Grant Wood Area Education Agency
Transition IEP Guidance
Critical
Element
CE #1 Interests
and
Preferences
Requirements
Break statements down
into three discrete areas:
 Strengths…..
 Interests …..
 Preferences….
Use verbs that indicate
information came directly
from the student: “Student
says, states, indicates”
For students who are
unable to consistently
communicate choices and
interests, reported
observation data from a
reliable source is
appropriate
December 2013
Example
In an interview with ______ on ________;
Strengths: He states that he has strengths in US History and Science
Interests: He states that his interests include playing video games, sports, and snowmobiling
Preferences: ____ and his family state that he prefers to work by himself in a noisy setting with a lot going on.
Strengths: In a personal interview with _____ on __________, he states his strengths are art, dodge ball,
science, and health.
Interests: ______states that his interests are participating in physical activities, computers, Internet, and animals
(specifically cats).
Preferences: ____ says he prefers to be outdoors and active.
______ is a non-verbal student who through observation and parent conversations has expressed:
Strengths: Persistence with activities she enjoys, ability to assist others with her self-help skills such as eating,
drinking, and dressing, and the warmth she shows to peers and others.
Interests: likes to be around people both peers and adults, likes swimming, and likes music.
Preferences: ______ demonstrates her preference and willingness by participating in the hand over hand activity
of using the electric stapler. She demonstrates her dislike for shredding by looking away when it is her turn to
participate in this activity and refusing adult prompts.
CE#2:
Transition
Assessment
Provide date
assessment(s) completed
Two sources of
information are needed
for each area (outside
evaluations may be
considered). Student and
parent interview counts
as one source.
At the end of the Living,
Learning and Working
sections, state very
clearly: “_____ is an
area of need,” and state
where it will be
addressed
(Goal, service, activity or
course of study).
OR
“_____ is not an area of
need.”
If there is a need listed in
this section, then a goal
and/or service or activity
is required.
For 4+ programs,
consider such
assessments as
ASVAB, SAT, ACT,
Compass, Work Keys
Living: Parent
information should be
considered.
Activities that will be
addressed in the home
setting (laundry, etc...)
should be listed as areas
of need and will be
addressed in the home.
December 2013
LIVING:
Information Sources:
Parent and student interviews, school and community-based observations, (Date
observed/interviewed/administered)
Results:
Parent/Student interview: _____ is able to function independently to meet his needs for post-secondary
living. __________ reports that he has a driver’s license and can access community resources. His
parents indicate that ________ can use a microwave, clean, take care of personal hygiene, balance his
checking account and use an ATM.
Based on observations: these skills are similar to same age peers. Any further development of these and
other independent living skills will be addressed in the home environment. Living is not an area of need
to be addressed in this IEP.
Information Sources:
School Records, including adaptive skills inventories, parent and caregiver interviews, school and
community-based observations, (Date observed/interviewed/administered)
Results:
Observations indicate that _____ can chew and swallow solid food when it is presented to her. She can
assist in transferring her weight from a sitting position and can sit without support for five minutes.
Interviews with her parents and respite caregivers, she can use her electric wheelchair to get around
indoors in familiar settings but needs assistance in crowded or unfamiliar settings. She also needs
assistance to complete all daily living tasks. A review of school records report that _____ adapts easily to
new people and new routines. She has been making steady progress on IEP goals. Living is an area of
need. It will be addressed in goals and services.
4+ Program
When considering a 4+ program, document the specific skills that justify the need for support in
the area of living (i.e. health, nutrition, mobility, safety, financial, etc.)
Information Sources:
Independent Living Inventory, Ansell Casey Life Skills Assessment
Results:
Based on the results from the Independent Living Inventory and the Ansell Casey Life Skill Assessment,
______ can plan and fix simple meals and snacks as well as generate a simple shopping list. She can
sort, wash, dry and fold laundry. She can use a vacuum and mop and moves furniture when cleaning
floors. Hygiene, such as showering and brushing teeth, is inconsistent and needs visual reminders.
Money management is a concern as ________ has not been able to consistently track her spending
habits. This, as well as hygiene, will need to be addressed to meet her goal of living on her own in an
apartment with a friend.
LEARNING:
Learning: We will
address the three
academic areas of
reading, written
language, and math.
Possible Sources: IA,
general education
teacher interview, general
education assessment
data, Curriculum Based
Measurement data,
rubrics.
