Class Iep

The School District of Philadelphia
440 N. Broad Street

Philadelphia, PA 19130
Individualized Education Program (IEP)
Student Name:
ID#:
Makalah W Hanible
7979050
PA Secure ID: 6560557286

DOB: 08/27/2005 Age: 11
Grade:
IEP Team Meeting Date (mm/dd/yyyy):
IEP Implementation Date (Projected Date when Services and

Programs will Begin): 10/20/2016
County of Residence:
Anticipated Duration of Services and Programs of this IEP:
10/18/2017
Anticipated Year of Graduation:
IEP Coordinator:
Brittany Bradshaw
IEP Coordinator Phone:
(215) 492-6455
10/19/2016
School:
2023
Penrose School (144)
Regional Office:
Neighborhood Network -1
Parent/Guardian Information
Name and address of Parent/Guardian: Gerald Hanible/lydia Hayward
8111 LYONS AVE
PHILADELPHIA, PA 19153
Relationship to child: Parent(s)
Phone: (H) None
(W) None
Fax: None
Email: None
Interpreter Needed?: No
Other: None
Cell: None
The LEA and parent/guardian have agreed to make the following changes to the IEP without convening an IEP meeting,
as documented by: none
Date of Revision(s)
Revised December 2013
Participants/Roles
IEP Sections Amended
Page 1
Date of Creation: 10/29/2016
Student: Makalah W Hanible

DOB: 08/27/2005
Student ID: 7979050
IEP Team Meeting Date: 10/19/2016

Current School Assignment: Penrose School (144)
Region: Neighborhood Network -1
Grade: 6
IEP Team/Signatures
The Individualized Education Program (IEP) Team makes all the decisions about Makalah Hanibles program and placement.
Makalah Hanibles parent(s)/guardian(s), Makalah Hanibles special education teacher, and a representative from the local education agency are required members of this team. Signature on this IEP documents attendance, not agreement.
Role
Name
Parent / Guardian / Surrogate
Gerald Hanible/lydia Hayward
Signature
Parent / Guardian / Surrogate

Student *
Makalah Hanible
Regular Education Teacher**
Lori Odum
Special Education Teacher
Phyllis M Graham
Local Education Agency
Mr. Huie A. Douglas
Career/Tech Ed Rep. ***

Community Agency Rep. ***
Teacher of the Gifted****
ESOL/Bilingual Teacher
Interagency Rep.
TEACHER,SPEC EDUCATION
Brittany Bradshaw
Other School District Participant
Brittany Bradshaw
TEACHER,SPEC EDUCATION
Dewayne Diggs
* The IEP team must invite the student if transition services are being planned or if the parent(s)/guardian(s) choose to have the student
participate.
** If the student is, or may be, participating in the regular education environment.
*** As determined by the LEA as needed for transition services and other community services.
**** A teacher of the gifted is required when writing an IEP for a student with a disability who is also gifted.
One individual listed above must be able to interpret the instructional implications of any evaluation results.
Written input received from the following members:

Transfer of Rights at Age of Majority
For the purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals with Disabilities Education Act, the age of majority is reached for students with disabilities
when they reach 21 years of age.
Page 2

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
Procedural Safeguards Notice

I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides
information about my rights, including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.
Parent/Guardian Signature:
Lydia Hayward
Page 3

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
Medical Assistance Program Billing Notice

(Applicable only to parents who have consented to the release of billing information
to Medical Assistance programs)
I understand that the school may charge the School-Based Access Program (SBAP)or any program that replaces or supplements the SBAPthe cost of certain special education and related services described in my childs IEP. To make these charges
to the SBAP, the school will release to the administrator of that program the name, age, and address of my child, verification of
Medicaid eligibility for my child, a copy of my childs IEP, a description of the services provided and the times and dates during
which such services were provided to my child, and the identity of the provider of such services. I understand that such information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have
provided written consent to disclose such information.
I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to write, at any time. My refusal to consent or my withdrawal of consent will not relieve the school
of the obligation to provide, at no cost to me or my family, any service or program to which my child is entitled under the Individuals with Disabilities Education Act (IDEA) or that is necessary to enable my child to receive a free appropriate public
education as described in my childs IEP.
I understand that the school cannot
Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a condition
of receiving a free appropriate public education for my child;
Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including
co-payments and deductibles, unless it agrees to pay such expenses on my or my familys behalf;
Cause a decrease in available lifetime coverage or any other insured benefit;
Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that
are required for my child outside the time that he or she is in school;
Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.
Page 4

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
IEP Summary Information

Makalahs educational placement:
Type of Support:
Learning Support
Type of Service:
Supplemental
Related Service(s):
None
Projected dates for annual goals progress reporting:
(1) December
(2) February
(3) April
Makalahs evaluation information:

Date of last review/re-evaluation/ER: 05/18/2015
Is this a review/reevaluation year? No
Review cycle: 3 years
Projected date for IEP Team review/reevaluation review to begin:
(4) June
The reevaluation is not due during this IEP cycle.
Page 5

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
I. Special Considerations The IEP Team Must Consider Before Developing The IEP.
Any Factors Checked As Yes Must Be Addressed In The IEP.
A.
Is Makalah blind or visually impaired?

[ ] Yes - The IEP Team must include a description of the instruction in Braille and the use of Braille unless the IEP Team
determines, after an evaluation of the childs reading and writing skills, needs, and appropriate reading and writing
media (including an evaluation of the students future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of Braille is not appropriate for the student.
[X] No
B.
Is Makalah deaf or hearing impaired?

[ ] Yes - The IEP Team must include a communication plan to address the following: language and communication
needs; opportunities for direct communications with peers and professional personnel in the students language and
communication mode; academic level; full range of needs, including opportunities for direct instruction in the students language and communication mode; and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The Communication Plan must be completed and is available at
www.pattan.net.
[X] No
C.
Does Makalah have communication needs?

[ ] Yes - Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual
goals, etc.).
[X] No
D.
Does Makalah need assistive technology devices and/or services?

[ ] Yes - Student needs must be address in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.).
[X] No
E.
Does Makalah have limited English proficiency?

[ ] Yes - The IEP team must address the students language needs and how those needs related to the IEP.
[X] No
F.
Does Makalahs behavior:

a) impede his/her learning or that of others in the school setting?
[ ] Yes - The IEP Team must complete a Positive Behavior Support Plan that is based on a functional assessment of behavior and that utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in
the Present Levels section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially
Designed Instruction sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that
is attached the IEP. A Positive Behavior Support Plan and a Functional Behavioral Assessment form are available at
www.pattan.net.
[X] No
b) affect the students safety or that of others in the school setting?;
[ ] Yes
[X] No
c) persist despite implementation of informal behavior change strategies?;
[ ] Yes
[X] No
d) affect the students safety or that of others on the districts transportation?;
[ ] Yes
[X] No
Page 6

DOB: 08/27/2005
Student ID: 7979050
G.

