Waldera Kimikaiep

INVITATION TO A MEETING OF THE
INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM

Form I-1 (Rev. 10/06)
Edgemont SCHOOL DISTRICT
Dear _Mr. and Mrs. Kanzia_________________________ Date __05/05/17____________
You are a participant on the IEP Team which will meet to address the educational needs of your child, Kamika
Kanzia_. IEP team meetings must be held at a mutually agreeable time and place. An IEP team meeting has
tentatively been scheduled for the following date ___05/14/17________, time ___8:00 am_______ and
location _Conference Room_. If these meeting arrangements are not agreeable to you, please call ___Jeryn
Waldera____ at ______444-111-3333______. You may bring other people who you believe have knowledge
or special expertise about your child to the meeting with you. If your child is transferring from a Birth to 3
Early Intervention Program we will, at your request, send to the Birth to 3 coordinator or other representative
an invitation to the IEP meeting.
The purpose of this IEP team meeting is (check all that apply):
EVALUATION AND REEVALUATION

Determine initial eligibility for special education
Determine continuing eligibility for special education
INDIVIDUALIZED EDUCATION PROGRAM (IEP) (if student is eligible)

Develop an initial IEP
Develop an annual IEP
Review/revise IEP
Transition the consideration of postsecondary goals and transition services
(required for students beginning at age 14)
PLACEMENT (if student is eligible)

Determine initial placement
Determine continuing placement
OTHER
Review existing information to determine need for additional assessments or other evaluation
materials (meeting optional)
Conduct a manifestation determination (check appropriate boxes under IEP and
placement if changes in either are contemplated)
Determine setting for services during disciplinary change in placement (must also check
appropriate boxes under IEP & placement)
Specify: _____________________________________________________________________
___________________________________________________________________________

If transition is checked as one of the purposes of this meeting, your child will be invited to
attend. Because you provided your consent we are also inviting representatives from the
following agencies who may assist in the transition planning for your child: None
_________________________________________________________________________________________
Agency Name ( if known), and Title/Position
_________________________________________________________________________________________
Agency Name ( if known), and Title/Position
If at any point during this meeting you or other IEP team participants believe that additional time is needed to
permit your meaningful involvement, additional time will be provided. Decisions related to the purpose(s)
checked above may be made in one meeting or may require more than one meeting, depending on individual
circumstances. In addition and upon request you may receive a copy of the IEP teams most recent evaluation
report.
The following individuals have been appointed as IEP team participants and will attend the meeting:
________Anna Baker___________________ _________Jeryn Waldera___________________

Name/Reg. Ed. Teacher Name/Sp. Ed. Teacher
______Theresa May __________________ ________Kelsey Fellrath, SLP________________

Name/LEA Representative Name &Title
_______Ben Tell, OT _________________ _______Corey Oman, Adaptive Phy ED________

Name & Title Name & Title
_____________________________________ ________________________________________
_____________________________________ ________________________________________
You and your child have protection under the procedural safeguards (rights) of special education law. The
school district must provide you with a copy of your procedural safeguards once a year.
You received a copy of your procedural safeguard rights in a brochure about parent and child rights
earlier this year. If you would like another copy of this brochure, please contact the district at the
telephone number above.
A copy of the parent and child rights brochure is enclosed with this invitation.
In addition to district staff, you may also contact _________________________________ at

___________________if you have questions about your rights.
Sincerely,
_____Jeryn Waldera_________________________________________________
Name and Title of District Contact Person
I-1 (2) Revised 10/13/06

Edgemont SCHOOL DISTRICT

Name of Student DOB Grade WISEid LEAs Student ID
Kimika Kanzia 04/21/08 4th grade
Parent or Legal Guardian Telephone (area code/number)

Mr.andMrs.Kanzia 555-123-4567
Address
234HouseStreet,Virginia
District of Residence Current District of Placement

Edgemont Edgemenont
For students transferring between public agencies: For students transferring between public agencies:
Evaluation Report reviewed and adopted (if applicable) by IEP reviewed and adopted (if applicable) by
______________________ on ________________ _______________ on ___________________
Date of Meeting: 05/14/17 (month/day/year)
PURPOSE OF MEETING (check all that apply):

EVALUATION AND REEVALUATION
Evaluation including determination of initial eligibility for special education
Reevaluation including determination of continuing eligibility for special education
INDIVIDUALIZED EDUCATION PROGRAM (IEP) (if student is eligible)

