will be provide:
Mid-Term
End of Grading Period
Other: ___________
Reporting Date ____/____/____
Progress:
Reporting Date ____/____/____
Progress:
Reporting Date ____/____/____
Progress:
Reporting Date ___/____/____
Progress:
Supporting Data Points:
Supporting Data Points
Supporting Data Points
Supporting Data Points
E.
Assistive Technology (if needed) IDEA 300.324(a)(2)(v):
*Insert more Annual Present Levels of Performance and Annual Goals pages as necessary
Draft 1/7/2016
Page 2
Document date:
Individual Education Program (IEP)
Page
This IEP is an: ___Initial ___Annual Review ___Amended
Student’s Name:
Native Lang:
District:
of ___
Projected Triennial Re-evaluation Date: ____
District ID:
Ethnicity:
State ID:
Birthdate:
Grade:
Sex:
Age:
School:
IEP Services IDEA 300.320(a)(4) and (7)
The information on this page is a summary of the student’s program/services, including when services will begin, where
they will be provided, who will be responsible for providing them, and when they will end:
Specialized Instruction
Area and/or Related
Service IDEA
300.320(a)(4)
Service Provider
Fully qualified Staff
IDEA 300.18
Total Amount of Time:
Location Codes:
01 Gen Ed
04 Hospital
Classroom
02 Sp Ed Classroom 05 Community
03 Home
06 Therapy Room
Frequency of Special
Education/Related Services
IDEA 300.320(a)(7)
Use ONE column only per identified service
Per Day
Per Week
Per Month
_____HPD
_____HPW
Location
Start Date
End Date
IDEA
300.320(a)(7)
IDEA
300.320(a)(7)
_____HPM
Optional Statement of Service Delivery
Describe how services will be provided to the student.
LEAST RESTRICTIVE ENVIRONMENT (LRE)
Check One:
The student will participate entirely in the general education classroom, the general education curriculum, and
nonacademic and extracurricular activities with nondisabled peers.
The student will participate in the general education classroom and curriculum, except for the following:
Check and explain all that apply.
General education classroom:_______________________________________________________________
_________________________________________________________________________________________
General education curriculum: ______________________________________________________________
_________________________________________________________________________________________
Non-academic and extracurricular activities with non-disabled peers: _______________________________
_________________________________________________________________________________________
Draft 1/7/2016
Page 3
Document date:
Individual Education Program (IEP)
Page
This IEP is an: ___Initial ___Annual Review ___Amended
Student’s Name:
Native Lang:
District:
of ___
Projected Triennial Re-evaluation Date: ____
District ID:
Ethnicity:
State ID:
Birthdate:
Grade:
Sex:
Age:
School:
Educational Environment for Ages 3-21 (Must match minutes on the IEP services and other considerations section.
IDEA 300.320(a)(5).
Students ages 6 through 21
Students ages 3-5
01
02
03
Student is inside the general education classroom 80% or more of the school day.
In a 6 hour school day, the student is inside the regular class at least 4 hours and 48
minutes.
Student is inside the general education classroom at least 40% but not more than
79% of the school day. In a 6 hour school day, the student is inside the regular
class at least 2 hours, 25 minutes, but not more than 4 hours, 47 minutes.
Student is inside the general education classroom less than 40% of the school day.
In a 6 hour school day, the student is inside the regular class 2 hours, 24 minutes or
less.
44
45
46
11
Student is in a district self-contained classroom in a separate special education
school for more than 50% of the school day – more than 3 hours in a 6 hour day.
47
12
Student is placed in a private special education day school/facility at public expense
for more than 50% of the school day – more than 3 hours in a 6 hour school day.
48
13
Student receives education services in public residential facility for more than 50%
of the school day and resides in that facility during the school week.
49
14
Student receives education services in a private residential facility at public expense
for more than 50% of the school day and resides in that facility during the school
week.