Grade: 6
Does the student require a TSS (Therapeutic Support Staff) from an agency in the school setting?
[ ] Yes - This is not a substitute for a 1:1 Assistant; while components of the plan can be collaborative SDP is not responsible for providing this service.
[X] No
H.
Does Makalah require:

a) Close Adult Supervision provided by The School District of Philadelphia?
[ ] Yes
[X] No
b) 1:1 assistant provided by The School District of Philadelphia?
[ ] Yes
[X] No
Does the student require transition services?
[ ] Yes
[X] No
Other (specify): not at this time
Page 7

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
II. Present Levels of Academic Achievement and Functional Performance

Include the following information related to the student:
Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments,
curriculum-based assessments, transition assessments, progress toward current goals)
Literacy: Makalah is a fourth grade student currently reading at a second grade level. Makalah has a command
of basic phonics and most sight words. She currently reads at a level 18 as determined by the Developmental
Reading Assessment (DRA). Makalah works to build her literacy skills using the Lexia online intervention system. She has mastered over 90% of the second grade skills and continues to move improve.
Math: Makalah is working on second grade math material, and does well in her learning support class, but
struggles to apply learned skills. She also has some misunderstandings and knowledge absences that need to be
addressed (shape identification, understanding word problems)
Behavior: Makalah is currently a sixth grade student who is performing at a second grade level in reading and
math. She does not have any major behaviors that inhibit the learning of others, but she lacks focus at times.
Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress toward current goals)
Literacy: Makalah is currently reading at a second grade level. She is reading in the second grade reading book,
and working on consonant blends, latin prefixes, irregular plurals and verbs as well and passage comprehension.
Math: Makalah is developing skills in addition and subtraction involving regrouping. She can read and recognize place value through the hundreds place. Makalah is also now able to add and subtract with greater speed
and accuracy using the counting up method instead of illustrations.
Behavior: Over the last year, Makalah had developed coping skills that have enable her to resolve conflict and
avoid fighting. She has also become more successful at building friendships. Our main concern at this point is
for Makalah to spend more time engaged and on task in class. Also, during class, Makalah sometimes engages
in sneaky and disobedient behaviors. Her teacher asks her to follow certain rules, and on occasion, Makalah does
not comply and tries to get away with small misbehaviors. Makalah functions slightly below average in Social
Studies and Science due to her struggles with reading.
Present levels related to current postsecondary transition goals if the students age is 14 or younger if determined appropriate
by the IEP team (e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)
Not at this time. Transition planning will begin at age 14.
Parental concerns for enhancing the education of the student

Lydia Hayward believes that Makalah can excel when she applies herself, but she needs to work on paying attention and staying focused. Ms. Hayward also is concerned about Makalahs reading abilities and hopes to see
progress this year.
How the students disability affects involvement and progress in the general education curriculum
Makalah
has a Specific
in reading
math
and is<1.0,
performing
far below her peers.
Grade equivalent
scores:Learning
ReadingDisability
comprehension
<1.0,and
Word
reading
and pseudoword
Makalah
decodingneeds
<1.0 chunked instructions, models and individual/ small group support when working in her general
education
placement.
Grade equivalent
scores: Math problem solving: k.6, numerical operations k.4,
Spelling grade equivalent: k.5; Alphabet writing fluency G.E. 1.7
On the KeyMath3 as administered by Ms. Morton, on 1/25/12, Makalah obtained a K.1
grade Equivalent. Makalah was administer the Key Math3 on April 27, 2015. Grade Equivalent level is 2.3. Numeration 2.2, Algebra 3.2, Geometry 4.2, Measurement 1.7,
WIATIII
Page 8

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
Makalah was administered the Wechsler Individual Achievement Test Third Edition (WIATIII).
The WIATIII
is an individually administered clinical test for assessing the achievement
of Prekindergarten through 12, or ages 4 years 0 months through 19 years 11 months.
Reading
Grade equivalent scores: Reading comprehension <1.0, Word reading <1.0, and pseudoword
decoding <1.0
Strengths: Phonological awareness: blending sounds
Difficulty: vowel digraphs, she commonly reversed the letter /D/ for /B/, and single short
vowels, recognizing ending sounds in words.
Mathematics
Grade equivalent scores: Math problem solving: k.6, numerical operations k.4,
Understanding of basic concepts, number formation and order,
Errors were noted: addition with single digit numbers, money, number patterns
Written Expression
Spelling grade equivalent: k.5; Alphabet writing fluency G.E. 1.7.
Able to print her name legibly
Overall, Makalah added sounds unable to consistently recognizes and distinguish between the
letters b/and d. At times, as described in the interview, she was inattentive and lost focus,
which may have led to some of her noticeable errors.
Overall, Makalah did not perform as on the WIATIII
given her abilities as measured by the
RIAS. In other words, results of current testing indicate there is a significant discrepancy
between her ability and achievement and she qualifies for specially designed instruction in all
areas.
Makalah needs special education services in math and reading to make progress in the general education
curriculum.
Students progress in general education curriculum in specific areas of need.

Makalah has progressed about .5 years in reading since her last IEP was written, and seems to have stayed at the
same level in mathematics. She has drastically improved her behaviors over the past year and no longer struggles
with physical conflict or social skills.
Why the student requires special education programs and services.

Makalah needs special education services to make progress in the general education curriculum.
Strengths
Behavior: Makalah enjoys small group instruction, educational games and is very committed to doing well in
her learning support room. She engages respectfully and pleasantly with other group members and is a joy to
have in the group.
Literacy: Makalah is developing her ability to sound out (decode) unfamiliar words. She recognizes all letters
and sounds in isolation. She can read most pre-primer and primer high frequency words. Makalah is able to recall details from stories and can re-tell events after reading.
Math: According to her recent assessment, Makalahs strengths in math are in the areas of measurement, addition, and subtraction and understanding place value.
Academic, developmental, and functional needs related to students disability
Page 9

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
Due to Makalahs Specific Learning Disability, she needs small group and individual instruction for literacy and
math. She has already shown growth this school year, but she is still nearly 4 academic years behind her own
grade level.
Student Needs:
Decoding Skills - Measurable Annual Goal #1
Writing Skills- Measurable Annual Goal #2
Reading Accuracy- Measurable Annual Goal #1
Problem Solving- Measurable Annual Goal #3
Reasoning with shapes and other attributes- Measurable Annual Goal #3
Representing and interpreting data- Measurable Annual Goal #3
Solving addition and subtraction problems not written in standard form- Measurable Annual Goal #3
Working with time and money - Measurable Annual Goal #3
Improving time engaged and on task - Measurable Annual Goal #4
Page 10

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
III. Transition Services

TRANSITION SERVICES - This is required for students age 14 or younger if determined appropriate by the IEP team.
If the student does not attend the IEP meeting, the school must take other steps to ensure that the students preferences and interests are considered. Transition services are a coordinated set of activities for a student with a disability that is designed to be
within a results oriented process, that is focused on improving the academic and functional achievement of the student with a
disability to facilitate the students movement from school to post school activities, including postsecondary education, vocational
education, integrated employment (including supported employment), continuing and adult education, adult services, independent
living, or community participation that is based on the individual students needs taking into account the students strengths, preferences, and interests.
Makalah is not of age to receive transition services at this time, but has expressed interest in becoming a teacher. SHe understadns thatshe
POST
SCHOOL
- Based
age year
appropriate
assessment,
and project
the appropriate
postsecentry to
a quality GOALS
high school
and aon
fouraccredited
universitydefine
to achieve
this goal.
She believesmeasurable
that she will
be able to perform well
ondary
goals
that
address
education
and
training,
employment,
and
as
needed,
independent
living.
Under
each
area,
list the serschool and contribute to society as an adult.
vices/activities and courses of study that support that goal. Include for each service/activity the location, frequency, projected
beginning date, anticipated duration, and person/agency responsible.
For students in Career and Technology Centers, CIP Code:
Is this the IEP period before the High School selection starts? No
Did the IEP Team discuss the High School selection process? No
Were the students interests and aptitudes considered in the process? No
Transition - Course of Study
Will the student graduate by the accumulation of necessary academic credits or by the successful completion of IEP goals
and objectives? IEP Goals & Objectives
Indicate the total number of credits needed for graduation:
Indicate the total number credits earned as of this IEP:
Indicate the total number of credits the student is anticipated to earn during this year:
Have arrangements been made for the student to receive academic credit(s) for work based or community based instructions? No
Page 11

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
Postsecondary Education and Training Goal: Upon graduating from Penrose, Makalah has a
Measurable Annual Goal
goal of attending a competitive high school and a four year university.
(Document in Section V)
Course of Study:
Math, ELA, Science, Social Studies, Art, Computers, Physical Education
Service/ Activity
Persons Responsbile
Location & Frequency Projected
Anticipated Duration
Makalah will be given the opportunity to
Beginning
Anticipated
Person(s)/Agency
Across all
Special Education Teacher,
improve her reading accuracy.
Service/Activity
Location
Frequency
Date October 2017Duration
Responsible
environmentsGeneral Education
Teacher
Makalah will be given the opportunity to
daily
N/A
N/A
N/A
N/A
N/A
N/A
write in complete and sensible sentences.
Employment Goal:
Course of Study:
Service/Activity
N/A

Makalah does not yet have an employment goal.
N/A
Location
N/A
Frequency
N/A
Projected
Beginning
Date
Anticipated
Duration
N/A
Person(s)/Agency
Responsible
N/A
Independent Living Goal, if appropriate:

Makalah does not yet have an independent living goal.
Course of Study:
Projected
Beginning
Anticipated
Person(s)/Agency
Service/Activity
Location
Frequency
Date
Duration
Responsible
N/A
N/A
N/A
N/A
N/A
N/A
Page 12

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
IV. Participation in State and Local Assessments

Pennsylvania System of School Assessment (PSSA), the Keystone Exam or Pennsylvania Alternate System of Assessment
(PASA)
Students will be taking the PSSA, the Keystone Exam or the PASA in the grade levels below.
Reading (Grades 3-8, and 11)
Math (Grades 3-8, and 11)
Writing (Grades 5, 8, 11).
Science (Grades 4, 8, and 11)
[ ]
Assessment is not administered at this students grade level; OR
[ ]
Student will participate in the Keystone Exam or the PSSA without accommodations; OR
[X]
Student will participate in the Keystone Exam or the PSSA with the following appropriate accommodations (allowable PSSA accommodations may be found in the PSSA Accommodations Guidelines at www.pde.state.pa.us under
Pre K-12 and Assessment):
PSSA Math (Grades 3-8)
Response - Visual/graphic organizers (S)
PSSA Reading (Grades 3-8)
Response - Calculators (S)
PSSA Science (Grades 4 & 8)
.
.
[ ]
Response - Calculators (S)

Timing - Extended Time (S)
Student will participate in the Keystone Exam or PASA (criteria regarding PASA eligibility may be found in the
PSSA Accommodations Guidelines at www.pde.state.pa.us under Pre K-12 and Assessment).
Explain why the student cannot participate in the PSSA:
Explain why the PASA is appropriate:
Choose how the students performance on the Keystone or PASA will be documented:
[ ]
Videotape (which will be kept confidential as all other school records)
[ ]
Written Narrative (which will be kept confidential as all other school records)
Page 13

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
Local Assessments
[ ]
Local assessment is not administered at this students grade level; OR
[ ]
Student will participate in local assessments without accommodations; OR
[X]
Student will participate in local assessments with the following accommodations; OR
.
.
.
.
.
.
.
[ ]
Small group testing (D)

Extension of allotted time per subtest (D)
Use of multiple shortened test periods (D)
Simplified directions (D)
Reading of mathematics and science tests (D)
Decoding of words upon request for mathematics and science tests (D)
Use of calculator (D)
The student will take an alternate local assessment.

Explain why the student cannot participate in the regular assessment:
Explain why the alternate assessment is appropriate:
Page 14

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
V. Goals and Objectives

GOALS AND OBJECTIVES - Include, as appropriate, academic and functional goals. Use as many copies of this page as
needed to plan appropriately. Specially designed instruction may be listed with each goal/objective or listed in Section VI.
Short term learning outcomes are required for students who are gifted. The short term learning outcomes related to the
students gifted program may be listed under Goals or Short Term Objectives.
Page 15

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
Instructional area(s) for graduation/promotion: Literacy

Makalahs current Level of Performance from Section II related to this specific annual goal:
Literacy Progress: Makalahs October 5, 2016 Woodcock Reading Mastery Test indicates that, in literacy, she is performing at the 2.5 GE. She was assessed in the following areas and the following results were reported: Word Identification 2.3
GE, Word Attack 1.6 GE, Word Comprehension 3.3 GE, and Passage Comprehension 2.7 GE.
Literacy Present Level of Academic Achievement: Makalah is a fourth grade student currently reading at a second grade
level. Makalah has a command of basic phonics and most sight words. She currently reads at a level 18 as determined by
the Developmental Reading Assessment (DRA). Makalah works to build her literacy skills using the Lexia online intervention system. She has mastered over 90% of the second grade skills and continues to move improve.
Instructional Level: 2.5
Literacy Functional Performance: Makalah is currently reading at a second grade level. She is reading in the second grade reading book, and working on consonant blends, latin prefixes, irregular plurals and verbs as well and passage
comprehension.
Literacy Strengths: Makalah is developing her ability to sound out (decode) unfamiliar words. She recognizes all letters
and sounds in isolation. She can read most pre-primer and primer high frequency words. Makalah is able to recall details
from stories and can re-tell events after reading.
Literacy Needs: Makalah needs to develop her decoding skills in order to be able to identify unknown words.She also
needs to develop her writing skills in order to write complete sentences including correct word word order, punctuation,
grammar and spelling. Makalah will need to work towards reading with greater accuracy to improve her reading level.
Baseline Date: 10/17/2016
Baseline: 50
MEASURABLE ANNUAL GOAL
Include: Condition, Name,
Behavior, and Criteria
(Refer to Annotated IEP for
description of these components)
Given matierials on her instructional level and daily, research

based, small group reading
instruction,
instruction, Makalah
Makalah will
will have
im- the
opportunity
to reading
improveaccuracy
her oral
prove her oral
reading
no more
with no accuracy
more thanwith
2 mistakes
than
2
mistakes
in
any
in any one sentence at one
85% by
sentence by 10/18/17.
10/18/2017.
Describe HOW the students

progress toward meeting this
goal will be measured
Reading Probes
Student self-monitoring
Checklists
Teacher Observation
Progress Monitoring
regular coaching on reading accuracy
Describe WHEN period

reports on progress will be
provided to parents
Report of Progress
Report Card Addenda