Develop an initial IEP
Annual IEP review
Review/revise IEP
Transition the consideration of post-secondary goals and transition services
(Required for students beginning at age 14.)
PLACEMENT (must be determined when the IEP is developed or reviewed/revised)

Determine initial placement
Determine continuing placement
OTHER
Review existing information to determine need for additional assessments or other evaluation materials
(IEP team meeting optional)

Conduct a manifestation determination (check appropriate boxes under IEP and PLACEMENT if
changes in either are contemplated)

Determine setting for services during disciplinary change in placement (must check appropriate boxes
under IEP & PLACEMENT)

Other. Specify: ________________________________________________________
I-1 (2) Revised 10/13/06

If a purpose of this meeting is IEP development, review, and/or revision related to the academic,
developmental and functional needs of the child, the IEP team considered the results of:

Initial or most recent evaluation Yes Not applicable
Statewide assessments Yes Not applicable
District-wide assessments Yes Not applicable

IEP Team Participants Attending or Participating by Alternate Means in the Meeting:

Parent/Guardian Regular education teacher/title: Regular education teacher/title:
Anna Baker
Mr.andMrs.Kanzia
Student (if appropriate): Special education teacher/title: Special education teacher/title:

Jeryn Waldera
LEA Representative/title: Other: Other:

Kelsey Fellrath, SLP Corey Oman, Adaptive Phy Ed
TheresaMay
Other: Other: Other:

BenTell,OT

If the parent did not attend or participate in the meeting by other means and did not agree to the time and place of the IEP
team meeting, document three efforts to involve the parent:

Date Method Result
I-1 (2) Revised 10/13/06

I. INFORMATION ABOUT THE STUDENT
Information about the student, including strengths, effects of the disability / special factors, present level of academic
achievement and functional performance, and any concerns must be considered when identifying the students
disability-related needs and developing goals and services to address those needs. Include strategies that have been
effective in improving the students academic achievement and functional performance and access to general education.
Parents are important members of the IEP team and are encouraged to share information throughout the process.
The student should be included, whenever appropriate, and encouraged to provide input throughout the process.
A. Strengths
Describe the students strengths (including academic skills, communication skills, social skills, and interests).
AcademicSkills:Kamikaenjoyscompletingworktasksandismotivatedtoparticipateinthe
classroom.Inreading,Kamikarecognizespre-primerwordsandinitiallettersounds.Inwritten
language,Kamikawriteslettersinthealphabetlegibly.Inmath,Kamikacanrotecountto12,
telltimetothehour,andcompleteadditionfactsupto5.

CommunicationSkills:Kamikaenjoysengagingwithstaffandpeersattheschool.She
recognizesfunctionalwordsanddirectionalwordswith60%accuracy.

Interests:Kimikaenjoysplayingoutside,doingpuzzles,coloring,andlisteningtomusic.She
enjoysreadingwithstaffandsittingontheclassroombeanbag.

GrossMotor:Kimikaenjoysgymclass,especiallythebowlingunit.Sheisreceptivetoprompts
andusescarewhentravelingthroughtheschool.
B. Current Academic Achievement and Functional Performance

Academic achievement generally refers to a students performance in academic content areas (e.g., reading, math, written
language, etc.). For preschool children, academic achievement generally refers to knowledge and skills such as early
language development/communication, early literacy, cognition and general knowledge. Academic achievement
statements must include information about student achievement and/or progress compared to grade-level expectations.
Sources of information may include state, district-wide, or classroom assessments, rubrics, screeners, recent evaluations,
etc.
1. Describe the students present level of academic achievement (including reading achievement). For preschool
children, describe the childs acquisition and use of knowledge and skills (including early
language/communication and early literacy).
Academic Achievement:
Reading: Kamika recognizes 5 pre-primer words (it, to, come, for, red) and seven initial letter
sounds (m, b, s, k, p, r, f). Currently, she recognizes 11 functional/emergency words (exit, danger, go,
police, poison, walk, keep out, in, ladies, women, and out).
Written Lanugage: Kimika can write letters of the alphabet and write numbers to 10.
Math: Kamika continues to rote count to 12, recognize number to 15, and tell the time to the
hour. She also has basic addition facts to 5 memorized, and recognizes the value of pennies, nickels, and
dimes.
Functional performance includes activities and nonacademic skills needed for independence, access to instruction and
performance at school, in the home, in the community, for leisure time, and for post-secondary and lifelong learning
(including reading). Some examples include: activities of everyday living, school/work/play habits, and social-emotional
behavior.
2. Describe the students present level of functional performance. For preschool children, describe the child's
positive social-emotional skills (including social relationships) and use of appropriate behaviors to meet their
needs and the impact on early literacy.
I-1 (2) Revised 10/13/06

