Poon Bethany Iep

Form 6c - IEP (without Transition) Page 1 August 2008 (Rev.
10/2013)
PURPOSE: The IEP is designed to clearly communicate to the parents, the student, and providers the type and amount of special education and any necessary related services or
supports that will be made available to the student. The most recent evaluation report is used to develop the IEP. The IEP is individualized to reflect the unique needs of the student and
how these needs will be addressed to permit the student to be included and progress in the general education curriculum.

INDIVIDUALIZED EDUCATION PROGRAM

Student name: Jia Qi Jia Qi Ng Student ID No.: 7214810 Date of IEP meeting:
Birthdate: 09/18/2007 Age: 6 Grade: 1st IEP annual review date: 02/24/2015
Eligibility category: Autism Date of most recent eval: 02/27/2013
Race/Ethnicity: Asian/ Chinese Primary language: English Reevaluation due date: 02/27/2016
District: Seattle Public Schools Resident School: Broadview Thompson K-8 Serving School (if different):
Parent(s) name(s): Yee Lian Ng, Yeuk Shan Lam Primary language at home: Mandarin
Parent interpreter needed? Yes No Surrogate parent: Yes No If yes, name:
Primary staff contact name: Title:

PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Present levels of academic achievement:
(Updated August 7, 2014)

Pre-reading skills:

When given a visual of individual upper-case letters, Jia Qi can accurately give the name of every letter. Jia Qi can
order lower-case letters alphabetically when using an alphabet skills picture puzzle (monkey). Jia Qi can also sing the
ABCs independently when an adult initiates the melody. Based off of limited testing, Jia Qi can read the following
sight words: the, I, a, am, can, and. Jia Qi can begin working on learning letter sounds and blending CVC words.

Writing:

When given an individual white board and marker, Jia Qi writes her name using all upper-case letters.

Math:

After hearing others count (as in during calendar), Jia Qi has been observed to rote count up to around 24
independently. She can count manipulative accurately to 10 and can write numbers 1-14 when using an individual white
POINTS THAT MUST BE
CONSIDERED IN
DEVELOPING THE IEP (refer
to WAC 392-172A-03110):
Results of the most current
evaluation, and the academic,
developmental, and functional
needs of the student.
Positive behavioral supports and
interventions, if the students
behavior impedes the students
learning or that of others.
Language needs of students with
limited English proficiency as
they relate to the childs IEP.
Supports for blind/visually
impaired students, include
Braille instruction.
Communication needs of the
student, including the needs for
deaf and hard of hearing
students.
Assistive technology devices and
services.
Supplementary aids/services,
program modifications, and
support for school personnel.
Form 6c - IEP (without Transition) Page 2 August 2008 (Rev. 10/2013)
play/academic activities independently. She currently completes each task independently but waits for adult prompting
prior to beginning tasks. Other tasks require constant redirection from adults for completion. As a result, Jia Qi has
completed 3-step tasks independently in 0/5 activities.

(Updated 2013)

AEPS:
Jia Qis cognitive skills were measured using the AEPS (Assessment, Evaluation, and Planning System). She
consistently demonstrates understanding of various cognitive concepts such as shapes and colors. She occasionally
demonstrates accurate understanding of spatial relation concepts such as put the person in the car (when playing with
toys in the block area). She continues to need some assistance in her ability to identify most spatial relations, grouping
objects according to feature or function, and in following 3-step directions. She is not demonstrating skills related to
understanding qualitative, quantitative, temporal concepts, phonological awareness, recalling events, and problem
solving.

Scores:
Area raw score- 17
Area raw score possible- 108
Area percent score- 15%
Based on evaluation information Jia Qi continues to need specially designed instruction for her cognitive development
Classroom observations:
Jia Qi continues to show us a repertoire of what she knows (point to, show me, 1-step directions, and imitating back
words verbally). Jia Qi is progressing in following 2-step directions but often times needs the directions broken down as
it is occasionally hard to gain and keep her attention. When using a motivating reinforcer (such as the iPad), Jia Qi is
much better at attending to and following through with a direction. This is an important tool to use to teach Jia Qi new
skills and expand on cognitive skills she has already mastered. Currently, she needs consistent instruction around being
able to attend properly. Right now, she inconsistently refers to the person talking to her and/or giving her a direction.
She continues to need physical assistance to follow through with imitation but can follow imitation routines that are
simple and motor actions she is familiar with when motivated and given verbal/gestural prompts to start.

Results of the AEPs were believed to be a reliable and valid estimate of the skills measured.
Present levels of functional performance (i.e. communication, motor, social, behavior, life/adaptive skills, etc.):
Communication


When Jia Qi initiates interaction with adults, she does so by leading or motioning. For example, she takes an adults
hand and brings it down toward a seat when she wants the adult to sit next to her. Jia Qi has also been observed to
verbalize one or two word phrases to adults such as open or help when motivated to do so- typically during a high-
interest activity such as music. Similarly, she says stop and no when she feels pressured to do something that she
does not want to.