Parent/Guardian Request
Documented Parental/Guardian
Phone Conference
Scheduled IEP Meetings
Refer to the stand-alone

IEP Progress Report.
Short Term Objectives/Benchmarks

Decode and encode words containing digraphs, consonant blends/clusters, short vowels, silent e, and r control vowels.
Produce speech sounds associated with all individual letter symbols and letter combinations for digraphs, blends and r control
vowels.
Read one-syllable and high frequency sight words.
Reread and self-correct word recognition errors while reading.
Segment and blend sequences of sounds to decode words (e.g., blends, digraphs and r control vowels).
Page 16

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
Discuss unknown words and word meanings as they are encountered in books.
Produce speech sounds associated with all individual letter symbols and letter combinations for digraphs, blends and r control
vowels.
Segment and blend sequences of sounds to decode words (e.g., blends, digraphs and r control vowels).
Specially Designed Instruction required to achieve this annual goal:

Modifications and SDI
Due
to Makalahs
needs in(D)
word decoding and accuracy,
Small
group testing
she will receive small group reading instruction with an
Responsecurriculum,
- Visual/graphic
organizers
(S)
intervention
extended time
for tests and
Timing - and
Extended
assignments
access toTime
a word(S)
wall.
Location
Frequency
Across all Environments

IEP Term
IEP Term
IEP Term
Projected
Beginning
Date
10/20/2016
10/20/2016
10/20/2016
Anticipated
Duration
10/18/2017
10/18/2017
10/18/2017
Page 17

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
V. Goals and Objectives (Continued)

Instructional area(s) for graduation/promotion: Literacy
Literacy Progress: Makalahs October 5, 2016 Woodcock Reading Mastery Test indicates that, in literacy, she is performing at the 2.5 GE. She was assessed in the following areas and the following results were reported: Word Identification 2.3
GE, Word Attack 1.6 GE, Word Comprehension 3.3 GE, and Passage Comprehension 2.7 GE.
Literacy Present Level of Academic Achievement: Makalah is a fourth grade student currently reading at a second grade
level. Makalah has a command of basic phonics and most sight words. She currently reads at a level 18 as determined by
the Developmental Reading Assessment (DRA). Makalah works to build her literacy skills using the Lexia online intervention system. She has mastered over 90% of the second grade skills and continues to move improve.
Literacy Functional Performance: Makalah is currently reading at a second grade level. She is reading in the second grade reading book, and working on consonant blends, latin prefixes, irregular plurals and verbs as well and passage
comprehension.
Literacy Strengths: Makalah is developing her ability to sound out (decode) unfamiliar words. She recognizes all letters
and sounds in isolation. She can read most pre-primer and primer high frequency words. Makalah is able to recall details
from stories and can re-tell events after reading.
Literacy Needs: Makalah needs to develop her decoding skills in order to be able to identify unknown words.She also
needs to develop her writing skills in order to write complete sentences including correct word word order, punctuation,
grammar and spelling. Makalah will need to work towards reading with greater accuracy to improve her reading level.
Baseline: 60

Given materials on her funcRubrics

tional level, Makalah will
Student self-monitoring
Makalah be given the opportuProgress Monitoring
nity to write organized sentences
using correct grammar, spelling
and punctuation with accuracy at
70% by 10/17/2017.

provided to parents
Report of Progress
Report Card Addenda

Phone Conference
Annual IEP Meetings, Monthly
goal progress check ups


Capitalize proper nouns.
Use proper end punctuation and commas.
Capitalize the first word of a sentence, names of people, and the pronoun I.
Edit writing using grammar and punctuation.
Recognize and use the correct word order in written sentences.
Page 18

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
Spell high- frequency sight words correctly.

Write complete simple sentences.

Location
Frequency
Extension
of allotted time per subtest (D)
Due to Makalahs needs in writing, she will receive
Regular Education
Across All Environments
Classroom
Regular Education
Classroom
Regular Education
Classroom
simplified instructions, several opportunities to edit
writingand access
to a dictionary
Simplified
directions
(D) and word wall.
Response - Dictionary (S)
Anticipated
Duration
IEP Term
Projected
Beginning
Date
10/31/2016
IEP Term
10/31/2016
10/16/2017
IEP Term
10/31/2016
10/16/2017
10/16/2017
Page 19

DOB: 08/27/2005
Student ID: 7979050

Grade: 6

Instructional area(s) for graduation/promotion: Math
Math Progress: On October 17, 2016, Makalah completed a Common Core aligned assessment that covers First and Second grade Math standards. On the First Grade assessment, she scored ___ % and on the Second Grade assessment, she
scored 27%.
Math Present Level of Academic Achievement: Makalah is working on second grade math material, and does well in her
learning support class, but struggles to apply learned skills. She also has some misunderstandings and knowledge absences
that need to be addressed (shape identification, understanding word problems)
Math Functional Performance: Makalah is developing skills in addition and subtraction involving regrouping. She can
read and recognize place value through the hundreds place. Makalah is also now able to add and subtract with greater
speed and accuracy using the counting up method instead of illustrations.
Math Strengths: According to her recent assessment, Makalahs strengths in math are in the areas of measurement, addition, and subtraction and understanding place value.
Math Needs: Makalahs needs in math, according to her recent Common Core assessment, continue to be in the areas of:
-problem solving -constructing arguments to explain her work -reasoning with shapes and other attributes -representing and
interpreting data -solving addition and subtraction equations written in non-standard form -working with time and money
Baseline: 27

Given a standards based math

Teacher-made tests
assessment, Makalah will
Progress Monitoring
be given will
the opportunity
to show
Makalah
show mastery
of
Math Probes
mastery
of
2nd
grade
common
second grade common core math
core mathwith
standards
with
50%
standards
50% of
questions
of questions answered with 75%
answered correctly with at 75%
accurately by 10/17/17.
by 10/17/2017.

provided to parents
Report of Progress
Report Card Addenda

Phone Conference
monthly goal check ups and annual IEP meetings


Demonstrate, solve, and describe story problems using addition or subtraction equations.
Gather, organize, display, and compare data using bar graphs, tallies, and pictographs.
Identify and interpret the data shown in tables and charts.
Solve number time
sentences
using concrete objects and symbols.
Manipulating
and money
Use concrete
numbers
determine
a missing
addend in a number sentence.
Reasoning
with
shapes to
and
other physical
attributes
Use the appropriate symbol for plus, minus, equal, greater than, less than and multiplication to solve problems.
Page 20

DOB: 08/27/2005
Student ID: 7979050

Grade: 6

Location
Frequency
Response - Manipulatives (S)
Regular Education
Across All Environments
Classroom
Special Education
Classroom
Due to Makalahs needs in mathematics,

she will receive small group instruction and access
to manipulatives.
Setting
- Small Group (2-5) (S)
Anticipated
Duration
IEP Term
Projected
Beginning
Date
10/31/2016
IEP Term
10/31/2016
10/16/2017
10/16/2017
Page 21