Communication: Kamika continues to have difficulty communicating effectively with staff and peers. She
continues to work on articulation of words and formulating 3-5 word phrases to express her needs and wants.
Functional Behavior: Kamika completes a variety of vocational tasks, such as putting items together, sorting, and
matching. She has just begun to package items.
Gross Motor: Kamika continues to work on traveling through the school independently as well as increase her
locomotor skills during games.
C. Special Factors
Special Factors must be considered when developing the individualized education program. Consider the special factors
when identifying the effects of disability, summarizing disability related needs, developing goals, and determining services
in the Program Summary. For example, if a students behavior impedes learning, the positive behavioral interventions,
strategies, and supports could include specially designed instruction, related services, supplementary aids and services
and/or program modifications and supports for staff. The behavioral needs of the student may be determined through a
functional behavioral assessment (FBA).
1. Does the students behavior impede his/her learning or that of others?

Yes No
If yes, describe how this factor affects learning: (Document positive behavioral interventions, strategies, and
supports, and other services in the Program Summary)
Kamikas ability to process multi-step directions and carry them out a well as her difficulty with appropriate
social skills impacts her rate of learning and ability to work in small and large groups like that of her grade
level peers. Kamika requires adult assistance in order to follow directions and complete academic tasks.
Successful strategies include, but are not limited to:
written and/or picture routines/schedules
verbal and/or visual cues
first/then language
sensory tools/breaks
2. Is the student an English Learner (EL)?

Yes No
If yes, describe how this factor affects the students needs related to this IEP:
3. In the case of a child who is blind or visually impaired, does the student need instruction in Braille or the use
of Braille? (Attach Determining Braille Needs (ER-3) from the latest evaluation/reevaluation or any updated
information.)
Not Applicable Yes
No
Cannot be determined at this time
If yes, describe needs, including Braille needs:
4. Does the student have communication needs that could impede his/her learning?
Yes No

a. If yes, describe the communication needs (including speech and language needs):
Kamika demonstrates a speech impairment with difficulty expressing her wants and needs as well as
articulating words.
b. If the student is deaf or hard of hearing, describe (a) the students language and communication needs; (b)
opportunities for direct communication with peers and professional personnel in the students language and
communication mode; and, (c) academic level and full range of needs including opportunities for direct
I-1 (2) Revised 10/13/06

instruction in the students language and communicative mode:
5. Does the student need assistive technology services or devices, including any services or devices needed to
assist with reading?
Yes No
If yes, describe the needed services in the Program Summary:
D. Concerns of the Parent(s)/Family

1. Describe the concerns of the parent(s)/family for enhancing the education of the student. This may include
concerns about reading achievement, early language/communication or early literacy skills, other academic
areas, social-emotional needs, sensory needs, behavior, the childs future and postsecondary transition, etc.:
Parents express their concern with Kamikas behaviors at school, especially her level and intensity of
aggression. They are would like her to continue to focus on functional reading and math skills.
2. Describe the concerns (if any) of the student for enhancing his or her education:
Kamika did not attend the Individualized Education Plan (IEP) Meeting. When asked about her concerns
or needs related to school she did not report any.
E. Effects of Disability
Effects of the disability identifies how the students disability affects academic achievement and functional performance. The
effects are what the IEP Team observes when the student has difficult accessing, engaging and making progress in the general
education curriculum, instruction, and environments.
1. Does the students disability adversely affect his or her progress toward meeting grade-level reading
standards? For preschoolers, does the disability adversely affect progress toward the early learning standards
for language development, communication and/or early literacy?
Yes No
2. Describe how the students disability affects his or her access, involvement and progress in the general
education curriculum, including how the disability affects reading. For preschool children, describe how the
disability affects participation in age-appropriate activities, including language development, communication
and/or early literacy.
Kamika has been identified with a moderate mental retardation. She also has a Speech/Language
Impairment and seizure disorder. She demonstrates needs in the areas of communication, gross motor, reading, written
language, math, and functional (vocational) skills. Kamikas disability affects her communication, gross motor, and
intellectual skills. This affects her access, involvement, and progress in the general education curriculum in the following
ways:
ability to understand and express language
retention of academic skills
rate of academic progress
knowledge and application of individual reading skills
I-1 (2) Revised 10/13/06