In the learning results,
national stanine scores
(NSS) should be reported
when available.
National Percentile Rank
(NPR) should be used
when reporting for NWEA
and MAP scores.
Data from each source
should be listed under
results.
Behavior should also be
listed in this area.
December 2013
Information Sources:
School records, teacher interviews, classroom data, (Date observed/interviewed/administered)
Results:
_____ uses a communication system to express basic needs. Typical same grade peers would use their
voice to express basic needs
Reading: ____demonstrates an understanding of common signs and symbols in the community and 250
selected sight words but does not read connected text. Peers would be reading grade level text at 105
CWPM.
Math: _____understands basic concepts of quantity (more/less), follows a picture schedule and
understands time signals (school bells) and can match amounts to a model but she does not count,
perform calculations or tell time or read a calendar. Peers are working with algebraic formulas involving
one and two variables.
Writing: _____ communicates using her switch system. Peers are writing research papers and single
page responses for classroom assignments and tests.
Teachers report that _____ enjoys learning new tasks and changes in routine.
Learning is an area of need and will be addressed in goals, supports and activities
Information Sources:
Iowa Assessments (IA) National Standard Score (NSS); results from (Date
observed/interviewed/administered); Written Language Probes; Reading Probes; Math Probes; Degrees
of Reading Power; Jamestown Reading Progress Monitoring, Teacher observation data, (Date
observed/interviewed/administered)
Results:
Iowa Assessment:
Reading: 219 NSS; Peers scored between 230-320 NSS
Written Language: 201 NSS; Peers scored between 228-297 NSS
Math: 250 NSS for computation. Math Total 260 NSS; Peers scored between 235-290 NSS
A degree of Reading Power assessment was administered to _____ and he scored an instructional level
of 5.0. Difficulty was displayed in the area of comprehension. Peers are reading at the 10.5 grade level
with comparable comprehension.
________ scores an average of 33% on Jamestown Reading Progress Monitoring using grade level
material. Peers would score between 87-100% using similar material at grade level.
CBM Probes:
Reading –123 Correct Words per Minute (CWPM) Peers read 130-165 CWPM
Math - 20 Responses correct (RC). Peers scored 14-29 RC
Writing- 26 total Words Written (TWW) with 18 Correct Word Sequences (CWS) Peers write 51-76 TWW
with 50-76 CWS. The writing probe indicates that he is unable to write 1 simple sentence correctly when
given a story starter.
Teacher observation:
In his daily work, ____ is not able to write simple sentences on his own. .
IA scores indicate that he is able to edit material but Written Language Probes indicate that he is unable
to compose original writing samples.
Learning is an area of need. _______ continues to need specially designed instruction in written
language (basic sentence writing skills) and reading comprehension. No specially designed instruction in
math is needed.
4+ Program
When considering a 4+ program, document the specific skills that justify the need for support in the area
of learning (i.e. reading, writing, math, 21st Century Skills, etc.).
Information Sources:
I Have a Plan Iowa (IHAPI), 6 Trait Writing Rubric, Compass
Results
Based on the information from the 6 Trait Writing Rubric, ________scored comparable to peers in the
areas of idea (4/5), voice (5/5), and conventions (4/5). Organization (3/5), word choice (2/5) and
sentence fluency (2/5) were all areas of weakness when compared to same grade peers.
Compass results indicate that _____________ scored 40 (100 maximum) in the area of reading, 75 (100
maximum) in the area of math and 19 (100 maximum) in the area of writing. He will be enrolled in
remedial classes for reading and writing.
IHAPI results indicate that ________ is interested in a career in advertising requiring written
presentations, scripts, and sales reports.
Reading and Written language are areas of need.
Working: Sources to
consider; Interest
Explorer (8th gr.),
volunteer work, part time
work (babysitting, lawn
mowing), I have a Plan,
ASVAB, Work Keys,
Goodwill Work
Evaluations, etc.
December 2013
WORKING:
Information Sources:
School permanent products, parent, student and community experience supervisor interviews, Job
Related Interests and Preferences Inventory (Iowa Assessment Matrix,) (Date
observed/interviewed/administered)
Results:
____ self-reports that he has a volunteer position in the community at the hospital where he helps
transport patients and delivers lab results. At work, his supervisor indicates that he is friendly and
completes his work duties on time. At times, however, he does not accept changes in assignments well
and is occasionally late or absent without calling in. At home, parents report that ____ has a number of
chores for which he receives an allowance. He needs reminders to complete those tasks and can be
explosive when asked to redo tasks. The Job Related Interests and Preferences Inventory results
indicate that he has a keen interest in continuing to work and receive further education in the area of
health care. Permanent products document that he cannot complete a resume or job application nor
does he know how to contact employers for potential work. Working is an area of need and will be
Results: Need to focus
on current and past work
skills/habits which affect
student’s ability to obtain
and maintain
employment.