50
15
Student receives special education services in a hospital or homebound setting (do
not include home-schooled students or virtual charter school students).
51
16
Student receives special education services in a detention center or correctional
facility.
52
21
SEPARATE SPECIAL EDUCATION CLASS: Student attends a special education
program in a class with a majority (at least 50%) of children with disabilities (i.e.
children on IEPs). (This category may include but is not limited to programs in regular
school buildings, portables, child care facilities, out patient hospital facilities, or other
community based settings.)
SEPARATE SCHOOL: Student receives education programs in a public or private
day
school designed for children with disabilities
RESIDENTIAL FACILITY: Student receives education program in publicly or privately
operated residential school or medical facility on inpatient basis.
SERVICE PROVIDER LOCATION OR SOME OTHER LOCATION: Student receives
the majority of special education and related services in a service provider location or
some other location not in any other category. (This category includes but is not
limited to clinicians’ offices located in school buildings, private clinicians’ office, and
hospital facilities on outpatient basis.)
HOME: Student receives the majority of special education and related services in the
principal residence of the child’s family or caregivers (includes babysitters). (Include
children who receive special education both at home and in a service provider
location or other location not in any other category.)
The student attends a public or private REGULAR EARLY CHILDHOOD
PROGRAM that includes a majority (at least 50%) of non-disabled children (i.e.
not on IEPs) at least 10 hours per week. And receives majority (at least 50%) of
Special Education and related services in the Regular Early Childhood Program.
The student attends a public or private REGULAR EARLY CHILDHOOD
PROGRAM that includes a majority (at least 50%) of non-disabled children (i.e.
not on IEPs) at least 10 hours per week. And receives majority of Special
Education and related services in some OTHER LOCATION.
The student attends a public or private REGULAR EARLY CHILDHOOD
PROGRAM that includes a majority (at least 50%) of non-disabled children (i.e.
not on IEPs) less than 10 hours per week. And receives majority (at least 50%) of
Special Education and related services in the Regular Early Childhood Program.
The student attends a public or private REGULAR EARLY CHILDHOOD
PROGRAM that includes a majority (at least 50%) of non-disabled children (i.e.
not on IEPs) less than 10 hours per week. And receives majority of Special
Education and related services in some OTHER LOCATION.
Student is voluntarily enrolled in a private school by parents.
Other Considerations
A. Special transportation is a related service IDEA 300.34(a)(16). The student requires
transportation. Describe if necessary:
Regular
Special
No
B. Are extended school year (ESY) services required for this student IDEA 300.106)?
Yes
No
TBD. If TBD,
when:_________.
If Yes, complete 1 – 6 below.
1. What are the skills this student will lose as a result of an interrupted educational program and will be unable to recoup
so as to make reasonable progress toward achieving the goals and benchmarks/objectives in the IEP?
2. What skills are emerging that require ESY services in order to make reasonable gains?
3. What acquisition of a critical life skill that aids the student’s ability to function independently would be threatened by an
interruption in services?
4. In what way are the above skills critical to the overall progress of the student?
5. Specify which goals and objectives/benchmarks should be part of the IEP for ESY services.
6. Begin and end dates of ESY: __________. Hours per week: ___________
C. Does the student have limited proficiency in English IDEA 300.324(a)(2)(II)?
__________. Explain what considerations are necessary:
Draft 1/7/2016
Yes
No. If yes, what native language?
Page 4
Document date:
Individual Education Program (IEP)
Page
This IEP is an: ___Initial ___Annual Review ___Amended
Student’s Name:
Native Lang:
District:
Projected Triennial Re-evaluation Date: ____
District ID:
Ethnicity:
State ID:
Birthdate:
Grade:
Sex:
Age:
School:
D. If hearing impaired/deaf, is hearing aid monitoring required?
what considerations are necessary:
Is the student deaf or hard of hearing IDEA 300.324(a)(2)(iv)?
Yes
No
Yes
E. If visually impaired/blind, is Braille required?
considerations are necessary:
Yes
Yes
No
No
Not hearing impaired/deaf. If yes, explain
No
Does the student have unique communication needs IDEA 300.324(a)(2)(iv)?
Communication Plan
Is the student blind or visually impaired?
of ___
Yes
No If yes, complete a
Not visually impaired/blind. If yes, explain what
If yes, complete the Learning Media Plan IDEA
300.324(a)(2)(iii)
F. Does the student require a Health Care Plan?
Yes
No
If yes, indicate location of Plan.
Behavior Intervention Planning IDEA 300.324(a)(2)(i)
A. Does behavior impede the student’s learning or that of others?...........................................……….
Yes
No
B. If yes, have positive behavior supports been
considered?.………………………………………….......
Yes
No
C. The positive behavior supports, if needed, are incorporated in this
IEP…………………….……...….
Yes
No
D. A behavior intervention plan (BIP), including positive supports, is included or attached to this
IEP..
Yes
No
Behavior Improvement Plan (complete if D is checked)
1. Target behavior (restate IEP goal that addresses behavior)
2. State prevention activities in observable
terms
How often
Who is responsible
Progress monitoring
method
3. State what will be taught
4. State response to target behavior
Draft 1/7/2016
Page 5
Document date:
Individual Education Program (IEP)
Page
This IEP is an: ___Initial ___Annual Review ___Amended
Student’s Name:
Native Lang:
District:
District ID:
Ethnicity:
of ___
Projected Triennial Re-evaluation Date: ____
State ID:
Birthdate:
Grade:
Sex:
Age:
School:
Accommodations, Adaptations, and/or Supports in General and Special Education IDEA 300.320(a)(4)(i)-(ii) &
300.320(a)(6)(i)
Document accommodations and/or adaptations the student requires, based on assessed needs, in order to advance
appropriately toward attaining the identified annual goals, be involved and make progress in general education
curriculum, and be educated in general education to the maximum extent possible. Include all necessary classroom
accommodations and adaptations.
Accommodation/Adaptations Needed
Accommodation/Adaptations Needed
Presentation
Setting
Response
Timing/Scheduling
Other:
Modification to the General Education Curriculum IDEA 300.320(a)(4)(ii)
Describe:
Describe:
Describe:
Describe:
Describe:
Describe:
Describe:
Draft 1/7/2016
Page 6
Document date:
Individual Education Program (IEP)
Page
This IEP is an: ___Initial ___Annual Review ___Amended
Student’s Name:
Native Lang:
District:
District ID:
Ethnicity:
of ___
Projected Triennial Re-evaluation Date: ____
State ID:
Birthdate:
Grade:
Sex:
Age:
School:
Participation in Statewide and Districtwide Assessment
* Only those accommodations listed above and regularly used by the student in classroom instruction and classroom testing may be used
during statewide or districtwide assessments.
Reading
Accommodation Needed:
ISAT
ISAT-Alt
IRI
Other
IRI-Alt
NAEP
Math
Accommodation Needed:
ISAT
ISAT-Alt
NAEP
Other
Language Arts
Accommodation Needed:
ISAT
ISAT-Alt
NAEP
Other
Science
Accommodation Needed:
ISAT
ISAT-Alt
NAEP
Other
Other
WIDA
College Entrance Exam
Civics (Fall 2017)
Accommodation Needed:
WIDA-Alt
Other
Eligibility for a student to take the ISAT-Alt IDEA 300.320(a)(6)(i):
The student must meet all of the criteria listed below for the IEP Team to determine that the student is eligible to
participate in an alternate assessment:
a. The student’s demonstrated cognitive ability and adaptive behavior prevent completion of the general academic
curriculum even with program accommodations and/or adaptations;
b. The student’s course of study is primarily functional-skill and living-skill oriented (typically not measured by state
or district assessments); and
c. The student is unable to acquire, maintain, or generalize skills (in multiple settings) and to demonstrate
performance of these skills without intensive and frequent individualized instruction.