F. Summary of Disability-Related Needs

If the IEP team determines the student has a disability-related need(s) that affects reading (academic and/or functional), the IEP
must include a minimum of one goal to address this need(s). Each identified disability-related need must have at least one
corresponding goal and/or service to address the need. A goal or service may address more than one need. Services include
special education, related services, supplementary aids and services, or program modifications or supports for school personnel.
List and number the disability-related needs. Include reading needs, or early literacy needs, and needs due to special
factors, if identified. Reference numbered needs in the measurable annual goal statements (add rows, as needed).
1 Reading:recognizesightwords
2 WrittenLanguage:writes5letterwords
3 Math:rotecountingto50
4 Communication: articulation
5 Gross Motor: 4th grade level locomotor skills
6 Functional Skills: 5 step task completion
7 Emotional/Social/Behavioral: recognizing self-regulation and the Zones of Regulation
I-1 (2) Revised 10/13/06

II. FAMILY ENGAGEMENT
How will school staff engage parent(s)/families in the education of the student (e.g. sharing resources,
communicating with parent(s)/families, building upon family strengths, connecting parent(s)/families to learning
activities, etc.)?
Parent/Teacherconferenceswillbeheldtwiceperschoolyeartoencouragefamilyengagementin
Kamikaseducationalperformance
Anopencommunicationpracticewillbeavailablefortheparentsand/orteacherstocommunicateona
regularbasisincludingbyphone,email,dailycommunicationfolder,and/orinpersonasneeded.
I-1 (2) Revised 10/13/06

III. PARTICIPATION IN GENERAL EDUCATION CURRICULUM Choose one of the following:
The IEP team determines whether the student is in the general education curriculum (the same curriculum as for students without
disabilities) or the curriculum aligned with alternate achievement standards. Unless a student is expected to take alternate
assessments aligned with alternate achievement standards, the student is full time in the general education curriculum. If the
student participates in curriculum aligned with alternate achievement standards, include benchmarks or short-term objectives with
the measurable annual goals. (Select one below.)
The student participates full-time in general education curriculum aligned with the general education standards that
apply to all students, or for preschoolers, in age-appropriate activities aligned with early learning standards.
The student is a student with the most significant cognitive disability participating in curriculum aligned with alternate
achievement standards. See the definition of a student with the most significant cognitive disability on the Participation
Guidelines for Alternate Assessment (DPI Model Form I-7-A).
I-1 (2) Revised 10/13/06

IV. MEASURABLE ANNUAL GOALS
Each goal must address at least one disability-related need.
Develop / revise one or more measurable annual academic or functional goal to:
address any lack of expected progress toward the annual goals, if appropriate;
address the unique needs of the student that result from the students disability (see section I.F. above);
enable the student to progress toward grade-level reading standards, or for preschoolers, early learning standards for
language development, communication and early literacy;
enable the student to be involved in the general education curriculum i.e., the same curriculum as for nondisabled students;
enable the student to progress toward meeting grade-level academic standards; and
enable the student to be educated and participate with nondisabled students.
If the IEP team determines the student has a disability-related need that affects reading (academic or functional), the IEP must
include a minimum of one goal to address this need.
A. Before developing annual goals, review the previous IEP goals and progress (document review and students
progress on the
I-5, Annual Review of IEP Goals)
Previous IEP goals reviewed: Yes No Not Applicable
.
B. Goal #__1___ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Kamika will go from recognizing 11 sight words (i.e. sight words, pre-primer words, functional sight words, etc)
to recognizing 50 sight words in 4 out of 5 opportunities.
a. Baseline (Students current level of performance from which progress toward this goal will be
measured):
Kamika recognizes 11 sight words in 4 out of 5 opportunities.
b. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kamika will recognize 50 sight words in 4 out of 5 opportunities. Kamikas reading goal relates
directly to Common Core Essential Elements (CCEE) English Language Arts Standard EE.RF.3.3.
2. Benchmarks or Short-Term Objectives (Required if student participates in curriculum and assessment aligned
with alternate academic achievement standards and each must include baseline and level of attainment.):
Not Applicable
1. Kamika will recognize 20 sight words in 4 out of 5 opportunities.
3. Annual goal addresses disability-related need(s) #___1____ of the student. (Needs identified in Section I.F).
4. Procedures for measuring the students progress toward meeting the annual goal from baseline to level of
attainment:
Charting Performance
Observation
5. When will reports about the students progress toward meeting the annual goal be provided to parent(s)?
(Document reviews and students progress on the I-6, Interim Review of IEP Goals.)
Reports regarding Kamikas progress toward meeting the annual goal will be provided to parents at the
conclusion of each quarter when all parents of students without disabilities are notified about progress.
I-1 (2) Revised 10/13/06