Update age appropriate
skills in living and working
indicating what the
student can and can not
do.
addressed as an activity on the services page.
Information Sources:
School records, parent and teacher interview, What’s My Bag (Iowa Assessment Matrix), (Date
observed/interviewed/administered)
Results:
School records and observations indicate that ____ can attend to tasks for up to ten minutes and can
remain in the same physical position for up to 45 minutes. She has difficulty with extremely fine motor
tasks, but can follow a three-step picture routine (match-to-sample). Both parents and teachers report
that she works well with others and prefers socially active environments with bright, active physical
attributes. What’s My Bag results support _________’s post-secondary expectation to work with children
in a nursery school or day care center. Working is an area of need and will be addressed as a goal and
services
Information Sources:
Interview with _____ and parents (Date interviewed); Choices Inventory; Classroom observation data
Results:
In an interview with _____, she states she is undecided in her career interests. She does however like to
cook, be with people, and clean. Her Choices Inventory results indicate that she would like a job outdoors
that has much activity and involves people and animals.
_____parents report that Mary completes the following chores/responsibilities at home; cleaning her
room, simple kitchen tasks, feeding the dog, watching siblings, and cleaning her bathroom. _____
receives an allowance when she can complete these tasks with simple reminders.
Work is not an area of need at this time but further career exploration may need to be addressed in the
future.
4+Program
Information Sources:
Interview with _____________ and parents (Date interviewed); Vocational Rehabilitation work
assessment; Functional Capacity skills check sheet
Results:
In an interview with __________, he states that he has classes and an internship in the area of auto
repair in high school. He would like to continue to pursue this area as a vocational career. His parents
report that he is constantly working on his car as well as that of his friends. He has been taking things
apart and putting them back together since he was in grade school.
The Vocational Rehabilitation work assessment reflects that he is punctual, even tempered, wellgroomed and accepts responsibility as well as consequences for actions. It also indicates that he has
had support in the area of reading and written language in high school and these are still areas of need
as it impacts his ability to be successful in the workplace.
The Functional Capacity skills check sheet indicates that he can use the computer to reference parts and
December 2013
Vocational Rehabilitation
Functional Capacity
Verbage
December 2013
record keeping, but he cannot hand write a parts or work order.
Working is an area of need for assistance in interpreting technical manuals and writing work orders.
To aid Vocational Rehabilitation (VR) Counselors in accessing the wealth of information contained in the
IEP and to document disability-related impediments to future learning and working environments, special
education teachers are encouraged to use VR verbage. See Addendum
CE#3
Postsecondary
Expectations
Project beyond high
school
Are observable
For younger students 1314, it is appropriate to use
introductory phrases like
“at this time….”
Become more specific as
the student becomes
older
Will be the foundation for
development of the IEP
services
4+ programs – Update
the student’s current
status in all PSE’s.
December 2013
LIVING:
______ will live in an apartment when he completes high school. Parental support will be provided as he
works toward independence.
______ will live in an apartment with friends after he has completed high school.
______ will live in a supported living environment with roommates.
(13-14 yrs.) At this time, _____ will live independently when he completes high school.
LEARNING:
____ will attend a 4 year college to obtain a degree in a health related field.
____ will enroll in a vocational program/community college or have on the job training in his desired
career field. ____ will access learning support services provided by the post secondary institution.
(13-14 yrs.) ____ will attend adult community education classes for art appreciation.
____ will participate in a variety of community activities including arts (especially music) and recreation.
She will have work-site job training as well.
WORKING:
_____ will perform work in a sheltered workshop.
(13-14 yrs.) _____ will work in a career field where she is able to use her interests in animals, especially
cats and dogs.
_____ will attend employment/vocational day program
_____ will work in a greenhouse or with a landscaping business.
_____ will continue his employment in retail after high school while pursuing his degree
CE#4
Course of
Study
Graduation Requirements:
1) The overall number of
credits the student needs to
graduate, and 2) overall
subject areas and required
number of credits (e.g., 4
credits of English) and 3)
other district graduation
requirements, if appropriate
OR if student is to graduate
by other means,
requirements specific to the
student.
Current status:
1) a targeted graduation
date, 2) the number of
credits/courses
in
each
subject area yet to be
completed out of the overall
number required (e.g., 2/4
credits of English, 3/4 credits
in science) and 3) any other
accomplishments
required
for graduation.
Middle School
Since ____ states in her
four year plan that she
has an interest working
with people in the health
care field, she will take the
following
courses:_________
(confer with counselor for
course track given
student’s PSE).
For courses and activities,
we will start by listing
electives and move to
activities making sure
these relate to student’s
interest, preferences and
post-secondary
December 2013
Example: (Middle School/Junior High)
Graduation Requirements: _____ needs to complete 3 years of English, 3 years of science, 3
years of math, and 3 years of social studies as well as 2 years of PE and 1 year of health and .5
years of FACS and .5 years of technology to transition from middle school to high school. When he
enrolls in high school, he will need 4 years of English, 3 years of Social Studies, 3 years of Math, 3
years of Science, 4 years of physical education, one trimester of Health, plus 21 electives.
Current Status: At this time, _______ has completed 2/3 years of English, 2/3 years of science,
2.5/ 3 years of math, and 3/3 years of social studies as well as 2/2 years of PE and 1/1 year of
health and 0/ .5 years of FACS and0/ .5 years of technology to transition from middle school to
high school. His current status towards earning high school credits are 0/ 4 years of English, 0/3
years of Social Studies, 0/3 years of Math,0/ 3 years of Science,0/ 4 years of physical education,
0/one trimester of Health, plus 0/ 21 electives.
Graduation date: 5/31/20—
Course and activities: At this time, ________ is unsure about a future career and plan of study. He
will complete I Have a Plan as well as participate in the school’s Career Day event to assist him in
his exploration of possible jobs.
Example:
Graduation Requirements: ______ needs 36 credits to graduate from _______ High School.
____ will need 4 credits of English, 3 credits of Social Studies, 3 credits of Math, and 3 credits of
Science, 4 credits of physical education, and .5 credits of Health, the remainder of credits, 18.5,
will be earned with elective courses. A portfolio is also a graduation requirement.
Current Status: ___ needs to complete 3/ 4 years of English, 2/3 years of Social Studies, 2/3
years of Math, and 3/3 years of Science, 3/4 years of physical education, and 0/.5 credits of Health
and 14.5/18.5 elective credits including art, family living, child development, keyboarding, sociology
and family consumer science to address her post-secondary expectation for living and working.
She is beginning work on her portfolio.
Graduation date: 5/31/20-- (use last day of May of graduation year if you do not know the specific
date. If the team is unsure of the year of graduation, record your target year and revise at each IEP
review.)
Course and activities _________will be involved in the following activities, working in the children’s
section at the local library, babysitting for PTA conference, and a job shadow at two local day
cares. Courses electives will include, Child Development IV, psychology, financial literacy, and
business education.
Example: 4+ program
expectations including
linkages specific for the
student to pursue postsecondary expectations.
These should all be
documented on the F
page.
Graduation date should
be the date the student
‘walks’ across the stage –
NOT the last day for
seniors.
Electives the student will
enroll in that align with the
PSE, activities the
student will participate in
that align with the PSE
(job shadowing, clubs,
career exploration,
internships, assessments
for post-secondary plans
[military, etc.] sports, etc.).
For students moving from
junior to senior high, we
will state: “The student is
on track to transition to
high school” or explain
what is needed to
transition
Must align student’s 4
year plan (8th grade plan)
If using Power School
graduation progress
sheet for
documentation, be sure
it is referenced or
attached (I page) (See
December 2013
Graduation Requirements: ______has completed minimum graduation requirements to graduate
from _______ High School. Requirements are 4 credits of English, 3 credits of Social Studies, 3
credits of Math, 3 credits of Science, 4 credits in physical education, one credit of Health and 16
electives for a total of 34 credits. _____ will participate in ___________ (4+ program
requirements) and in activities such as… (List activities and be specific.)
Current Status: ____ needs to complete 4/4 credits in English, 3/3 credits in Social Studies, 3/3
credits in Math, 3/3 credits in Science, 4/4 credits in physical education, 1/ one credit of Health,
18/18 electives (list them) and the portfolio completion.