PRIOR WRITTEN NOTICE OF SPECIAL EDUCATION ACTION
The purpose of this notice is to inform you of the following:
A. Actions proposed IDEA CFR 300.503(a)(1):
☐
The student is due for a reevaluation to determine continued eligibility, and it has been determined that further
assessment is not necessary.
☐
The school district proposes to initiate/change identification.
☐
The school district proposes to initiate/change educational placement.
☐
The school district proposes to initiate/change educational placement due to disciplinary action.
☐
Other:
Draft 1/7/2016
Page 7
Document date:
Individual Education Program (IEP)
Page
This IEP is an: ___Initial ___Annual Review ___Amended
Student’s Name:
Native Lang:
District:
of ___
Projected Triennial Re-evaluation Date: ____
District ID:
Ethnicity:
State ID:
Birthdate:
Grade:
Sex:
Age:
School:
B. Actions refused IDEA CFR 300.503(a)(2):
☐
The school district refuses to initiate/change identification.
☐
The school district refuses to initiate/change evaluation/reevaluation.
☐
The school district refuses to initiate/change educational placement.
☐
The school district refuses to change the Individualized Education Program (IEP).
☐
Other:
C. Explanation of why actions were proposed or refused IDEA CFR 300.503(b)(1) - (2)):
☐
The student has met IEP or district graduation requirements.
☐
The student has completed the semester in which he or she turned 21 years old and is no longer entitled to
special education services.
☐
The current data on school performance along with previous assessments are adequate.
☐
The student’s disability adversely affects his or her educational performance, preventing satisfactory achievement.
☐
Special education services are required in order for the student to benefit from an educational program.
☐
The student’s disability does not adversely affect his or her educational performance.
☐
Behavioral and academic interventions can be implemented within the current placement.
☐
Other:
D. The following options were considered and rejected because IDEA CFR 300.503(b)(6):
E. The following evaluation procedures, tests, records, and reports were used as a basis for the decision IDEA
CFR 300.503(b)2):
F. The following information and other factors are relevant to the decision IDEA CFR 300.503(b)(7):
You have protection under the procedural safeguards of the Individuals with Disabilities Education Improvement Act If
you need an explanation or a copy of the Procedural Safeguards Notice, please contact
_______________________at________________________________.
(Case Manager)
(Building)
After contacting the school district, if further assistance is needed, you may contact any of the agencies below:
Idaho State Department of Education
208/332-6910
800/432-4601
TT: 800/377-3529
Draft 1/7/2016
Idaho Parents Unlimited, Inc.
800/242-4785
V/TT: 208/342-5884
DisAbility Rights Idaho
V/TT: 208/336-5353
V/TT: 866/262-3462
Page 8
Document date:
Individual Education Program (IEP)
Page
This IEP is an: ___Initial ___Annual Review ___Amended
Student’s Name:
Native Lang:
District:
Idaho Legal Aid Services
Administration Office:
1447 Tyrell Lane
Boise Idaho 83706
Phone: (208) 336-8980
Fax: 342-2561
Web: http://www.idaholegalaid.org/
*Offices in Boise, Caldwell, Coeur
d’Alene, Idaho Falls, Lewiston,
Pocatello and Twin Falls
Draft 1/7/2016
District ID:
Ethnicity:
of ___
Projected Triennial Re-evaluation Date: ____
State ID:
Birthdate:
Grade:
Sex:
Age:
School:
Idaho Bar Association
P.O. Box 895
Boise Idaho 83701
Phone (208) 334-4500
Fax: 334-4515
Web: https://isb.idaho.gov/
Online Lawyer Referral:
https://isb.idaho.gov/member_ser
vices/lrs/lrs_search_panel.cfm
Wrightslaw Idaho Yellow Pages for
Kids
http://www.yellowpagesforkids.co
m/help/id.htm
Page 9