DOB: 08/27/2005
Student ID: 7979050

Grade: 6

Instructional area(s) for graduation/promotion: Behavior
Behavior Progress: In her general education classroom, Makalah is often off task when working independently. She needs
to develop her ability to maintain focus for a longer period of time. She needs to focus in order to ensure task completion.
Conversely, Makalah is always focused and on task in her learning support classroom and performs very well there.
Makalah has difficulty resolving conflicts with other children. She needs to develop behavior and coping skills that will
eliminate fighting. Makalah need to develop interpersonal skills that will help her build friendships with her peers.
Behavior Present Level Present Levels of Academic Achievement: Makalah is currently a sixth grade student who is
performing at a second grade level in reading and math. She does not have any major behaviors that inhibit the learning of
others, but she lacks focus at times.
Behavior Functional Performance: Over the last year, Makalah had developed coping skills that have enable her to resolve conflict and avoid fighting. She has also become more successful at building friendships. Our main concern at this
point is for Makalah to spend more time engaged and on task in class. Also, during class, Makalah sometimes engages in
sneaky and disobedient behaviors. Her teacher asks her to follow certain rules, and on occasion, Makalah does not comply
and tries to get away with small misbehaviors.
Behavior Strengths: Makalah enjoys small group instruction, educational games and is very committed to doing well in
her learning support room. She engages respectfully and pleasantly with other group members and is a joy to have in the
group.
Behavior Needs: Makalah needs to improve her time engaged and task to ensure task completion in her general education
classroom.
Baseline: 50

Given teacher support and posTeacher Observation

itive reinforcement, Makalah
Progress Monitoring
will
given the
to
will be
Makalah
willopportunity
actively paractively
participate
and
remain
ticipate and remain on task in
on
in her
general education
hertask
general
education
classroom
classroom work and
work and discussions with 4
discussions with 4 of 5
of 5 observations
at 70%
by
observations
at 70%
by 10/17/17.
10/17/2017.

provided to parents
Report of Progress
Report Card Addenda

Phone Conference
Annual IEP Meetings, monthly
goal check ups


Demonstrate on task behavior, as specified during class.
Attempt tasks that may be considered challenging and be willing to take a risk with new material.

Page 22

DOB: 08/27/2005
Student ID: 7979050

Due
to Makalahs
behavior needs,
she will receive
Gestures
and non-verbal
expressions
(D)
non-verbal cues and gestures from her teachers as a cue
to focus and return to her task.

Grade: 6
Location
Frequency
IEP Term
Projected
Beginning
Date
10/31/2016
Anticipated
Duration
10/16/2017
Page 23

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
VI. Special Education / Related Services / Supplementary Aids and Services /

Program Modifications
(Include, as appropriate, for nonacademic and extracurricular services and activities.)
A. Program Modifications and Specially Designed Instruction (SDI):

SDI may be listed with each goal or as part of the table below.
Include supplementary aids and services as appropriate.
For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or
modifications to the general educations curriculum, as appropriate for a student with a disability.
.
.
.
Makalah does not have any general modifications and SDI.

B.
Related Services - List the services that Makalah needs in order to benefit from or access her special education program:
The IEP Team has determined that Makalah does not have a need for related services at this time.
Transportation: Provide a detailed summary which clearly explains the IEP Teams decision regarding special education transportation.
The IEP Team has considered Makalahs transportation needs and determined that she is in need of special transportation, as described below.
Makalah exhibits the following needs that necessitate specialized transportation:
Safe Transport: Makalah uses school district transportation for safe curb to curb transport.
Based on these needs, Makalah requires the following specialized transportation:
Curb to curb pick-up and delivery
C. Supports for School Personnel - List the staff to receive the supports needed to implement the students IEP.
School Personnel
to Receive
Support
Teachers and support professionals
Support
Description
of Support
Location
Frequency
Training
Training
Regular Education
Classroom
100 minutes/IEP Term
Projected
Beginning
Date
10/19/2016
Anticipated
Duration
10/17/2017
D. Gifted Support for a Student Identified as Gifted Who Also is Identified as a student with a Disability - Support Services are required to assist a gifted student from gifted education (e.g., psychological services, parent counseling and education, counseling services, transportation to and from gifted programs to classrooms in buildings operated by the school
district).
Support Service:
N/A
Support Service:
N/A
Support Service:
N/A
Support Service:
N/A
Page 24

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
E. EXTENDED SCHOOL YEAR (ESY) - The IEP team has considered and discussed ESY services, and determined
that:
[ ]
Student IS eligible for ESY based on the following information or data reviewed by the IEP team:
OR
[X]
As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed
by the IEP team:
Observations and opinions by educators, parents, and others.
Page 25

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
VII. Educational Placement

A. QUESTIONS FOR THE IEP TEAM - The following questions must be reviewed and discussed by the IEP team prior to
providing the explanations regarding participation with students without disabilities.
It is the responsibility of each public agency to ensure that to the maximum extent appropriate, students with disabilities, including those in public or private institutions or other care facilities, are educated with children who are not disabled. Special classes,
separate schooling or other removal of children with disabilities from the regular educational environment occurs only when the
nature or severity of the disability is such that education in regular education classes, EVEN WITH the use of supplementary
aids and services, cannot be achieved satisfactorily.
[ x ] What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary aids and services will or will not enable the student to make progress on the goals and
objectives (if applicable) in this IEP in the general education class.
[ x]
What benefits are provided in the regular education class with supplementary aids and services versus the benefits
provided in the special education class?
[ x]
Will supplementary aids and services enable the student to make progress on the goals and objectives (if applicable)
in this IEP in the general education class?
[ x]
What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the
other students in the class, even with supplementary aids and services?
[ x]
To what extent, if any, will the student participate with non-disabled peers in extracurricular activities or other
nonacademic activities?
Explanation of the extent, if any, to which Makalah will not participate with students without disabilities in the regular
education class: Makalah will receive specially designed instruction in the Learning Support classroom in the areas of Literacy
and Math. Makalah will remain in her General Education classroom for science, social studies, literacy, math, writing and specials including art and physical education. In all general education environments, Makalah should receive tiered instruction to be
able to access the curriculum.
Explanation of the extent, if any, to which Makalah will not participate with students without disabilities in the general
education curriculum: Makalah will participate with her non-disabled peers in the general education curriculum.
B. Type of Support
1.
2.
Amount of special education supports

[ ]
Itinerant: Special education supports and services provided by special education personnel for 20% or less of the
school day
[X]
Supplemental: Special education supports and services provided by special education personnel for more than 20%
of the day but less than 80% of the school day
[ ]
Full-Time: Special education supports and services provided by special education personnel for 80% or more of the
school day
Type of special education supports

[ ]
[ ]
[ ]
[ ]
[X]
Autistic Support
Blind-Visually Impaired Support
Deaf and Hard of Hearing Support
Emotional Support
Learning Support
Page 26

DOB: 08/27/2005
Student ID: 7979050
[
[
[
[
]
]
]
]

Grade: 6
Life Skills Support

Multiple Disabilities Support
Physical Support
Speech and Language Support
C. Location of students program:

Name of School District where the IEP will be implemented: School District of Philadelphia
Name of School Building where the IEP will be implemented: Penrose School
Is this school the students neighborhood school (i.e., the school the child would attend if he/she did not have an
IEP)?
[X]
Yes
[ ] No. If answer is No, select the reason why not.
[ ] Special education supports and services required in Makalahs IEP cannot be provided in the neighborhood
school.
[ ] Other. Please explain:
Page 27

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
VIII. PENNDATA Reporting - Educational Environment

(Complete either Section A or B; Select only one Educational Environment)
To calculate the percentage of time inside the regular classroom, divide the number of minutes the student spends inside regular
classroom by the total number of minutes in the school day (including lunch, recess, study periods). The result is then multiplied
by 100.
A. For Students Educated in Regular School Buildings with Non-Disabled Peers - Indicate the percentage of time INSIDE
the regular classroom for this student:
Time spent outside the regular classroom receiving services unrelated to the students disability (e.g., time receiving ESL services) should be considered time inside the regular classroom. Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as
time spent inside the regular classroom.
Calculation for this Student:
Column 1
Column 2
Calculation
Indicate Percentage
Percentage Category
Total number of
Total minutes in a typ- (Minutes inside regular Section A: The perUsing the calculation reminutes the student
ical school day (inclassroom / minutes in centage of time student sult - select the appropriate
spends in the regular
cluding lunch, recess,
school day) x 100 = % spends inside the regu- percentage category
classroom
and study periods)
(Column 1/Column 2) lar classroom:
x 100 = %
403.80
403.80
(403.80/403.80)
100 % of the day
x 100 = 100
[X] INSIDE the Regular
Classroom 80% or More of
the Day
[ ] INSIDE the Regular
Classroom 79-40% of the
Day
[ ] INSIDE the Regular
Classroom Less Than 40%
of the Day
SECTION B. This section is required only for Students Educated OUTSIDE Regular School buildings for more than 50%
of the day - select and indicate the Name of School or Facility on the line corresponding with the appropriate selection:
(If a student spends less than 50% of the day in one of these locations, the IEP team must do the calculations in Section A)
For Students Being Educated Outside Regular School Buildings
( )
Approved Private School (Non Residential)
( )
Approved Private School (Residential)
( )
Other Private Facility (Non Residential)
( )
Other Private Facility (Residential)
( )
Other Public Facility (Residential)
( )
Other Public Facility (Non Residential)
( )
Hospital/Homebound (Temporary Excusal)
( )
Correctional Facility
( )
Out of State Facility
( )
Instruction Conducted in the Home
Name of School or Facility
Page 28

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
EXAMPLES for Section A: How to Calculate PennData - Educational Environment Percentages

Column 1
Column 2
Calculation
Indicate Percentage
Total number of
Total minutes in a typ- (Minutes inside regular Section A: The percentage of
minutes the student
ical school day (inclassroom / minutes in time student spends inside the
spends in the regular
cluding lunch, recess,
school day) x 100 = % regular classroom:
classroom
and study periods)
(Column 1/Column 2)
x 100 = %
Example 1
330
390
(330 / 390) x 100 =
85% of the day (Inside 80% or
85%
More of Day)
Example 2
180
300
(180 / 300) x 100 =
60% of the day(Inside 79-40%
60%
of Day)
Example 3
60
300
(60 / 300) x 100 =
20% of the day (Inside less
20%
than 40% of Day)
For help in understanding this form, an annotation IEP is available on the PaTTAN website at www.pattan.net Type Annotated
Forms in the Search feature on the website. If you do not have access to the internet, you can request the annotated form by
calling PaTTAN at 800-441-3215.
Page 29

440 N. Broad Street
Notice of Recommended Educational Placement/Prior Written Notice (NOREP/PWN)
Student Name: Makalah W Hanible
Student ID: 7979050
PA SecureID: 6560557286
DOB: 08/27/2005
School Address: 2515 S. 78th Street
Date Sent: 10/29/2016
Current School Assignment: Penrose School

Regional Office: Neighborhood Network -1
Grade: 6
School Phone: (215) 492-6455
(144)
Age:
11
For LEA Use Only:

Date of Receipt of Signed NOREP/PWN:
Name and Address of Parent/Guardian/Surrogate:

8111 LYONS AVE
PHILADELPHIA, PA 19153
Dear Gerald Hanible/lydia Hayward,
This is to notify you of the Local Education Agencys (LEAs) action regarding your childs educational program.
1. Type of action taken:
Proposes initial provision of special education and related services (For this action, the school may not proceed
without your written consent in Section 8 of this document)
Refusal to initiate an evaluation (Must issue Procedural Safeguards Notice)
Proposes to change the identification, evaluation or educational placement of the child or the provision of a free
appropriate public education (FAPE)
Refusal to change the identification, evaluation or educational placement of the child or the provision of a free
appropriate public education (FAPE)
Change of placement for disciplinary reasons (Must issue Procedural Safeguards Notice)
Due process hearing, or an expedited due process hearing, initiated by LEA
Graduation from high school
Exiting special education
Exiting high school due to exceeding the age eligibility for a free appropriate public education (FAPE)
Extended School Year (ESY) services
Response to request for an independent educational evaluation (IEE) at public expense
NOREP is provided with creation of an annual IEP
Other
2. A description of the action proposed or refused by the LEA:
The regular educational environment with supplementary aids and services was considered as an option.
Supplemental Learning Support in the regular education class is proposed
3. An explanation of why the LEA proposed or refused to take the action:
The IEP team has determined that the proposal satisfies a free and Appropriate Education (FAPE) requirement.
4. A description of other options that the IEP team considered and the reasons why those options were rejected. If the
action proposed or refused is in regard to educational placement, options considered must begin with the regular educational environment with supplementary aids and services (information about supplementary aids and services is available
on the PaTTAN website at www.pattan.net):
Options Considered
Reason for Rejection
Page 30

DOB: 08/27/2005
Student ID: 7979050

Grade: 6

The regular educational environment with supplementary
aids and services was considered as an option.
Makalah will be included in the regular education programs
and receive Supplemental services in the regular education and/
or special education environment where appropriate.
regular education with supplementary aids and services is proposed and not rejected.
This represents FAPE for Makalah at this time.
5. A description of each evaluation procedure, assessment, record or report used as a basis for the proposed action or
action refused:
Psychoeducational evaluation: RIS
6. A description of other factors that were relevant to the LEAs proposal or refusal:
There are no other factors at this time
7. The educational placement recommended for Makalah is (State the amount of and type of special educational supports,
e.g., Itinerant Learning Support, Supplemental Autistic Support, Full-Time Emotional Support):
Placement Recommendation: Supplemental Learning Support
School District Representative
Signature
Date (mm/dd/yy)
You have rights and protections under the law described in the Procedural Safeguards Notice. If you need more information or
want a copy of this notice, please contact:
Name: Ms. B. Bradshaw
Address: 2515 South 78th Street
Position: Special Education Teacher