Jia Qi does attempt to engage with peers in a parallel manner when she wants to participate in a favorable activity. For
example, she approaches and sits next to a classmate to in order to listen to music from a CD player.

Jia Qi sometimes seems unaware that she is expected to respond to requests. Frequently, Jia Qi will imitate the last
word or phrase of a statement or question in a singsong manner. For example, when told that the class will be going
next to the playground, Jia Qi will repeat playground, playground. Another example is when asked if she wants to use
a blue or red market, Jia Wi will repeat blue or red, blue or red.

Jia Qi is more receptive and responsive to requests when she is prompted to look and listen to the speaker. With a
verbal reminder to look, Jia Qi sometimes finds the speaker with her eyes on her own. Other times, tracing fingers from
her eyes to the speaker or gently turning her head to face the speaker prompts Jia Qi more effectively to listen.

When responding to requests, it has been observed to be helpful for Jia Qi to have opportunities to respond non-verbally
by pointing or motioning.

(Updated 2013)

Jia Qi is a bright, happy girl who is making good progress on her communication goals.
Both English and Chinese (Cantonese and Mandarin) are spoken in Jia Qis home; Jia Qis parents report that she
understands both languages. Jia Qi speaks primarily in English, although she will sing familiar songs in both languages
and uses some Chinese words.

Standardized testing is a poor measure of Jia Qi's overall receptive and expressive language ability as she is not
motivated to engage in testing. Jia Qi will engage in some desk or table activities, but she must be motivated to do so by
the immediate reinforcement of being allowed to engage in an activity she likes. She has a wide range of activities she
is motivated to engage in and is appropriately excited about them.

Jia Qi does occasionally seek out adults and occasionally peers to interact with.

Jia Qi is attempting to use oral speech more. She is making oral approximations of single words frequently. These
words are usually intelligible when the context is known.

Based on observation, she attempts to produce oral speech and language when she is motivated to do so. She is
sometimes frustrated or resistant when her attempts are not successful.

Jia Qi has been observed to produce a phrase of up to three words to make requests during highly motivating activites,
such as snack. She has also been observed to use some spontaneous comments and requests during choice time for
highly preferred objects. Jia Qi has increased her use of eye contact prior to making a request.

Jia Qi does attempt to interact with peers in a parallel manner when she wants to engage in a novel and interesting

activity. Jia Qi is beginning to understand there are communicative expectations associated with school and she is even
beginning to learn how to meet those expectations.

She sometimes is still unaware that she is expected to respond to requests. Transitions are sometimes difficult for Jia
Qi and she requires some warning that a change in activities is expected. A visual schedule is of great benefit to Jia Qi.
She is developing an awareness of complying with school expectations. An ability to begin reading facial and verbal
cues is an appropriate goal for her.

Jia Qi has been working on the following goals:

- When given typical classroom activities, Jia Qi will use words from a variety of semantic categories (i.e.,
actions, adjectives, prepositions) to requests or comments, improving expressive vocabulary skills, from 0
independent requests/comments containing actions, adjectives, or prepositions, to at least 10 independent
requests/comments containing actions, adjectives and prepositions within one week, as measured by systematic
observation and documentation. Progress -- dependent on motivation for reinforcement, goal met for desired
reinforcers.
- When given interactions with adults and peers during low-structured activities (e.g., free choice activities,
recess), Jia Qi will use spoken words or pictures symbols to request objects and actions, improving social
communication skills, from 2/5 independent requests, to 8/10 independent requests during each of two
consecutive weeks, as measured by systematic observation and documentation. Progress -- goal met for desired
reinforcers.
- When given initiations from both adults and peers, Jia Qi will respond promptly (<4 seconds) and appropriately
(using speech, gesture, picture symbol, etc.), improving social communication skills, from ~4/10 independent
responses, to 8/10 independent responses with at least 3 different adults/peers, during each of two consecutive
weeks, as measured by systematic observation and documentation. Progress -- goal met for desired reinforcers.

Jia Qi is able to produce the majority of consonant sounds across word positions. She produced the sounds /s/ and /z/
similar to the sound sh (e.g., housh/house and pesho/pencil). These altered productions are typical of the dialects
spoken in Jia Qis home and were not considered errors. She speaks primarily in one-word utterances and intelligibility
is sometimes context-dependent.

Jia Qi continues to be eligible for communication service in the areas of receptive, expressive and pragmatic language.
Therapy will focus on comprehension, analysis, understanding and response to academic and social situations and
increasing her success in interacting with adults and peers. Visual supports (picture schedules) are likely to benefit Jia
Qi in school.

Jia Qi is a girl in kindergarten at Broadview K-8 School. Her disability in the area of communication disorders impacts
her involvement and progress in the general education environment. Jia Qi receives specially designed instruction in the
area of communication to address this impact.

