Individualized Instructional Plan
I. Student Information
_____________________________________
Student’s Name
________________________
Projected Completion Date
___________________
Date of Birth
___________________________
School of Origin
________________________________
Parent/Guardian’s Name
_______
Age
________
Gender
________
Race
________
Grade
_______________________
Date of Placement
___________________________________________________________ IEP
Reason for Placement
yes no
_______________________________________________
Address
_______________________
Home Phone
__________________
Cell Phone
II. Pre-Entry Transition Meeting Date: _________ Committee Members: ________________ ________________ _______________ ______________
PRESENT LEVEL OF PERFORMANCE (Please include strengths and weaknesses)
To be completed by Transition Team
English/Language Arts
Math
Science
Social Studies
Measureable Academic Goal (English)
Disability
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Measureable Short Term Objective:
Method of Assessment
Reporting
Intervals
□ 4 Weeks
1st
2nd
Report of Progress
3rd
4th
PEM
□ 6 Weeks
□ 9 Weeks
Measureable Short Term Objective:
□ 4 Weeks
□ 6 Weeks
□ 9 Weeks
Measureable Academic Goal (Math)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Measureable Short Term Objective:
Method of Assessment
Reporting
Intervals
□ 4 Weeks
□ 6 Weeks
□ 9 Weeks
Measureable Short Term Objective:
□ 4 Weeks
□ 6 Weeks
□ 9 Weeks
1st
2nd
Report of Progress
3rd
4th
PEM
Measureable Academic Goal (Science)
_________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Measureable Short Term Objective:
Method of Assessment
Reporting
Intervals
□ 4 Weeks
1st
Report of Progress
2nd 3rd
4th
PEM
□ 6 Weeks
□ 9 Weeks
Measureable Short Term Objective:
□ 4 Weeks
□ 6 Weeks
□ 9 Weeks
Measureable Academic Goal (Social Studies))
_________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Measureable Short Term Objective:
Method of Assessment
Reporting
Intervals
□ 4 Weeks
1st
Report of Progress
2nd 3rd
4th
□ 6 Weeks
□ 9 Weeks
□ 4 Weeks
Measureable Short Term Objective:
□ 6 Weeks
□ 9 Weeks
Areas
Reporting Intervals
Measureable Goal/s:
Report of Progress
PEM
Behavioral Interventions
1.
(Include target behavior/s)
□ 4 Weeks
□ 6 Weeks
□ 9 Weeks
Method of Assessment
2.
Reviewer:
Measureable Objective/s:
1.
Reviewer:
2.
Reviewer
3.
Reviewer:
Career Education
(Career Aspirations or type of
academic or vocational program
the student will pursue post
secondary)
Measureable Career Education Plan of Action:
Report of Progress
Reviewer:
□ 4 Weeks
□ 6 Weeks
Reviewer:
□ 9 Weeks
Reviewer:
Reviewer:
III. Transition Exit Plan
Date: _______________
Academic Needs __________________________________________________________________________________________________________________
Social/Counseling Needs___________________________________________________________________________________________________________
IIP Committee Signatures
AE Administration:
Principal:
Counselor:
Teacher:
Student:
Parent:
Teacher:
Other:
Other:
Post Exit Meeting (one month post exit)
Subject
Academic Outcome
Social/Behavioral Outcome
IIP Committee Signatures
AE Administration:
Principal:
Counselor:
Teacher:
Student:
Parent:
Teacher:
Other:
Other:
Teacher