MEASURABLE ANNUAL GOALS
C. Before developing annual goals, review the previous IEP goals and progress (document review and students
progress on the
.
D. Goal #__2___ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Kamika will go from writing single letters to writing 5 letter words in 4 out of 5 opportunities.
c. Baseline (Students current level of performance from which progress toward this goal will be
measured):
Kamika can write single letters in 4 out of 5 opportunities.
d. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kamika will write 5 letter words in 4 out of 5 opportunities. Kamikas written language goal relates
directly to Common Core Essential Elements (CCEE) English Language Arts Standard EE.W.K.2.
Not Applicable
1. Kamika will write 2 letters together with a model in 4 out of 5 opportunities.
2. Kamika will write 3 letter words with a model in 4 out of 5 opportunities.
5. Kamika will write 3 letter words independently in 4 out of 5 opportunities.
6. Kamika will write 4 letter words independently in 4 out of 5 opportunities.
attainment:
Observations
I-1 (2) Revised 10/13/06

V. MEASURABLE ANNUAL GOALS
E. Before developing annual goals, review the previous IEP goals and progress (document review and students
progress on the
.
F. Goal #__3___ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Kamika will go from rote counting to 12 to rote counting to 50 in 4 out of 5 opportunities.
e. Baseline (Students current level of performance from which progress toward this goal will be
measured):
Kamika can rote count to 12 in 4 out of 5 opportunities.
f. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kamika will rote count to 50 in 4 out of 5 opportunities. Kamikas math goal relates directly to
Common Core Essential Elements (CCEE) Mathematics standard EE.1.NBT.1.a.
Not Applicable
1. Kamika will rote count to 15 in 4 out of 5 opportunities.
4. Kamika will rote count in 40 in 4 out of 5 opportunities.
attainment:
Observations
I-1 (2) Revised 10/13/06

VI. MEASURABLE ANNUAL GOALS
G. Before developing annual goals, review the previous IEP goals and progress (document review and students
progress on the
.
H. Goal #__4___ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Kamika will go from producing intelligible 3 word utterances with 40% accuracy to producing intelligible 3-5
word utterances with 80% accuracy.
g. Baseline (Students current level of performance from which progress toward this goal will be
measured):
Kamika produces intelligible 3 word utterances with 40% accuracy.
h. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kamika will produce intelligible 3-5 word utterances with 80% accuracy. Kamikas communication
goal relates directly to Common Core Essential Elements (CCEE) English Language Arts Standard EE.L.K.1.
Not Applicable
1. Kamika will produce intelligible 3 word utterances with 60% accuracy.
attainment:
Data probes
Conversational speech samples
I-1 (2) Revised 10/13/06

VII. MEASURABLE ANNUAL GOALS
I. Before developing annual goals, review the previous IEP goals and progress (document review and students
progress on the
.
J. Goal #__5___ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
By next annual review, Kamika will increase her ability to perform 4th grade level locomotor skills correctly
from a current level of 40% to 80%.
i. Baseline (Students current level of performance from which progress toward this goal will be
measured):
Kamika currently performs 4th grade level locomotor skills proficiently 40% of the time.
j. Level of Attainment (Must relate to the baseline measurement and reflect progress):
By the next annual review, Kamika will reach a locomotor proficiency level of 80%.
Not Applicable
1. Kamika will perform locomotor skills at a 4th grade level 50% of the time.
attainment:
Observations
I-1 (2) Revised 10/13/06

VIII. MEASURABLE ANNUAL GOALS
K. Before developing annual goals, review the previous IEP goals and progress (document review and students
progress on the
.
L. Goal #__6___ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Given a visual of at least 5 tasks, Kamika will increase her level of independence from completing 2 tasks in the
visual to completing all 5 tasks in 4 out of 5 opportunities.
k. Baseline (Students current level of performance from which progress toward this goal will be
measured):
Kamika completes 2 tasks when given a visual of 5 tasks to complete in 4 out of 5 opportunities.
l. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Given a visual of at least 5 tasks, Kamika will complete all 5 tasks in 4 out of 5 opportunities.
Kamikas functional goal relates directly to Common Core Essential Elements (CCEE) English Language Arts Standard
EE.L.3.6.
Not Applicable
1. Given a visual of at least 5 tasks, Kamika will complete at least 3 tasks in 4 out of 5 opportunities.
2. Given a visual of at least 5 tasks, Kamika will complete at least 4 tasks in 4 out of 5 opportunities.
attainment:
Observations
I-1 (2) Revised 10/13/06

