Individualized Education Program (IEP) for

Student
1. Student Information
Student
Student A
DOB

2/3/05

IEP Meeting

1/22/16

IEP Due

1/27/16

Eligibility Date

1/20/12

Next Re-Evaluation
Completed By

12/20/18

Attending School

School A

Home Language

English

Student Language

English

Classification

SLD

Grade

6th

2. Present Levels of Academic Achievement and functional

Performance
Reading
Students A is always prepared with their reading
book, and can read 80 words per minutes with a 89%
accuracy on a 4th grade ORF, same age peers can
read 120 words per minute at the 6th grade level with a 97%
accuracy this will negatively impact their learning in the general
education environment.
Writing
Student A has lots of great ideas for their writing,
student A can write 37 TWW and 25 CWS on a three
minute timing, regular education peers can write 55
TWW and 46 CWS on a three minute timing, this will
effect their learning in the regular education
environment.
Math
Student A is always is on task during math and can
complete 32 correct digits on a 4th grade level,
regular education peers can complete 65 correct digits
on the 6th grade level with a 97% accuracy, this will affect their
learning in the regular education environment.
Social/Behavior Student A is always willing to participate in class
discussions but is on task 60% of the time compared
to regularly education peers who are on task 85% of
the time during a 20 minute observation, this will
effect their learning in the general education
environment.

3. The IEP Team considered the following Special Factors

[ ]Student needs
[ x]Student does
[ ]Student needs
Behavior

Language

Braille

Communication

Assistive
Technology

behavioral
strategies because
his behavior
impedes his
learning and/or the
learning of others.
[ ]Student has
special language
needs addressed in
his IEP because he
is an limited
English proficient
student
[ ]Student needs
Braille instruction
because he is blind
or visually
impaired.
[ ]Student has
special
communication
service needs such
as a student who is
deaf or hard of
hearing.
[ ]Student needs
assistive
technology devices
and/or services
without which
she/he would not
benefit from
special education.

not need
behavioral
strategies.

behavioral
strategies are
addressed in his
IEP.

[ x]Student does
not have special
language needs

[ ]Students special
language needs are
addressed in his
IEP.

[ x ]Student does
not need Braille
Instruction.

[ ]Student needs
for Braille
instruction are
addressed in his
IEP.
[ ]Student needs
for special
communication
services are
addressed in his
IEP.

[ x ]Student does
not need any
special
communication
services.
[ x ]Student does
not need assistive
technology devices
and/or services to
benefit from
special education.

4. Measurable Annual goals

1. Student progress towards his annual goals
will be measured using

[ ]Student needs
for assistive
technology devices
and/or services are
addressed in his
IEP.

Progress monitoring,
imputing grades,
work samples
Progress reports, IEP
meetings
yes

2. Student progress will be reported to his

parents using
3. Student progress will be reported as often as
progress is reported for children without
disabilities.
4.1 Reading
Annual Goal 1
Student A will be able to read 92 words per minute
with a 95% accuracy on a 4th grade level by 32 school
weeks.
Annual Goal 2

4.2 Writing
Annual Goal 1
Annual Goal 2
4.3 Math
Annual Goal 1
Annual Goal 2
4.4 Behavior
Annual Goal 1

Student A will be able to write 46 total words written

on a three minute timing with a 95% accuracy on a 4th
grade level by 32 school weeks.
Student A will be able to write 34 correct word
sequences on a three minute timing with a 95%
accuracy on a 4th grade level by 32 school weeks.
Student A will be able to complete 68.8 correct digits
at the 4th grade level with a 95% accuracy by 32
school weeks.
Student A will be on task 85% of the time during a 20
minute observation time.

5. Service plus Adaptation

Special education service student needs to achieve his annual goals
and advance in the general curriculum:
Service
Location
Minutes/Frequency
Reading
SPED Class
120minutes per week
Writing
SPED Class
120minutes per week
Math
SPED Class
120minutes per week
Related Services student requires to benefit from hi Special Education:
Service
Location
Minutes/Frequency
Program Modifications, supports for schools personnel and/or
supplementary aids in his regular education programs:
Modifications
Frequency
Extended response time
As needed
Test read allowed
As needed
Use of calculator
As needed
Check if transportation will be provided as a related service.
Are the post-secondary transition services, experiences, and/or
specialized instruction listed above likely to be provided or paid by
other agencies?
x Not Applicable
No, Considered and not needed
Yes
Projected initiation of services:
Anticipated duriation:

6. Participation in State & District Assessment

See addendum
7. Regular Curriculum, Extra- Curricular & Non Academic Activities
Except for special education class times noted in the services section
of this IEP the student will participate in the regular class, regular PE,
extra-curricular and non-academic activities to the same extent as
children without disabilities, or with other exceptions (explain and
specify below).

8. Transition Plan
Not Applicable
9. Special Requirements for Graduation
Not Applicable
10. Notices & Participants
Extended School Year (ESY) services: Extended School Year (ESY)
services are provided to a child with a disability when the IEP team
determines that without ESY services, the educational program would
be of little or no benefit to the child, due to the lack of services during
the break between the normal school year and the next. Data will be
considered in determining eligibility for ESY services for your child. The
IEP team has determined that:
You child _is__not______ eligible for ESY services.
Placement Review: [ ] Initial placement [ x ]Maintain current
placement [ ]Change current placement
Parent Prior Notice for Free Appropriate Public Education: The
IEP team proposes to implement this program based on the student's
needs and represents the free, appropriate public education the
student will be provided. You have received and have protection under
the Procedural Safeguards and Annual Notifications, which were sent to
you upon the student's referral for evaluation and in conjunction with
this meeting. You may receive another copy of the Procedural
Safeguards and Annual Notifications from the special education
teacher. lf you have any questions regarding this notice or the
Procedural Safeguards and Annual Notifications, contact the special
education teacher at the student's school. Parent/guardian signature
on this form indicates that parent/guardian has received a copy of this
IEP and a copy of your Procedural Safeguards and Annual Notifications,

which includes annual notices for Child Find, Carson Smith Special
Needs Scholarship, Destruction of Records and Medicaid.
Note: Each teacher and service provider must be informed of his or her
specific responsibilities related to implementation of this IEP for the
student, and the specific accommodations, modifications, and supports
that must be provided for him in accordance with this lEP.
IEP Team Participants:
Student

Date

Parent

Date

Special Education Teacher

Date

General Education Teacher

Date

LEA

Date

[ ]The IEP team has reviewed the previous year IEP in preparation for
the development of the current lEP.
Note: lf parent signature is missing, provide them with a copy of the
IEP and the Procedural Safeguards and Annual
Notifications and indicate a reason: