Summary of Performance
Student Name: ____________________________ Birthdate: _____________ District: _____________
Completed By: ___________________________________Phone: _________________ Date: _________________
This student is expected to:
 Graduate with a regular high school diploma on _________
 Achieve a certificate of completion on ________
Student’s Post Secondary Goals: (from the last IEP dated_________________________)
1. Career/Employment: As an adult, what kind of work do you want to do?
 Integrated/Supported Employment,  Competitive Employment,  Other
2. Post-secondary education/training: After high school, what additional education/training do you want?
 Post-Secondary,  Continuing Education,  Adult Education,  Other
3. Adult Living: As an adult, where do you want to live?
4. Community Participation: As an adult, what hobbies and activities do you want to have?
Recommendations to Assist Student in Meeting Post-Secondary Goals:
1. Career/Employment:
2. Post-secondary education/training:
3. Adult Living:
4. Community Participation:
Summary of Academic Achievement:
Academic Testing: Testing date:_______________
Name of Test:________________________
Reading _____
Math _____
Spelling _____
 grade levels or  standard scores
Modifications/Accommodations needed:
Summary of Functional Performance:
Significant Functional Skill Limitations:
 Self-Care,  Receptive/Expressive Language,  Self-Direction,  Learning,  Mobility,  Independent Living,
Economic Self-Sufficiency,  Employment
Supports needed:
Summary of Performance
(Page 2)
Student Name:_______________________________________ Date:__________
Community Agency/Services Involvement
Agency
Contact Person
Phone #
Michigan Rehab Services ( MDLEG-RS)
Community Mental Health
Michigan Dept Human Services (FIA)
Disability Resource Center
SSI/Medicaid
Police/Probation/Corrections
Alternative Ed/Other School Program
Substance Abuse/C.A.S.S.
YOU/WIA
Other:
Other:
Other:
Other:
Social/Emotional/Behavioral
Description of behavior concerns:
DSM IV Diagnosis
yes
no
If so, by whom:
Report Attached
Physical/Health Diagnosis
(Diabetes, Heart, Back, Seizure, ADHD, CP, Asthma, etc.)
Physician Statement Attached
Diagnosis
By Whom
Date
Medications
Type
Dosage & Frequency
Special Education Eligibility:
Primary:__________________________________________________________________
Secondary: _______________________________________________________________
Test Data:
VIQ:__________ PIQ:__________ FSIQ:__________ Testing Date: __________
Test Name: ____________________________ Administered By: _____________
Multi-Agency Release Form Included