IX. MEASURABLE ANNUAL GOALS

M. Before developing annual goals, review the previous IEP goals and progress (document review and students
progress on the
.
N. Goal #__7___ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Kamika will go from identifying feelings in each of the 4 zones (Green, Red, Blue, Yellow) from the Zones of
Regulation to utilizing self-regulation strategies based on tools identified through the Zones of Regulation when
completing activities with adult prompts in 4 out of 5 opportunities.
m. Baseline (Students current level of performance from which progress toward this goal will be
measured):
Kamika identifies feelings in each of the 4 zones (Green, Red, Blue, Yellow) from the Zones of
Regulation in 4 out of 5 opportunities.
n. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kamika will utilize self-regulation strategies based on tools identified through the Zones of
Regulation when completing activities with adult prompts in 4 out of 5 opportunities. Kamikas ESB goal relates directly
to Common Core Essential Elements (CCEE) English Language Arts Standard EESL.3.6.
Not Applicable
3. Annual goal addresses disability-related need(s) #____7___ of the student. (Needs identified in Section I.F).
attainment:
Observations
I-1 (2) Revised 10/13/06

X. PROGRAM SUMMARY
Include a statement for each of A, B, C and D below to allow the student to (1) access, be involved in and make progress in the
general education curriculum, (2) be educated and participate with other students with and without disabilities to the extent
appropriate, (3) participate in extracurricular and other nonacademic activities, and (4) advance appropriately toward attaining the
annual IEP goals. Include frequency, amount, location, & duration (if different from projected IEP beginning and ending dates). The
services must be stated in the IEP so the level of the LEAs commitment of resources is clear to the parent(s) and other IEP team
members. At least one special education service must be specified; include other services, if needed.
Projected beginning and ending date(s) of IEP services & modifications from _05/17/17 to 05/16/18.
(month/day/year) (month/day/year)
A. Supplementary Aids and Services

Aids, services, and other supports (accommodations) that are provided in regular education, other educational settings, and in
extracurricular and nonacademic settings, to enable students with disabilities to be educated with nondisabled children to the
maximum extent appropriate. The amount of time specified for each service must be appropriate to the service and stated in a
manner that can be understood by all involved in developing and implementing the IEP.For each supplementary aid and
service, identify the corresponding annual goal(s). In some situations, there may not be a corresponding goal. In those
situations it is acceptable to identify the disability-related need(s).
None needed
Describe Frequency & Amount Location Duration Addresses Addresses
(describe the circumstances, Goal(s) Need(s)
if appropriate) #_______ #_______
Modified Curriculum: selective Suggested, but not limited to, All School Duration of 1-7 1-7
curriculum and shortened when curriculum is above Environments IEP
assignments Kamikas cognitive, ability,
or adaptive level
Modified Materials: picture cues, When necessary to aid in All School Duration of 1-7 1-7
multiple choices, visual and/or success and understanding of Environments IEP
written schedule subject matter. Suggested, but
not limited to, daily schedule
or task list
Modified Grading: Grading in the 4 times per year All School Duration of 1-7 17
general education classes will be Environments IEP
based on Kamikas IEP goals and
objectives
Educational Assistant, Special When required in order for All School Duration of 1-7 1-7
Education Teacher, General Kamika to be successful in all Environments IEP
Education Teacher school environments.
Access to Sensory Items When necessary in order for All School Duration of 1-7 1-7
Kamika to be successful in all Environments IEP
school environments.
Including, but not limited to,
trampoline, swing, hand
fidget items, etc
B. Special Education / Specially Designed Instruction

Adapting, as appropriate to the needs of an eligible student, the content, methodology, or delivery of instruction to address the
unique needs of the student that result from the students disability; and ensure access of the student to the general curriculum,
so the student can meet the educational standards of the public agency that apply to all students.For each special education
service, identify the corresponding annual goal(s).
Describe Frequency/ Location Duration Addresses Goal(s)
Amount #________
I-1 (2) Revised 10/13/06