Adaptive/Self Help/ Life Skills



Jia Qi independently completes toileting and hand washing routines with the occasional exception of needing a gestural
prompt to rub soap between her hands before washing it away. She also puts on her shoes, socks, and jacket without
adult assistance.

On occasion, Jia Qi removes her clothing in public. She once pulled her dress down to her ankles on the playground and
has moved her pants down to her knees in the classroom and cafeteria a few times.

When food is prepared into small pieces and Jia Qi is prompted to kiss, kiss, taste, taste (in accordance with her food
program), Jia Qi sometimes tastes bits of food with her tongue before placing the food back on the table. Based on
observation, she mostly chooses to taste soft, bready food when given the choice of three foods from bread, crackers,
cheese, fruit, and vegetables. Jia Qi opens lunch and utensil packets on her own and consistently uses a straw to poke
through and drink juice cups. She also peels open marinara sauce cups and spoons sauce into her mouth independently.
Foods that Jia Qi has been observed eating so far include: orange juice, apple juice, marinara sauce, gummy bears, and
fruit snacks. After a meal, Jia Qi is always cleans up her area- even using napkins to wipe spills on the floor. She
frequently helps other students clean their areas, as well.

(Updated Feb 2, 2014)

Jia Qi independently completes toileting routines and consistently asks to use the restroom when needed, but needs
verbal/gestural assistance with washing hands and during rare unexpected incidences. Jia Qi is doing well with her food
program and currently takes 7-13 samples (puts food into mouth and closes mouth for a few seconds) of new food per
day when given immediate reinforcements of mini oreos or strawberry pocky sticks. She will continue to work on
taking bites of new foods. She is able to put on her shoes independently and put on and zip up her jacket independently.

(Updated 2013)

AEPS: Jia Qis adaptive skills were measured using the AEPS (Assessment, Evaluation, and Planning System).
Though not consistently and usually when given some assistance, Jia Qi is putting proper amounts of food in her
mouth, trying to use utensils to eat when necessary, and taking in proper amounts of liquid and returning the cup to the
surface of the table. She needs full physical assistance, every time, when preparing and serving food. Jia Qi consistently
voids in the toilet and needs reminders to use toilet paper, flush, and proceed to wash her hands. She continues to need
support in fastening garments of clothing including zipping, buttoning/unbuttoning, and untying and tying string
fasteners. She consistently zips her jacket up when it is threaded together at the start by a teacher.
cores:Area raw score- 27Area raw score possible- 70Area percent score- 37%

Based on evaluation information, Jia Qi continues to need specially designed instruction for her adaptive (self-care)
skills.

Jia Qi continues to explore new foods by smelling and touching them (and occasionally tasting/eating them when she
decides to). Her classroom team continues to want to expand on the foods she eats here at school. When positioned on
the floor so she can put her arms in and flip it up and over her body, she is able to put on her coat with minimal help.
Results of the AEPS were believed to be valid and reliable estimates of the skills measured

Motor


Jia Qi is very active. She runs, gallops, and skips. She climbs stairs on the playground by walking up alternate steps and
smoothly transitions from to many play structure platforms. She also jumps down from the edge of the playground
(about 24 inches) and lands on both feet. When Jia Qi walks and runs, she consistently uses the ball of her feet- never
touching the ground with her heels.

Jia Qis uses her fingers to pull open lunch and utensil packages. From her utensil packages, she consistently retrieves
the straw and spork by grasping with her fingers and similarly unfolds the napkin. When writing with a white board
marker, Jia Qi uses a tripod grip to write her name in upper case letters and numbers 1-14. Jia Qi also works with Ms.
Judy, the OT, to trace her name on an iPad. Both the whiteboard and the iPad are motivating and high-interest tools to
engage Jia Qi in writing.

Sensory: Jia Qi is soothed by large, repetitive motions such as swinging her arms with a partner when singing London
Bridges or rocking when in a hug with an adult. She consistently uses her sense of smell to explore new people and
things. She frequently wanders the cafeteria during lunchtime to smell adults, students, and juice pouches. She enjoys
foods that are soft and chewy (liquids, sauce, gummies).

(Updated 2013)

Most recent evaluation results from 2/27/2013: Jia Qi was challenged by fine and gross motor tasks (i.e. jumping, ball
skills, multi-step activities, copying letters, scissor skills). The z- scores of the Miller Function & Participation Scales
were -3.0 SD from the mean. In addition, she demonstrated difficulties with sensory processing as measured by the
Sensory Processing Measure and observations within the classroom.

February 2014 update: Jia Qi is active on the playground. She plays on a variety of structures and is able to climb
ladders and smoothly transition to play structure platforms. She swings on monkey bars, jumps down from eighteen
inches landing on her feet, runs, gallops, and skips. Jia Qi is able to balance on one foot and put on her socks
demonstrating excellent ability to balance. During classroom gross motor activities, she is beginning to imitate
movements demonstrated by her peers and teachers. When shown yoga poses, she will form them briefly once she
receives assist to initiate them. She is able to throw a ball to a target from over five feet away and is beginning to gaze
at partners who are engaging in ball activities. At times, she will present her arms to catch a ball by trapping it against
her body. She will kick balls held in a stationary position with adequate force in a forward direction, but has more

difficulty kicking a ball rolled to her.