Phone: 215-215-492-6455
Email: bbradshaw@philasd.org
8. PARENTAL CONSENT:
Directions for Parent/Guardian/Surrogate: Please check one of the options, sign this form, and return it within 10 calendar
days. In circumstances when this form is NOT completed and parental consent is NOT required, the school will proceed as proposed after 10 calendar days.
[ ] I request an informal meeting with school personnel to discuss this recommendation.
[ ] I approve this action/recommendation,
[ ] I do not approve this action/recommendation.* My reason for disapproval is:
I request (Contact the Office for Dispute Resolution at 800-360-7282 for information on Mediation and
Due Process Hearing):
[ ] Mediation
[ ] Due Process Hearing
Page 31

DOB: 08/27/2005
Student ID: 7979050

Grade: 6
* Except for placement in an interim alternative educational setting due to drugs, weapons, or serious bodily injury (300.530(g),
300.530(i), and 300.531), if you do not approve the action/recommendation, your child will remain in the current program/placement only if you request a due process hearing or mediation through the Office for Dispute Resolution. If you do not
request Due Process or Mediation through the Office for Dispute Resolution, the LEA will implement the action/recommendation
SIGN HERE:
Parent/Guardian/Surrogate Signature
Please return this entire form to:
Date
(mm/dd/yy)
Daytime Phone
Ms. B. Bradshaw
Penrose School
2515 S. 78th Street
Attached are state and local resources you can consult to help you understand your rights and how the special education process
works.
For help in understanding this form, an annotated NOREP/Prior Written Notice is available on the PaTTAN website at
www.pattan.net. TypeAnnotated Forms in the Search feature on the website. If you do not have access to the Internet, you can
request the annotated form by calling PaTTAN at 800-441-3215.
Page 32

DOB: 08/27/2005
Student ID: 7979050

Grade: 6

RESOURCES
THE ARC OF PENNSYLVANIA
101 South Second Street, Suite 8
Harrisburg, PA 17101
800-692-7258
www.thearcpa.org
800-692-7443 (Toll-Free Voice)

877-375-7139 (TDD) 717-346-0293 (TDD)
717-236-8110 (Voice)
717-236-0192
www.drnpa.org
PARENT EDUCATION NETWORK (PEN)

107 Industrial Highway
York, PA 17402-2223
717-600-0100 (Voice/TTY) 800-522-5827 (Voice/TTY)
800-441-5028 (Spanish in PA) 717-600-8101 (Fax)
www.parentednet.org
PENNSYLVANIA BAR ASSOCIATION

100 South Street
800-932-0311
www.pabar.org
PARENT EDUCATION AND ADVOCACY

LEADERSHIP CENTER (PEAL)
1119 Penn Avenue, Suite 400
Pittsburgh, PA 15222
412-281-4404 (Voice) 866-950-1040 (Voice)
412-281-4409 (TTY) 412-281-4408 (Fax)
www.pealcenter.org
HISPANICS UNITED FOR EXCEPTIONAL
CHILDREN (HUNE, INC.)
202 West Cecil B. Moore Avenue
215-425-6203 (Voice)
215-425-6204 (Fax)
www.huneinc.org
THE MENTOR PARENT PROGRAM, INC.
270 Mayfield Road
Clarion, PA 16214
814-226-4151 (Voice) 888-447-1431 (Voice in PA)
800-855-1155 (TTY) 814-226-4850 (Fax)
www.mentorparent.org
DISABILITIES RIGHTS NETWORK
1414 North Cameron Street, Suite C
800-692-7443 (Toll-Free Voice)
PUBLIC INTEREST LAW CENTER OF PHILADELPHIA
United Way Building
1709 Benjamin Franklin Parkway, Second Floor
215-627-7100 (Phone)
215-627-3183 (Fax)
www.pilcop.org
BUREAU OF SPECIAL EDUCATIONS

CONSULTLINE, A PARENT HELPLINE
800-879-2301
ConsultLine personnel are available to parents and advocates of
children with disabilities or children thought to be disabled to explain
federal and state laws relating to special education; describe the
options that are available to parents; inform the parents of procedural
safeguards;identify other agencies and support services;and describe
available remedies and how the parents can proceed.
OFFICE FOR DISPUTE RESOLUTION
6340 Flank Drive
Harrisburg, PA 17112-2764
717-541-4960 (Phone)
800-222-3353 (Toll free in PA only)
800-654-4984 (TTY)
717-657-5983 (Fax)
http://ODR.pattan.net
The Office for Dispute Resolution administers the mediation and
due process systems statewide, and provides training and
services regarding alternative dispute resolution methods.
THE PENNSYLVANIA TRAINING AND TECHNICAL

ASSISTANCE NETWORK (PaTTAN)
Harrisburg 800-360-7282
King of Prussia 800-441-3215
Pittsburgh 800-446-5607
www.pattan.net
STATE TASK FORCE ON THE RIGHT TO EDUCATION
3190 William Pitt Way
Pittsburg, PA 15238
1-800-446-5607 ext. 6830
Page 33

440 N. Broad Street
PA Medical Assistance (MA) Billing One Time Parental Consent Form
Student ID: 7979050
DOB: 08/27/2005

Grade: 6
School Phone: (215) 492-6455
Age: 11
10/19/2016
IEP Meeting Date
Local Education Agencies (LEAs) are eligible to receive federal Medicaid reimbursement for medically necessary services provided to
their special education students when the services meet the requirements of the states Medicaid program and are provided in
accordance with the students IEP.
The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) and the Family Educational Rights and Privacy Act
(FERPA) require schools to obtain written parental consent to share students education and health-related records such as IEPs and
Evaluation Reports. We are requesting your permission to share this information with the PA Department of Education, the PA
Department of Public Welfare, and a physician or nurse practitioner in order to bill Medical Assistance.
In addition to the Medicaid-covered services your child receives as part of his/her IEP; MA will continue to pay for medically
necessary, Medicaid-covered services that are provided to your child outside of the school.
I understand that...
Local Educational Agencies (LEAs) are eligible to receive federal reimbursement through the School-Based Access Program for
certain medically necessary services provided to students with disabilities ages 3-21 in accordance with the students IEP.
LEAs use of this reimbursement program does NOT in any way affect or impact other medically necessary, covered services that are
provided to your child out of school. Medical Assistance will continue to pay for these services. Any reimbursement that the School
Districts or Intermediate Units receive from the School-Based Access program is used to help cover the cost of special education
services.
Before the LEA can apply for reimbursement for services, a one-time written parental consent is required by The Individuals with
Disabilities Education Improvement Act of 2004 (IDEA) under Part 300 (Assistance to the States for the Education of Children with
Disabilities) and the Family Educational Rights and Privacy Act (FERPA).
By giving consent, I am authorizing the LEA to share my childs information such as records or information about the services that
may be provided to my child with the PA Department of Education, the PA Department of Public Welfare, and a physician or nurse
practitioner in order to bill Medical Assistance for services my child receives as part of his/her IEP. The only purpose of this
disclosure is to bill for services provided.
I have the right to withdraw my consent at any time. Withdrawing my consent or not giving consent, will not affect the services that
my child is receiving in school. It is still the responsibility of the LEA to provide my childs required services as written in his/her
Individual Education Plan at no cost to me.
Upon request, I may receive copies of my childs records that are disclosed as a result of this authorization.
Yes, I Accept
I give my childs school permission to share my childs education and health-related information and bill Medical Assistance.
Parent/Guardian Name (print)
Parent/Guardian Signature
Date
No, I DO NOT Accept