Direct Specialized Instruction: Reading 60 minutes daily Special Education Duration of 1, 7
Environment IEP
Direct Specialized Instruction: Written Language 60 minutes daily Special Education Duration of 2, 7
Environment IEP
Direct Specialized Instruction: Math 60 minutes daily Special Education Duration of 3, 7
Environment IEP
Speech and/or Language Impairment 30 minutes 3 Special Education Duration of 4, 7
times per week Environment IEP
Adaptive Physical Education 45 minutes 3 Special Education Duration of 5, 7
times per week Environment IEP
Direct Specialized Instruction: Functional Skills 160 minutes per Special Education Duration of 6, 7
day Environment IEP
Direct Specialized Instruction: 30 minutes per Special Education Duration of 7
Emotional/Social/Behavioral Development day Environment IEP
C. Related Services Needed to Benefit from Special Education

Transportation and such developmental, corrective, and other supportive services as are required to assist a student with a disability to
benefit from special education. For each related service, identify the corresponding annual goal(s). In some situations, there may not
be a corresponding goal. In those situations it is acceptable to identify the disability-related need(s).
None needed
Describe Frequency/ Location Duration Addresses Addresses
Amount Goal(s) Need(s)
#_______ # ______
Assistive Technology
Audiology
Counseling
Educational Interpreting
Medical Services for Diagnosis and Evaluation
Occupational Therapy 30 minutes Special Education Duration 5, 6, 7 5, 6, 7

weekly Setting of IEP
Orientation and Mobility
(For students with Visual Impairments)
Physical Therapy
Psychological Services
Recreation
Rehabilitation Counseling Services
School Health Services
School Nurse Services
School Social Work Services
Speech / Language
I-1 (2) Revised 10/13/06

Transportation Daily to and from All School Duration 1-7 1-7

school Environments of IEP
Other: specify
D. Program Modifications or Supports for School Personnel

Services or activities for school personnel to meet the needs of the student. Identify the goal(s) or need(s) addressed.
None needed
Describe Frequency A Location Duration Addresses Addresses
m Goal(s) Need(s)
ou #_______ #_______
nt

XI.
I-1 (2) Revised 10/13/06

STUDENT PARTICIPATION
A. Participation in Regular Education Environment (location, including regular education classrooms,
extracurricular and nonacademic activities, and workplace settings) Ensure any supplementary aids and services
needed for the student to participate in the regular education environment, including regular education classrooms,
extracurricular and nonacademic activities, and workplace settings, are included in the Program Summary.
The student will participate full-time with non-disabled peers in regular education environment, or for
preschoolers, with non-disabled peers in age-appropriate settings.
If you have indicated in the Program Summary a location other than regular education environment, or
age-appropriate settings for preschoolers, you must check the box below and answer Questions 1 and 2.
The student will not participate full-time with non-disabled peers in regular education environment, or for
preschoolers, with non-disabled peers in age-appropriate settings.
1. Describe the extent to which the student will not participate with non-disabled students in the regular
education classroom, or age-appropriate settings in the case of a preschooler, including extracurricular and
nonacademic activities:
Kamika requires pull out instruction in the academic areas of reading, written language, and math. She also
requires pull-out small group, or individual instruction in the areas of communication, gross motor, and
emotional/social/behavioral development. She will be provided these services within the special education
setting during th general education classroom core academic areas.
2. Explain why full-time participation with non-disabled peers is not appropriate, or in the case of a
preschooler, participation in age-appropriate settings including extracurricular and nonacademic activities:
Based on data collection over the past IEP term, Kamika is not currently meeting 4th grade level standards in
all areas and is working off of the Common Core Essential Elements (CCEE). This alternative curriculum will help
develop and master the essential standards for Kamikas continued academic progress. Kamika is at a level that is
significantly below that of her same-age peers. She requires direct instruction at her level of ability and rate of progress in
the areas of reading, written language, math, functional skills, and emotional/social/behavioral development. She also
receives services through Adaptive Physical Education and Speech/Language.