Jia Qi made many gains in gross motor skills over the last year. She continues to work on imitation of body motions
and to work on ball skills for greater participation in classroom motor games with classroom peers.

Physical therapy is recommended to support skills needed for greater participation in motor games with peers.
Jia Qi is willing to trace and copy letters in her handwriting book and in daily work book including her name, letters of
the alphabet and numbers. Tracing accuracy is variable as is the quality of her copying. She is able to independently
print her name with capital letters, but now that lowercase letters have been introduced for all but the first letters in her
first name Jia Qi she still tends to use upper case when printing from memory, and lowercase letters are more difficult
for her to trace with correct letter formation. Some work has been done using the iPad to trace and she often requires
some minimal physical assistance to be successful in tracing letters to meet requirements of the app, but she is
motivated and will stick with this for a few letters with much better accuracy. This is a helpful learning tool prior to
printing on paper.

Jia Qi will participate in art projects but continues to need adult support for the sequencing of a multi-step project and
to stay involved in the project to completion. She will independently fill in a space when painting, and imitates parts of
the project when presented step by step. She requires assistance to place fingers correctly into child scissors, but will
cut across paper without assistance, holding the paper with her other hand. If assisted to start, she will cut about 3
inches on a line, but then she needs assistance to continue on the line.

Sensory: She enjoys play on moveable equipment such as swings, and will swing with a peer, but needs adult assistance
to initiate this and to take turns on equipment. She seeks out sensory tools such as the body sock, which she likes to sit
in during circle and desk activities. She prefers to have shoes off, but is able to put shoes and socks on independently
when transitioning outside of the classroom. She continues to be picky about foods, enjoying crunchy food, but is
increasing the variety of food she will taste during snack time. She enjoys having access to a water bottle at her desk
during the day.

Occupational Therapy services continue to be needed to support Jia Qi in development of functional fine motor skills to
allow greater participation and independence in the classroom, play skills with peers, and sensory consultation.

Social/Behavior


Jia Qi stays in proximity of the group (in the classroom and on the playground) when engaged in an activity. She
sometimes runs away from the group when disinterested in an activity and during unstructured time and transitions.
When running from the classroom, she often runs to the nurses office. Other times, she runs around the hallway
towards the cafeteria. At the playground, she runs across the parking lot toward the street. For safety, an adult pursues
Jia Qi and leads her back to the group. Most times, Jia Qi returns willingly with a verbal direction or by being led
gently by the shoulders. Once in a while, Jia Qi resists returning by saying no, no, no, running further, and pushing

the adult who is obstructing her path.

Jia Qi sometimes engages in parallel play by using the same material as peers. She helps herself to materials that are of
high interest and needs adult support in turn taking and sharing with peers.

Jia Qi follows short 2-3 word directions when prompted to attend before direction are given, when directions are
delivered firmly, and when given significant wait time following the directions.

During a learning activity, Jia Qi needs constant redirection from an adult in order to complete the task.

(Updated Feb 2, 2014)

Jia Qi stays within proximity of the group in structured settings in 9/10 opportunities within one week. She continues to
work on proximal play in unstructured settings. She is currently willing to work with the same materials during
structured activities but needs constant redirection. Jia Qi continues to need support in turn taking and does so
successfully within structured playtime, but continues to struggle with turn taking when items are of high preference for
her. Jia Qi continues to need support in attending to small group and large group activities.

(Updated 2013)

AEPS:
Jia Qis social skills were measured using the AEPS (Assessment, Evaluation, and Planning System). Jia Qi
consistently defends her possessions when it is a highly preferred item (iPad or musical cause and effect toy). She
consistently remains with both large and small groups within the classroom but needs reminders to stay with the group
when out at recess. She consistently selects preferred activities/items and initiates them. She inconsistently takes turns,
initiates greetings, and maintains cooperative activities with others and needs assistance to follow through in these
areas. She continues to need support in attending to both large and small group activities in meeting. She is not
demonstrating identifying information about self and others.

Scores:
Area raw score- 34
Area raw score possible- 94
Area percent score- 36%
Based on evaluation information Jia-Qi continues to need specially designed instruction for her social/emotional
development.

Jia Qi loves singing and playing with her teachers. Jia Qi, with help from a staff member, will stay with peers during
large motor games that often include running. She needs encouragement to follow and keep up but will stay with the
group when an adult helps her stay engaged in the play. She would benefit from continuous support to attend to adults
and peers to look at them first (attend) and then listen/follow the direction. Being able to consistently follow these steps

(1. Attend and 2. Listen) will help her in all of her social interactions with adults and peers.

Results of the AEPS were believed to be valid and reliable estimates of the skills measured.