Graduation date: 5/31/20-Course and activities: She has applied to the Kirkwood Health Careers program. She needs to
complete the COMPASS and the TEAS test. She will inquire about volunteer work at a local
hospital. She will inquire about possibly assisting athletic trainers and/or job shadowing through
Kirkwood’s student volunteer program. She will also need to complete the process for adult
services.
Example: (IEP completion)
Graduation Requirements: Due to the nature of _____ disability, the team has determined that he
will graduate via IEP completion through progress monitoring of his IEP goals. _____ will attend
school a minimum of 4 years and participate in activities related to his current goals. IEP
completion requirements will be revisited each year to determine if additional transition services
are necessary.
Current Status: _____ is currently in his 3rd year and is making satisfactory progress as measured
by progress monitoring and participation in activities related to his current goals. His independent
living skills include making his own bed, brushing his hair and teeth without physical prompts and
cooking simple meals using a microwave. He still requires visual prompts for teeth brushing and
doing his own laundry. He requires adult assistance in purchasing items and receiving change. He
can identify 70% of the words from his functional sight word list in isolation. He is working on
identifying these words in naturally occurring settings within the community. He can verbally
provide his name, address and phone number but cannot write it without a visual prompt. He is
able to walk to and from home to school and the rec center independently. He is working on using
public transportation independently. He uses a computer for game playing only and not as a
learning or communication tool.
Graduation Date: 5/31/20_ _
Courses and Activities: _____ will take the following courses to align with interests and PSE:
Metals/Jewelry and Foods. _____ will participate in work experience and community experiences.
The focus of his education will be to make him as independent as possible by the time he
Addendum B for
example taken from
Power School)
December 2013
graduates with instruction on functional skills including reading, math, and basic occupational
skills. Emphasis will be given to communication, mobility, self-care, career training, and community
involvement. Learning opportunities will be provided at school and in the community to generalize
the above mentioned skills. County case management services have been applied for on the
student’s behalf.
CE#5
Annual Goals
All goals must identify a
need identified in the
PLAAFP (Present Level
of Academic
Achievement and
Functional Performance)
and is a priority/essential
skill for the student to
pursue targeted PSE’s
(Post Secondary
Expectation).
All goals must meet
criteria for well written
goals: timeframe,
conditions, behavior,
criteria (SMART goal)
Include student’s
percentile rank when
using normed comparison
data as well as standard
score (SS).
When comparing to peers
put where typical same
grade peers would be
scoring (25%ile - 75%ile)
Must be written so that
progress monitoring data
is collected and visually
represented (i.e.
graphed) at least every 2
weeks.
Consider instructional
decision making
strategies
“If 4 consecutive data
points area above/below
the aim line an
instructional change will
December 2013
Goal Page:
Current Academic Performance: (Results of the initial or most recent evaluation and results on
district-wide assessments relevant to this goal; performance in comparison to general education peers
and standards)
Baseline (Describe individual's current performance in measurable terms using the same
measurement as measurable annual goal and progress monitoring procedures)
Measurable Annual Goal: conditions (when and how the individual will perform); behavior (what the
individual will do); and criterion (acceptable level of performance)
Progress Monitoring procedures (State how progress toward meeting this goal will be measured,
how often progress will be measured, and the decision making rule that will be used in considering
instructional changes)
9th grade student: Reading
Current Academic Performance:
______ reads a median of 40 correct words per minute (CWPM), on a 9th grade passage. This is in the
1% ile. Typical same grade peers score 140-173 CWPM (25%ile – 75%ile) using winter GWAEA
norms. On an 8th grade probe, he reads 49 CWPM (2nd%ile) and 55 CWPM (3rd%ile) on a 7th grade
passage.
Iowa Assessment (IA) Fall 20-- Reading Total 191SS, NPR 10th%ile, (typical peer range 221-254 SS,
25-75%ile).
Baseline:
____reads median of 71 CWPM on 6th grade reading passage. This is in the 10th%ile using winter
GWAEA 6th grade norms.
Goal: In order to be successful in high school, college and life, and after direct instruction in decoding
strategies and techniques, in 36 weeks, ____ will read 108 CWPM on 6th grade passage (33rd%ile).
7th grade student: Written Language
Current Academic Performance:
_____ writes simple sentences without punctuation. ___ struggles with spelling. Iowa Assessments
(IA) Fall 20-- Punctuation 175 SS NPR 10th%ile and Spelling 189 SS NPR 5%ile, Typical peers score
between the 200-273 (Punctuation) and 210-255 (Spelling) 25th%ile and 75%ile.
Baseline: _____ writes using a median of 27 Correct Writing Sequences in a three minute sample (7
%ile GWAEA 7th grade Winter Norms)
be considered”
“If the trend line when
compared to the aim line
shows the goal will not be
met an instructional
change will be
considered”
When a phase change
is made the trend line
will start over.
Optional statement to
place at end of goal:
Meeting this goal will
allow ____ to be more
successful in a variety of
post-secondary living
and/or work settings.
(only list domains
identified as areas of
need)
Goal: In order to write a resume or college application and after direct instruction in punctuation and
spelling strategies, in 36 weeks, when given a story starter, with one minute to think and three minutes
to write ______ will write using 37 correct writing sequences
8th grade student: Math
Current Academic Performance:
_____ can compute basic facts in addition, subtraction, and multiplication. ___ struggles with division,
fractions and decimals. Iowa Assessment (IA) fall 20-- computation score 159 SS 4%ile, Total Math
score 198 SS 6th%ile. Typical peers score between 219–270 SS on computation and 220-268 SS on
Total Math (25%ile and 75%ile).
Baseline: ___ scored a median of 24 correct digits on Math Computation probes (15%ile, winter grade
8 GWAEA norms)
Goal: In order to continue progressing in math classes in high school and following direct instruction
in the area of math computation, in 36 weeks, when given a 6th grade math computation probe and 4
minutes to work, ______ will score 30 correct digits.
9th grade student, functional curriculum
Current Academic Performance:
_____can identify penny, nickel, dimes, and dollar. ____ can tell time to the hour and half-hour. He
can not compute time needed to get ready for school, leave and arrive on time. _____can say the
days of the week in order and leaves out October when reciting the months of the year. _____can not
use time as a reference in relation to the calendar. He struggles with past, present and future on
calendar. _____does not take Iowa Assessments but does take Iowa Alternative Assessment. On
last year’s Alternative Assessment he scored in the proficient range on the following skill areas: add
and subtract whole numbers using objects, pictures or symbols; can identify and label shapes; can
count to 20, and identifies ‘one more’ than. Same age peers have mastered money, time, and
calendar skills.
Baseline: ____ scores a median of 11 correct responses on an untimed 4th grade math application
probe and a median of 27 correct digits on an untimed 3rd grade math computation probe
Goal: In 36 weeks when given a 3rd grade math application probe, ___ will score 20 correct
responses.
Major Milestones:
In 9 weeks 3rd grade application, 13 correct responses
In 18 weeks 3rd grade application, 15 correct responses
In 27 weeks 3rd grade application, 17 correct responses
December 2013
11th grade student, functional curriculum
Current Academic Performance:
____ requires one on one physical assistance to activate a switch and participate in class. ___
requires hand over hand physical prompting to activate a switch. Although ____ uses blinking of his
eyes to show like and dislikes, his does not use this consistently. ____ is beginning to indicate
preferences using the switch with hand over hand prompting.
Baseline: _____ requires 2 full physical prompts to activate his switch.
Goal: In 36 weeks when prompted with questions ___ will respond to the question by activating the
switch within 15 seconds and no physical prompting.
Major Milestones: In 18 weeks when prompted with questions ___ will respond to the question by
activating the switch within 15 seconds and one physical prompt.
December 2013
CE#6
Supports,
Services,
Activities,
Linkages
Identify and clearly
describe all services,
activities and supports that
are committed to or on
behalf of student
Each postsecondary area
of Living, Learning, and
Working is addressed
through goals, services or
activities OR detailed
explanation supports
there are no needs in the
missing postsecondary
areas.
Only describe
activities/services/support
to occur during current IEP
year
Must include a supports
for school personnel
service
Must include specially
designed instruction
* See page 432-436 (Red
Documentation Guide) for
definitions of services
December 2013
Specially Designed Instruction:
Modified Special Services - Off-Site
____ will receive all of his instruction in a self-contained off-site classroom. Specially Designed
Instruction is provided in the areas of reading comprehension, math computation, and behavior.
Behavior instruction will include appropriate interactions (accepting feedback and following
directions from adults)
Co-Teaching Services - Teaming (LRE minutes)
____ will receive specially designed instruction in reading comprehension during the 9th grade
English class. Class will be co-planned and co-taught by the general education and special
education teachers.