I do not give my childs school permission to share my childs education and health-related information and bill Medical Assistance.
Parent/Guardian Name (print)
Revised March 2013
Parent/Guardian Signature
Date
Page: 34

440 N. Broad Street
IEP at a Glance
Student ID: 7979050
DOB: 08/27/2005
Level of Support: Learning Support
IEP Begin Date: 10/20/2016
IEP Coordinator: Brittany Bradshaw
Grade: 6
School: Penrose School (144)
Resident County:
Type of Service: Supplemental
IEP End Date: 10/18/2017
Instructional Levels Based on Most Recent Assessment(s):

Reading: 2.5
IEP Goals and Objectives:
Math: 2.2
Domain: Literacy
Goal 1: Given matierials on her instructional level and daily, research based, small group reading instruction, Makalah will improve her oral reading accuracy with no more than 2 mistakes in any one
sentence at 85% by 10/18/2017.
Objective 1:
Decode and encode words containing digraphs, consonant blends/clusters, short vowels, silent
e, and r control vowels.
Objective 2:
Produce speech sounds associated with all individual letter symbols and letter combinations for
digraphs, blends and r control vowels.
Objective 3:
Read one-syllable and high frequency sight words.
Objective 4:
Reread and self-correct word recognition errors while reading.
Objective 5:
Segment and blend sequences of sounds to decode words (e.g., blends, digraphs and r control
vowels).
Objective 6:
Discuss unknown words and word meanings as they are encountered in books.
Objective 7:
Produce speech sounds associated with all individual letter symbols and letter combinations for
digraphs, blends and r control vowels.
Objective 8:
Segment and blend sequences of sounds to decode words (e.g., blends, digraphs and r control
vowels).
Goal SDI 1:
Small group testing (D)
Goal SDI 2:
Response - Visual/graphic organizers (S)
Goal SDI 3:
Timing - Extended Time (S)
Domain: Literacy
Goal 2: Given materials on her functional level, Makalah will Makalah be given the opportunity to write
organized sentences using correct grammar, spelling and punctuation with accuracy at 70% by
10/17/2017.
Objective 1:
Capitalize proper nouns.
Objective 2:
Use proper end punctuation and commas.
Page 35

440 N. Broad Street
IEP at a Glance
Objective 3:
Capitalize the first word of a sentence, names of people, and the pronoun I.
Objective 4:
Edit writing using grammar and punctuation.
Objective 5:
Recognize and use the correct word order in written sentences.
Objective 6:
Spell high- frequency sight words correctly.
Objective 7:
Write complete simple sentences.
Goal SDI 1:
Extension of allotted time per subtest (D)
Goal SDI 2:
Simplified directions (D)
Goal SDI 3:
Response - Dictionary (S)
Domain: Math
Goal 3: Given a standards based math assessment, Makalah will Makalah will show mastery of second
grade common core math standards with 50% of questions answered correctly with at 75% by
10/17/2017.
Objective 1:
Demonstrate, solve, and describe story problems using addition or subtraction equations.
Objective 2:
Gather, organize, display, and compare data using bar graphs, tallies, and pictographs.
Objective 3:
Identify and interpret the data shown in tables and charts.
Objective 4:
Solve number sentences using concrete objects and symbols.
Objective 5:
Use concrete numbers to determine a missing addend in a number sentence.
Objective 6:
Use the appropriate symbol for plus, minus, equal, greater than, less than and multiplication to
solve problems.
Goal SDI 1:
Response - Manipulatives (S)
Goal SDI 2:
Setting - Small Group (2-5) (S)
Domain: Behavior
Goal 4: Given teacher support and positive reinforcement, Makalah will Makalah will actively participate
and remain on task in her general education classroom work and discussions with 4 of 5 observations at 70% by 10/17/2017.
Objective 1:
Demonstrate on task behavior, as specified during class.
Objective 2:
Attempt tasks that may be considered challenging and be willing to take a risk with new
material.
Goal SDI 1:
Gestures and non-verbal expressions (D)
General SDIs (apply to all domains):
Page 36

440 N. Broad Street

Student ID: 7979050
DOB: 08/27/2005
Current School Assignment: Penrose School

Grade: 6
Age: 11
School Phone: (215) 492-6455
(144)
Individualized Education Program (IEP) Signature Pages

SDP EasyFax Cover Page
.
.
.
IEP Team Signature Page

Notice of Recommended Educational Placement / Prior Written Notice (NOREP/PWN)
PA Medical Assistance (MA) Billing Parental Consent Form
Document Creation Date: 10/29/2016
16/-.00070EFF
Instructions:
1. Double check that this cover sheet is for the IEP Signature Pages
2. Attach the signed pages of the:
(1) IEP Team Signature Page,
(2) NOREP/PWN with district representative and parent signatures,
(3) PA Medical Assistance (MA) Billing Parental Consent Form.
***Be sure to place this cover page ON TOP of the signature pages. This cover page
must be the FIRST page faxed into the system.***
3. Fax this cover page and the IEP Signature Pages to the number listed in the EasyFax Training
Manual.

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The School District of Philadelphia

440 N. Broad Street

PA Secure ID: 6560557286

IEP Team Meeting Date (mm/dd/yyyy):

IEP Implementation Date (Projected Date when Services and

Anticipated Year of Graduation:

IEP Coordinator Phone:

Penrose School (144)

Revised December 2013

IEP Sections Amended

Student: Makalah W Hanible

Individualized Education Program (IEP)

Parent / Guardian / Surrogate

Gerald Hanible/lydia Hayward

Parent / Guardian / Surrogate

Regular Education Teacher**

Special Education Teacher

Local Education Agency

Mr. Huie A. Douglas

Career/Tech Ed Rep. ***

Other School District Participant

Written input received from the following members:

Revised December 2013

Student: Makalah W Hanible

Individualized Education Program (IEP)

Procedural Safeguards Notice

Revised December 2013

Student: Makalah W Hanible

Individualized Education Program (IEP)

Medical Assistance Program Billing Notice

Revised December 2013

Student: Makalah W Hanible

Individualized Education Program (IEP)

IEP Summary Information

Makalahs evaluation information:

Revised December 2013

The reevaluation is not due during this IEP cycle.

Student: Makalah W Hanible

Individualized Education Program (IEP)

Is Makalah blind or visually impaired?

Is Makalah deaf or hearing impaired?

Does Makalah have communication needs?

Does Makalah need assistive technology devices and/or services?

Does Makalah have limited English proficiency?

Does Makalahs behavior:

Student: Makalah W Hanible

Individualized Education Program (IEP)

Does Makalah require:

Does the student require transition services?

Other (specify): not at this time

Revised December 2013

Student: Makalah W Hanible

Individualized Education Program (IEP)

II. Present Levels of Academic Achievement and Functional Performance

Not at this time. Transition planning will begin at age 14.

Parental concerns for enhancing the education of the student

Student: Makalah W Hanible

Individualized Education Program (IEP)

Students progress in general education curriculum in specific areas of need.

Why the student requires special education programs and services.

Academic, developmental, and functional needs related to students disability

Revised December 2013

Student: Makalah W Hanible