Effect of the disability on the students involvement and progress in the general education curriculum (or for preschool children, as
appropriate, how the disability affects the childs participation in appropriate activities):
Jia Qis disability affects her participation in general education curriculum and activities. Difficulties and concerns lie in Jia Qis engagement in
activities and tasks, attention and responsiveness to others, maintaining proximity to the group, and demonstrating understanding.

Jia Qi will engage in some desk or table activities, but she must be motivated to do so by the immediate reinforcement of a reward such as a gummy
bear, scented ticket, or an activity that she likes. When she is not engaged, Jia Qi is unresponsive to prompts and redirections. Instead, she looks away,
gets an activity that is of higher interest, or leaves the classroom.

Attention and responsiveness to others
Jia Qi consistently looks away from the speaker and is unresponsive when addressed by others. At times, she seems unaware that she is expected to
respond to requests. When talking with Jia Qi, it is often difficult to determine when she has or has not heard and understood. With prompts to look and
listen, Jia Qi more frequently indicates understanding of questions and directions by giving verbal and non-verbal responses.

Maintaining proximity with group
Jia Qi stays in proximity of the group (in the classroom and on the playground) when engaged in a preferred activity. She sometimes runs away from
the group when disinterested in an activity and during unstructured time and transitions. When running from the classroom, she often runs to the
nurses office or around the hallway towards the cafeteria. At the playground, she runs across the parking lot toward the street. An adult always pursues
Jia Qi and leads her back to the group with a verbal direction or by being led gently by the shoulders. Once in a while, Jia Qi resists returning by saying
no, no, no, running further, and pushing the adult who is obstructing her path.

Demonstrating understanding and knowledge
Many more standardized assessments, such as alphabet inventories, are a poor measure of Jia Qis skills. It is difficult to get a sense of what Jia Qi truly
knows because of the challenges discussed previously such as engagement in assessments and responsiveness to teachers/assessors.

CONSIDERATION OF SPECIAL FACTORS:
If yes, describe (if not addressed on the service matrix):
1. Does this student require special
transportation?
Yes No
Door to door transportation with assigned seating.
2. Does this student require Extended School
Year (ESY) services?
Yes No
Will be determined by
the IEP team by:
If ESY is determined by the IEP team to be necessary, complete and
attach the ESY addendum.
Date:
3. Does the students behavior negatively impact
his/her learning or the learning of others?
Yes No
If yes, consider the students need for positive behavioral supports/
interventions, a Functional Behavioral Assessment, and/or a
Behavioral Intervention Plan.
4. Does this student require the use of aversive
interventions?
Yes No If yes, complete and attach the Aversive Intervention Plan addendum.
If yes, describe:
5. Are there any other factors not already
addressed (such as medical concerns or other
issues), or other adaptations needed?
Yes No


PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the students educational needs that result
from the students disability to enable the student to be involved and make progress in the general education curriculum. In order to be measurable, the goal should include a baseline,
a target, and a unit of measure. For students who will be assessed through the WAAS Portfolio this year, the IEP team should use the Measurable Annual Goal(s) with Short-term
Objectives/Benchmarks page (see next page).

MEASURABLE ANNUAL GOAL(S)
Progress Notes (if not maintained separately)
POINTS TO
CONSIDER:
Date Date Date Date
Goal
#
Measurable Annual Goal
Method/Criteria for
Evaluating Progress
(if not addressed in a
separate document)

1
By 02/24/2015, when given interactions
with adults and peers during low-
structured activities (e.g., free choice
activities, recess), Jia Qi will use spoken
words to request objects and actions
improving social communication from
0/5 opportunities to 4/5 opportunities as
measured by teacher observation.
Teacher observation,
weekly data collection
10/10/2014 12/19/2014 2/3/2015
2
By 02/24/2015, when given
opportunities to respond orally to a
request, Jia Qi will respond promptly (<4
seconds) using a spoken utterance of at
least two words improving social
communication from 0/5 opportunities to
4/5 opportunities as measured by teacher
observation.
10/10/2014 12/19/2014 2/3/2015
Measurable
annual goals stem
from the
recommendations
for specially
designed
instruction in the
evaluation report.
Measurable
annual goals must
relate to the
general education
curriculum or, for
preschool
students,
participation in
appropriate
activities.
Measurable
annual goals must
also address other
educational needs
that result from
the students
disability.
The IEP must
include a
description of
how the district
will measure the
students progress
and when
progress will be
reported to
parents
(concurrent with
the issuance of
report cards).
Copy additional pages as necessary

PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the students educational needs that result
from the students disability to enable the student to be involved and make progress in the general education curriculum. For students who take alternate assessments aligned to
alternate achievement standards (WAAS Portfolio), benchmarks or short-term objectives in the areas being assessed must also be included. In order to be measurable, the goal should
include a baseline, a target, and a unit of measure.