Co – Teaching Services - Parallel Teaching (LRE minutes)
____ will receive math computation instruction in a small group made up of general education and
specially education students. Group membership changes bi-weekly based on student data.
General Education Consulting Services: (LRE minutes)
Mrs. Green, (general education teacher) will consult with the special education teacher on math
computation curriculum standards and benchmarks, strategies, assessments, progress, and
grades. ____ will receive specially designed instruction in the special classroom in math
computation based on this consultation.
Supportive Special Services – pull out
____will receive specially designed instruction in a special education classroom in the areas of Math
Computation and Reading Comprehension and Fluency.
____ participates in specially designed instruction that provides a high adult student ratio and
provides functional academics, life skills training, and vocational training.
___________receives specially designed instruction in Learning Support in the areas of
Composition and Reading Comprehension. He also receives small group support for social
communication skills.
Support for School Personnel:
Special education teachers engage in joint planning for 1 hour or less per month with general
education teachers and/or para-educators to support involvement and progress in the general
education curriculum and IEP goals.
Or
Special education teachers conduct joint planning with 1 general education teacher or para-educator
over the course of each month, focusing on Mary’s IEP goals #1 and #3.
Special education teachers engage in joint planning for 1 to 2 hours per month with general
education teachers and/or para-educators to support involvement and progress in the general
education curriculum and IEP goals.
Or
Special education teachers conduct joint planning with 2 or 3 general education teachers and/or
para-educators over the course of each month, focusing on IEP goal for reading fluency.
Special education teachers engage in joint planning for more than 2 hours per month with general
education teachers and/or para-educators to support involvement and progress in the general
education curriculum and IEP goals.
Or
Special education teachers conduct joint planning with more than 3 general education teachers
and/or para-educators over the course of each month, focusing on IEP goals 1, 2, and 3.
Linkages/Inter-agency Responsibilities:
____ is receiving services through ______County that include case management services provided
by _____ County Mental Health and Developmental Disability (MHDS), as well as job coaching
provided by the MR Waiver. The direct job coaching services are provided by Employment
Systems. Supported living services are provided through ____ (ex. REM, Discovery Living, Tailored
Living).
____ has applied for Vocational Rehabilitation services and has been accepted as a client.
____ has applied for Student Disability Services at (fill in post-secondary institution) and will receive
accommodations.
______ will complete application the 4+ application process involving written application,
questionnaires, and interviews. (This is applicable for any 4+ vocational or college program a
student might be considering.)
Transition Activities & Support:
____ will participate in 2 or more job experiences in the area of janitorial services and retail services
supervised by the special education teacher.
____ will learn to be independent on the public bus system by practicing the bus routes with the help
of a job coach. (Purpose: to develop independence with getting to and from employment)
____ will do 3 job shadows through Work Place Learning Connections but will be supported by the
special education teacher and the job coach.
____ will practice his social skills by explorations in the community with the help of his special
education teacher and/or para-educator.
____ has a work evaluation currently being completed by Goodwill Industries and supported by
Vocational Rehabilitation Services
Community Experiences:
____ will have a wide variety of community education including experiences in the work setting,
recreation leisure experiences (register for recreation class in the community), and life skills
experiences. _____will need adult supervision while in the community.
____ will learn to be independent on the public bus system by practicing the bus routes. (Purpose:
to develop independence within the community)
December 2013
Addendum
If any limitation is marked in this column and the individual requires
services, and there are no corresponding serious limitations, then
the case is assigned to category 6.
Other Eligible
This individual has functional limitations with (check all that apply)
If there are indicators of serious limitations marked in three
functional areas under SD and requires multiple services over an
extended period of time, then the individual is considered MSD
and is assigned to category 2. If one or two areas are checked
and requires multiple services over an extended period of time,
then the individual is listed as a category 4.
SD
This individual has Serious Limitation Areas: (check the indicators of serious
limitations in each functional area)
Requires Services
Requires Multiple Vocational Rehabilitation Services Over an Extended Period
of Time
BECAUSE OF THE DISABILITY:
BECAUSE OF THE DISABILITY:
1. MOBILITY:
Walking
Kneeling
Twisting
Climbing
Crouching
Stooping
Balancing
Crawling
Travel
Other ______________________________________
______________________________________________
2. SELF CARE
Eating
Child Care
Medication Management
Hygiene
Housekeeping
Money Management
Laundry
Toileting
Shopping
Cooking
Dressing
Using the Telephone
Grooming
Independent Living
Self-injurious behavior
Repeat Hospitalization
Other ______________________________________
______________________________________________
3. SELF DIRECTION
Dependability
Judgment
Planning Activities
Following Routine
Frequent Changes
Initiating Activities
Making Decisions
Being Punctual
Being Organized
Other______________________________________
______________________________________________
December 2013
1. MOBILITY:
Unable to move safely, including changing body position, without help or
device. Explain: _______________________________
_____________________________________________________
Takes significantly longer to move about
Explain: __________________________________________
____________________________________________________
Cannot drive due to physical or problems in learning the skill.
Explain: ____________________________________________
_____________________________________________________
Other limitations - Explain: _____________________________
2. SELF CARE
Requires home modifications to perform self-care tasks in order
to get to work
Is restricted/limited in the ability to perform average daily living activities to
get ready for work
Explain: ____________________________________________
Requires a personal assistant, guardian, public administrator, payee or
community support worker for self-care skill deficits in order to work
Has episodes of repeated hospitalizations and problems with
stability
Other limitations – Explain: ________________________
3. SELF DIRECTION
Needs adaptive equipment to do tasks
Has a case manager/social worker due to the disability
Has difficulty performing tasks without modifications.
Has serious difficulty concentrating on tasks, organizing, and following
through on expectations.
Requires detailed directions to adequately plan activities
Demonstrates impulsivity and poor judgment not typically seen in individuals
of comparable age, education, and experience which results in legal problems or
equally negative consequences that impact employment
Has episodes when assistance/monitoring or personal assistance is needed
4. WORK SKILLS
Memory
Attention Span
Comprehension
Learning Speed
Quantitative Skills
Motor Coordination
Manual Dexterity
Eye/hand Coordination
Manipulates Objects
Spatial/Time Management
Learning
Other ______________________________________
_____________________________________________
5. WORK TOLERANCE
Stamina
Strength
Temperature Change
Cold/Heat
Hazards
Noise/Vibrations
Fumes/Dust
Work Speed
High Places
Wet/Humid Environment
Sitting
Reaching
Chemical Sensitivity
Psychological Factors
Stress
Standing
Absenteeism
Lifting (lbs., specifics)______________
Other ______________________________________
______________________________________________
6. INTERPERSONAL SKILLS
Cooperation
Getting along with others
Controlling Emotions
Tact/diplomacy
Understanding Social Cues
Accepting Supervision
Social Withdrawal
Other ______________________________________
______________________________________________
7. COMMUNICATION
Speaking
Reading
Hearing
Writing
Interviewing
Other ______________________________________
______________________________________________
Revised 5/2012
December 2013
to do tasks
Other limitations – Explain: _____________________________
4. WORK SKILLS
Does not have work skills usually possessed by individuals of comparable
age, education, and experience
Requires instructions to be paired with multiple strategies, as compared to
peers, to learn work skills
Requires assistive technology, adaptive equipment, or prosthetic to perform
work skills
Requires a personal assistant or a job coach to learn and/or perform work
skills
Has difficulty performing fine and gross motor skills required by work tasks
Requires extra time to adequately perform tasks
Explain: ____________________________________________
Other limitations – Explain: _____________________________
5. WORK TOLERANCE
Has difficulty tolerating common work environmental factors.
Explain: ____________________________________________
Has difficulty tolerating common work psychological stresses.
Explain: ____________________________________________
Has difficulty tolerating common physical demands of the job.
Explain: ____________________________________________
Requires adaptive equipment and/or work schedule to meet
job training demands
Explain: ____________________________________________
Other limitations – Explain: ____________________________
6. INTERPERSONAL SKILLS
Exhibits emotional behaviors which interfere with work/training
with co workers and managers
Requires monitoring, behavior management, accommodations or
adaptations, not typically made for other employees to develop or maintain
working relationships.
Lacks insight into self that results in a lack of tact/diplomacy which creates
difficulties in maintaining work relationships.
Other limitations – Explain: ____________________________
7. COMMUNICATION
Cannot hear/understand ordinary speech
Has difficulty reading or writing beyond simple sentences typically found in
elementary school level and in comparison to peers of equivalent age.
Requires an interpreter or other hearing accommodation to obtain
employment
Requires a reader or other accommodation to read in order to obtain
employment
Cannot readily be understood on first contact
Other limitations – Explain: ____________________________