INDIVIDUALIZED EDUCATION PROGRAM
COVER PAGE
Student Name Teran
Grade
5
Page 1 of 6
DOB ____/____/____ Disability(ies)______________________________________________
Parent Name________________________________________________________________________________
Home Address_____________________________________________________ Phone # (H)
(____)__________________
____________________________________________________ Phone # (W)
(____)__________________
Date of IEP
meeting…………………...…………………….……………………….....……..………….._____/_____/_____
Date parent notified of IEP
meeting………………………………..……………………...………………_____/_____/_____
This IEP will be reviewed no later than
………..…………………….……………..……….……………_____/_____/_____
Most recent eligibility
date…………………………….…………………………………….……………._____/_____/_____
Next re-evaluation, including eligibility, must occur before
………..……..…………..…..…………….._____/_____/_____
Copy of IEP given to parent (Name) _____________________________________________ On
(Date)_____/_____/_____
IEP Teacher/Manager_________________________________________ Phone Number
(____)______________________
The Individualized Education Plan (IEP) that accompanies this document is meant to support the positive process
and team approach. The IEP is a working document that outlines the student’s vision for the future, strengths and
needs. The IEP is not written in isolation. The intent of an IEP is to bring together a team of people who understand
and support the student in order to come to consensus on a plan and an appropriate and effective education for the
student. No two teams are alike and each team will arrive at different answers, ideas and supports and services to
address the student’s unique needs. The student and his/her family members are vital participants, as well as
teachers, assistants, specialists, outside service providers, and the principal. When all team members are present, the
valuable information shared supports the development of a rich student profile and education plan.
INDIVIDUALIZED EDUCATION PROGRAM
PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE
Student Name
Teran
Date 07/31/2014 Page 2 of_6
Student ID Number_____________________________________________________
The Present Level of Academic Achievement and Functional Performance summarize the results of assessments that
identify the student’s interests, preferences, strengths and areas of need, including assistive technology and/or
accessible materials. It also describes the effect of the student’s disability on his or her involvement and progress in
the general education curriculum, and for preschool children, as appropriate, how the disability affects the student’s
participation in appropriate activities. This includes the student’s performance and achievement in academic areas
such as writing, reading, mathematics, science, and history/social sciences. It also includes the student’s
performance in functional areas, such as self-determination, social competence, communication, behavior and
personal management. Test scores, if included, should be self-explanatory or an explanation should be included, and
the Present Level of Academic Achievement and Functional Performance should be written in objective measurable
terms, to the extent possible. There should be a direct relationship among the desired goals, the Present Level of
Academic Achievement and Functional Performance, and all other components of the IEP.
Teran is a ten-year-old fifth grade student at Longdale Elementary School. Teran has strength in
reading fluency as well as reading comprehension. She enjoys reading long passages and exhibits an
understanding of reading material that is on grade-level. She is below grade-level in Mathematics. Teran is
able to add and subtract up to 6-digit numbers, but needs to use manipulatives in order to do so. She does
not know her multiplication or division facts and needs step-by-step assistance in completing multiplication
and division problems even with the use of manipulatives. Teran typically becomes frustrated by math
work, but is able to express her frustration verbally to her teacher in an appropriate way. She is typically
able to work through her frustration and complete challenging math work when she is provided with oneto-one instruction.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
MEASURABLE ANNUAL GOALS, PROGRESS REPORT
Student Name
Teran
Date 07/31/2014 Page 3 of_6
Student ID Number________________________ Area of Need________________________________________
# 1 _ MEASURABLE ANNUAL GOAL: Teran will independently complete one-digit and two-digit
multiplication problems with 80% accuracy on 4/5 trials as measured by curriculum based assessments.
The IEP team considered the need for short-term objectives/benchmarks.
 Short-term objectives/benchmarks are included for this goal. (Required for students participating in the
VAAP)
 Short-term objectives/benchmarks are not included for this goal.
Objective #1: Teran will complete one-digit multiplication facts with 80% accuracy over 4/5 trials.
Objective #2: Teran will complete two-digit multiplication problems with 80% accuracy over 4/5 trials.
How will progress toward this annual goal be measured? (check all that apply)
____ Observation
____ Classroom Participation
____ Special Projects
____ Criterion-referenced test:_________________________
____ Checklist
____ Tests and Quizzes
____ Norm-referenced test: ___________________________
__ Class work
____
Written
Reports
__ Other: __data collection________________________
____ Homework
# 2 MEASURABLE ANNUAL GOAL: Teran will independently complete a 2-digit division problem with
80% accuracy over 4/5 trials as measured by curriculum based assessments.
The IEP team considered the need for short-term objectives/benchmarks.
☐Short-term objectives/benchmarks are included for this goal. (Required for students participating in the
VAAP)
 Short-term objectives/benchmarks are not included for this goal.
How will progress toward this annual goal be measured? (check all that apply)
____ Observation
____ Classroom Participation
____ Special Projects
____ Criterion-referenced test:_________________________
____ Checklist
____
Tests
and
Quizzes
____ Norm-referenced test: ___________________________
__ Class work
____
Written
Reports
__ Other: __data collection________________________
____ Homework
# 3 MEASURABLE ANNUAL GOAL: Teran will independently add and subtract fractions with like and unlike
denominators up to 12 with 80% accuracy on 4/5 trials as measured by classwork and curriculum based measures.
The IEP team considered the need for short-term objectives/benchmarks.
 Short-term objectives/benchmarks are included for this goal. (Required for students participating in the
VAAP)
 Short-term objectives/benchmarks are not included for this goal.
Objective #1: Teran will independently add fractions with like and unlike denominators up to 12 with 80% accuracy
on 4/5 trials as measured by classwork and curriculum-based measures.
Objective #2: Teran will independently subtract fractions with like and unlike denominators up to 12 with 80%
accuracy on 4/5 trials as measured by classwork and curriculum-based measures.
How will progress toward this annual goal be measured? (check all that apply)
____ Observation
____ Classroom Participation
____ Special Projects
____ Criterion-referenced test:_________________________
____ Checklist
____ Tests and Quizzes
____ Norm-referenced test: ___________________________
__ Class work
____
Written
Reports
__ Other: __data collection________________________
____ Homework
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT
ACCOMMODATIONS/MODIFICATIONS
Student Name_Teran________________________________________ Date 07_/31/2014 Page 5_of_6
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
including assistive technology and/or accessible materials. The impact of any modifications listed should be
discussed.
ACCOMMODATIONS/MODIFICATIONS (list, as appropriate)
Accommodation(s)/Modification(s)
Frequency
Access to math manipulatives and
hundreds chart
Mathematics
Location
(name of school
*)
Longdale Elem.
Small group testing
testing
Frequent scheduled breaks
Access to math strategies
Instructional
Setting
General education
classroom
Duration
m/d/y to
m/d/y
08/01/201408/01/2015
Longdale Elem.
General education
classroom
08/01/201408/01/2015
Daily
Longdale Elem.
General education
classroom
08/01/201408/01/2015
Mathematics
Longdale Elem.
General education
classroom
08/01/201408/01/2015
* IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns
about the location of the services or refuses the proposed site. A listing of more than one anticipated location is
permissible, if the parents do not indicate that they will object to any particular school or state that the team should
identify a single school.
Supports for School Personnel: (Describe supports such as equipment, consultation, or training for school staff to meet the
unique needs for the student)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
________________________
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued
Student Name_Teran________________________________________ Date 07_/_31_/2014_ Page 6_of 6
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 shall be served in a program with age-appropriate peers unless it can be shown that
for a particular student with a disability, the alternative placement is appropriate as documented by the IEP.
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 and/or accessible
materials
Transportation
 Nonacademic and Extracurricular Services and
Activities
 Physical Education
 Extended School Year Services (ESY)
 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 and/or accessible materials, 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. * These services are listed on the “Accommodations/Modifications” page
and “Extended School Year Services” page, as needed.
Service(s)
Frequency
**School/location
Duration
m/d/y to m/d/y
Instructional
Setting
(classroom)
MathematicsDirect
Instruction
MathematicsSupport in
Content Area
Disability
Service Area:
Primary,
Secondary,
Tertiary ***
Daily
General Education
Classroom
08/01/201408/01/2015
Primary
Daily
General Education
Classroom
08/01/201408/01/2015
Primary
Percentage
Special
Education
Service by
Disability
Category
** IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns
about the location of the services or refuses the proposed site. A listing of more than one anticipated location is
permissible, if the parents do not indicate that they will object to any particular school or state that the team should
identify a single school.
***Not required for the IEP-may be included for data collection purposes. The total percent of services for the
primary, secondary, and tertiary disabilities cannot exceed 100. To calculate the percentage of special education
services, the amount of time required to provide all special education services described in the IEP is divided by the
length of the standard instructional day multiplied by 100.