MEASURABLE ANNUAL GOAL(S) WITH SHORT-TERM OBJECTIVES/BENCHMARKS

Progress Notes (if not maintained separately)
POINTS TO
CONSIDER:
Date Date Date Date
Goal
#
Measurable Annual Goal
Method/Criteria for
Evaluating Progress
(if not addressed in a
separate document)

3
By 02/24/2015, when given
opportunities to interact with peers in
a small group setting, Jia Qi will
respond appropriately to peer prompts
(e.g. replying with "Hi" when peers
say "Hi Jia Qi," or replying with
"Good (or) bad" when peers ask,
"How are you?"), improving social
interactions with peers from 0/5
successful opportunities across one
week to 4/5 successful opportunities
across one week as measured by
teacher observation.
10/10/2014 12/19/2014 2/3/2015
Benchmarks or Short-Term Objectives
Goal #1 Benchmark #1: By 10/10/2014, when given interactions with adults and peers during low- structured activities (e.g.,
free choice activities, recess), Jia Qi will use spoken words or pictures symbols to request objects and actions improving social
communication from 0/5 opportunities to 2/5 opportunities as measured by observation.

Goal #1 Benchmark #2: By 12/19/2014, when given interactions with adults and peers during low- structured activities (e.g.,
free choice activities, recess), Jia Qi will use spoken words or pictures symbols to request objects and actions improving social

Goal #1 Benchmark #3: By 2/3/2015, when given interactions with adults and peers during low- structured activities (e.g., free
choice activities, recess), Jia Qi will use spoken words to request objects and actions improving social communication from 0/5
opportunities to 3/5 opportunities as measured by observation.
Measurable annual
goals stem from the
recommendations
for specially
designed instruction
in the evaluation
report.
Measurable annual
goals must relate to
the general
education
curriculum or, for
preschool students,
participation in
appropriate
activities.
Measurable annual
goals must also
address other
educational needs
that result from the
students disability.
The IEP must
include a description
of how the district
will measure the
students progress
and when progress
will be reported to
parents (concurrent
with the issuance of
report cards).
Goal #2 Benchmark #1: By 10/10/2014, when given opportunities to respond orally to a request, Jia Qi will respond promptly
(<4 seconds) using a spoken utterance of at least one word by the second time a request is made improving social

Goal #2 Benchmark #2: By 12/19/2014, when given opportunities to respond orally to a request, Jia Qi will respond promptly
(<4 seconds) using a spoken utterance of at least one word improving social communication from 0/5 opportunities to 3/5
opportunities as measured by observation.

Goal #2 Benchmark #3: By 2/3/2015, when given opportunities to respond orally to a request, Jia Qi will respond promptly (<4
seconds) using a spoken utterance of at least two word improving social communication from 0/5 opportunities to 3/5
opportunities as measured by observation.
Goal #3 Benchmark #1: By 10/10/2014, when given opportunities to interact with peers in a small group setting, Jia Qi will say
Hi when peers say Hi Jia Qi improving social interactions with peers from 0/5 successful opportunities across one week to
2/5 successful opportunities across one week as measured by observation.

Goal #3 Benchmark #2: By 12/19/2014, when given opportunities to interact with peers in a small group setting, Jia Qi will
respond appropriately to peer prompts (e.g. replying with "Hi" when peers say "Hi Jia Qi," or replying with "Good (or) bad"
when peers ask, "How are you?"), improving social interactions with peers from 0/5 successful opportunities across one week to

Goal #3 Benchmark #3: By 02/3/2015, when given opportunities to interact with peers in a small group setting, Jia Qi will
respond appropriately to peer prompts (e.g. replying with "Hi" when peers say "Hi Jia Qi," or replying with "Good (or) bad"
when peers ask, "How are you?"), improving social interactions with peers from 0/5 successful opportunities across one week to

Copy additional pages as necessary


PURPOSE: The purpose of the report of student progress is to inform the parents and the student of the students progress toward meeting the measurable annual goal(s) and to
specify how and when parents will be informed.

REPORT OF STUDENT PROGRESS:
POINTS TO CONSIDER:
Parents should be provided periodic reports on the students progress (such as through the
use of quarterly or other periodic reports, concurrent with the issuance of report cards).
State how the students progress toward meeting the annual goal(s) will be measured (if not already addressed on measurable annual goal page(s)):

State how the parents will be periodically informed of the students progress toward meeting the annual goal(s):

PARTICIPATION IN STATE AND DISTRICTWIDE ASSESSMENTS OF STUDENT ACHIEVEMENT
State Assessment The student will participate in the following state assessment(s) during this IEP year:
Reading Math Writing Science
Regular State Assessment
Regular State Assessment with Accommodations
Alternate Assessment (WAAS Portfolio - requires benchmarks/objs.)
Other:
Districtwide Assessment The student will participate in the following districtwide assessment(s) this school year:

Accommodations List any individual accommodations in the administration of the state or districtwide
assessments that are necessary for the student to participate:

If the student: (a) will not participate in the regular state assessment (with or without accommodations) or (b) is unable
to participate in a regular districtwide assessment, explain why the student cannot participate in the regular assessment
and why the selected assessment option is appropriate:

POINTS TO CONSIDER:
The IEP team makes the
determination of what type of
assessment the student will take
and what administrative
modifications and individual
accommodations are necessary.
Accommodations provided on
state and districtwide
assessments should be those
that are provided as part of the
regular instructional program.
Parents and students should be
informed that any assessment
other than the regular state
assessment (with or without
accommodations) leads to a
Certificate of Individual
Achievement (CIA), rather than
a Certificate of Academic
Achievement (CAA).
For further information
regarding the state assessment
system, allowable
accommodations, and
graduation requirements, please
refer to OSPIs website
(www.k12.wa.us/assessment).


PURPOSE: The purpose of this page is to document the modifications and/or accommodations that the student requires, based on the students assessed needs, in order to advance
appropriately toward attaining the identified annual goals, to be involved and make progress in the general education curriculum, and to be educated with non-disabled peers to the
maximum extent appropriate.

ACCOMMODATIONS, MODIFICATIONS, AND ASSISTIVE TECHNOLOGY
Subject
(codes below)
Accommodations/Modifications Needed
Subject
(codes below)
Accommodations/Modifications Needed
Presentation Setting
Use large print/Braille/recorded books a Provide individualized/small group instruction
Alter format of materials (highlight, type, spacing, color-code etc.) Read class materials orally
Low-vision devices (magnifiers, Closed Circuit TV, etc.) Provide study outlines/guides/graphic organizers
Sign Language ASL or SEE a Modify/repeat/model directions
a Shortened assignments Take test in separate location
Preview test procedures Preferential seating
Limited multiple choice Other:
Rephrase test questions and/or directions Response
Provide test/quiz study guide Utilize oral responses to assignments/tests
Provide extra credit options Text-to-Speech (Kurzweil, WYNN, Text Help, etc.)
Simplify test wording Allow dictation to a scribe
Read class materials orally Allow use of a calculator
Assign peer tutor/note taker Allow use of tape recorder
a Other: Use visuals to accompany oral presentations Spelling and grammar devices
Timing/Scheduling Speech-to-text software
Prior notice of tests/quizzes Hands-on assignments
Extra time to complete assignments a Other: Allow to point to pictures or other cues.
Modify students schedule (describe below): Other
Provide desktop list of tasks
Provide homework lists
a Behavior plan/contract
Extra time on tests/quizzes a Provide daily assignment list
a Allow breaks (during work, between tasks, during testing, etc.) Modified grading

Other: Create visual schedule to keep on desk and give
warning before transitions.

Other: Behavior plan includes rewarding Jia Qi for
engaging in expected behavior with scented tickets.
Expectations are made clear by reviewing rules
frequently using short phrases and pictures.
Assistive Technology
Describe:
Describe:
Describe:
POINTS TO
CONSIDER:
The IEP team
makes the
determination of
what
modifications and
individual
accommodations
are necessary for
the student.
Copies of this
page should be
provided to the
general education
teacher(s) or other
staff who will be
responsible for
making these
accommodations.
Accommodations
provided on state
and districtwide
assessments (as
noted on the
previous page)
should be those
that are provided
as part of the
regular
instructional
program.
a. All subjects
b. Reading
e. Math
f. Science
i. Health
j. Economics
m. Vocational
n. Lunch/Recess
p. Extracurricular Activities
q. Other:
c. English
d. Spelling
g. Social Studies
h. History
k. Physical Education
l. Music/Art
o. Library

r. Other:


PURPOSE: The information on this page is a summary of the students program/services, including when services will begin, where they will be provided, who will be responsible for
providing them, and when they will end.

SUMMARY OF SERVICES MATRIX

Service
Initiation
Date
Frequency
(i.e. minutes per week)
Location of
Service
(setting)
Duration
Staff Responsible for
Delivering Service
Special Education (specially designed instruction):
Pre-Academics/
Functional Academics
9/8/2014
45 Minutes/ 5
Times Weekly
Special Education
Until
2/24/2015
Special Education
Teacher
Adaptive/ Life Skills 9/8/2014
30 Minutes/ 5
Times Weekly
Special Education
Until
2/24/2015
Special Education
Teacher
Pre-Academic/
9/8/2014
60 Minutes/ 5
Times Weekly
Special Education
Until
2/24/2015
Instructional Assistant
Social/Behavior 9/8/2014
60 Minutes/ 5
Times Weekly
Special Education
Until
2/24/2015
Special Education
Teacher
Pre-Academics/
9/8/2014
60 Minutes/ 5
Times Weekly
Special Education
Until
2/24/2015
Social/ Behavior 9/8/2014
45 Minutes/ 5
Times Weekly
General Education
Until
2/24/2015
Adaptive/ Life Skills 9/8/2014
30 Minutes/ 5
Times Weekly
Special Education
Until
2/24/2015
Related Services (i.e. speech, motor, counseling, vision/hearing, transportation, interpreting services, orientation/mobility, parent training, etc.):
Physical Therapy 9/8/2014
30 Minutes/ 3
Times Monthly
Special Education
Until
2/24/2015
PT
Occupational Therapy 9/8/2014
30 Minutes/ 3
Times Monthly
Special Education
Until
2/24/2015
OT
Speech Language
Pathology
9/8/2014
30 Minutes/ 6
Times Monthly
Special Education
Until
2/24/2015
SLP

Supplementary Aids and Services (allows student to be educated with non-disabled peers to the maximum extent in general education or other
educational setting):
Opportunity for alternate
response methods (e.g.,
visuals or objects to point to
during small and large
group activities.
9/8/2014
Until
2/24/2015

POINTS TO
CONSIDER:
If the position
responsible for
delivering the
specially designed
instruction is
anyone other than
a certificated
special education
teacher or related
service provider,
then the
certificated
special education
teacher/related
service provider
must design and
supervise the
instruction, and
monitor and
evaluate the
students
progress.
For definitions of
special education,
related services,
and
supplementary
aids and services,
refer to WAC
392-172A-01020
through -01200.

Visual aids (picture
symbols, task sequence
strips, etc.)
9/8/2014
Until
2/24/2015

Positive behavior supports
(token charts, tangible
reinforcers such as iPad,
stickers, and preferred
edibles)
9/8/2014
Until
2/24/2015

Sensory supports
(movement breaks, sit at
edge of chair, etc.)
9/8/2014
Until
2/24/2015

Program Modifications or Supports for School Personnel (i.e. staff development/training, technical assistance, etc.):


PURPOSE: The purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum, participate in extracurricular and
nonacademic activities and be educated and participate with other special education students and non-disabled students.

LEAST RESTRICTIVE ENVIRONMENT:
Students ages 3 to 5 Choose one:
A Regular Early Childhood (REC) program
means a program outside the childs home
that includes at least 50% children without
disabilities.

If the child attends a REC program, check the
appropriate box from the first four choices. If
the child does not attend a REC program,
check the appropriate box from the five
remaining options.

In a REC program:

REC Program ! 10 hours per week &:
Special education services with non-
disabled peers
Special education services elsewhere

REC Program <10 hours per week &:
Special education services with non-
disabled peers
Special education services elsewhere

Not in a REC program:

Separate class
In separate day school (public
or private)
Residential facility (public or
private)
Home
Service provider location
Students ages 6 and above Choose one:
A.
= Total minutes per week of building
instructional time available for this student
(excluding lunch)
B.
= Total of those minutes in A. above in which
this student is in a special education setting
(excluding lunch)

= Percent of time spent in a general education
setting (A minus B divided by A)
In general ed. setting 80 to 100% of the time
In separate day school (public or private)
Residential facility (public or private)
Correctional facility
Homebound/hospital
Home-school/parentally-placed private school
POINTS TO CONSIDER:
Children should be
educated with non-
disabled peers to the
maximum extent
appropriate.
The IEP Team, including
the parent(s), is
responsible for
determining the
educational placement of
the child.
Job placements and
community-based
instruction are considered
to be general education
settings, unless only
disabled individuals are
present (such as in a
sheltered workshop).
For additional information
on LRE for students ages 3
to 5 and ages 6 and above,
refer to the LRE
Calculator.

An explanation of the extent, if any, to which
the student will not participate with
nondisabled students in the general education
class, and in nonacademic and extracurricular
activities, including a description of any
adaptations needed for participation in
physical education:


PARTICIPANTS IN IEP MEETING (Signatures are used to document participation in the meeting and do not constitute
agreement or disagreement):

Parent/Guardian Name/Title

Parent/Guardian Name/Title

Student Name/Title

Special Education Teacher Name/Title

General Education Teacher

Name/Title

District Representative

Name/Title

POINTS TO CONSIDER:
IEP team membership is described
in WAC 392-172A-03095.
School district must give prior
written notice when proposing or
refusing to initiate or change the
identification, evaluation,
educational placement, or
provision of FAPE.
A required team member may be
excused from attending an IEP
meeting with the agreement/
consent of the parent(s) and the
district, depending upon whether
that members area is being
discussed or modified at the
meeting. See WAC 392-172A-
03095 (5) for additional related
requirements.
The IEP must include the districts
procedures for notifying parents
regarding the use of restraint or
isolation. Districts must also
provide parents with a copy of the
districts policy on the use of
isolation and restraint.

Other individuals who should be informed of his/her responsibilities in implementing the IEP (bus driver, librarian, etc.):

The district has procedures for notifying parents regarding the use of restraint or isolation. A copy of those procedures is attached to this IEP.

*Note: Before providing initial special education services to a student, the district must obtain informed written parental consent.
(See model form 3)

Poon Bethany Iep

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Form 6c - IEP (without Transition) Page 1 August 2008 (Rev.

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