Ensure any supplementary aids and services needed for the student to participate in the regular education environment, including
regular education classrooms, extracurricular and nonacademic activities, and workplace settings, are included in the Program
Summary.
B. Participation in Physical Education Not Applicable (If the student is in a grade-level where physical
education is not offered and the student does not require specially designed physical education as part of a free
appropriate public education.)
Regular Physical Education

Specially Designed Physical Education

If the IEP team determines the student requires specially designed physical education, there must be a corresponding
disability-related need and goal, and this service must be included in the Program Summary with the appropriate frequency and
amount.
I-1 (2) Revised 10/13/06

PARTICIPATIONGUIDELINESFORALTERNATEASSESSMENT
FormI-7-A(Rev.05/2017)
NameofStudent___KamikaKanzia_______________________________________________
IEP teams are responsible for deciding whether students withdisabilitieswillparticipateingeneraleducation

assessments with or without testing accommodations, or in the alternate assessment with or without
accommodations.1 In a given year, a studentmustparticipateineitherallgeneraleducationassessmentsorall
alternateassessments,notpartsofboth.
Agree(Yes)or
ParticipationCriterion ParticipationCriterionDescriptors Disagree(No)?

Inordertodefineastudentashavingamostsignificant
cognitivedisability,theIEPteammustreviewstudent
recordsandagree:
Thestudenttypicallycharacterizedasfunctioningat
leasttwoandahalftothreestandarddeviations
belowthemeaninbothadaptivebehaviorand
1.Thestudenthasamost cognitivefunctioning;and
significantcognitive Thestudentperformssubstantiallybelowgradelevel Yes/No
disability. expectationsontheacademiccontentstandardsfor
thegradeinwhichtheyareenrolled,evenwiththe
useofadaptationsandaccommodations;and
Thestudentrequiresextensive,directindividualized
instructionandsubstantialsupportstoachieve
measurablegains,acrossallcontentareasand
settings.
GoalslistedintheIEPforthisstudentarelinkedtothe
2.Thestudentisinstructed
enrolledgradelevelalternateachievementstandardsand
usingthealternate Yes/No
addressknowledgeandskillsthatareappropriateand
achievementstandards.
challengingforthisstudent.
Theparent(s)andLEAhavediscussed:
Thedifferencesbetweenthealternateachievement
standardsandacademiccontentstandardsforthe
gradeinwhichthechildisenrolled,and
Thatthestudentsachievementwillbemeasured
3.Parentnotification Yes/No
basedonalternateachievementstandards,and
Howthestudentsparticipationinalternate
standardsandassessment(s)maydelayorotherwise
affectthestudentfromcompletingtherequirements
foraregularhighschooldiploma.
TheIEPteamagreesthatallthreeofthecriteriadescribethestudent,anddeterminedthe
Yes/No
studentmustparticipateinalternateassessment(s).
Decisions for determining participation in the alternate assessment must not be based solely on any of the
following:
1. Adisabilitycategoryorlabel educationassessment
2. Poorattendanceorextendedabsences 5. Academicandotherservicesstudent
3. Nativelanguage/social/culturaloreconomic receives
difference 6. Educationalenvironmentorinstructional
4. Expectedpoorperformanceonthegeneral setting
I-1 (2) Revised 10/13/06

7. Percentoftimereceivingspecialeducation 12. Administratordecision
8. EnglishLearner(EL)status 13. Anticipatedemotionaldistress
9. Lowreadinglevel/achievementlevel 14. Needforaccommodations(e.g.,assistive
10. Anticipatedstudentsdisruptivebehavior technology/AugmentativeandAlternative
11. Impactofstudentscoresonaccountability Communication)toparticipatein
system assessmentprocess
I-1 (2) Revised 10/13/06

INDIVIDUALIZED EDUCATION PROGRAM: To be completed for students participating
in
PARTICIPATION IN DISTRICT-WIDE ASSESSMENTS district-wide assessments
Form I-7 District-wide Assessment (Rev. 05/2017)
Name of Student___Kamika Kanzia________________________
District-wide assessments are tests given at the district level and can apply to students in all grade levels (4K-12).
District wide assessments include the high school civics test requirement and the assessment for reading readiness.
Students with disabilities must be included in district-wide assessments unless the IEP team determines that an
alternate to the district-wide assessment is appropriate. Alternate assessments are intended only for students with the
most significant cognitive disabilities. If the student will be taking an alternate assessment, the I-7-A Participation
Guidelines for Alternate Assessment (http://dpi.wi.gov/sites/default/files/imce/sped/doc/form-i7a.doc) must be
included with the IEP.
District-wide Assessment-If the IEP team determines the student will take district-wide assessments, the IEP
must contain a statement of any individual appropriate accommodations needed to measure the academic
achievement and functional performance of the student on district-wide assessments.
Students with IEPs must take the civics exam unless the IEP team determines it is not appropriate, but
graduation cannot be conditioned upon passing a certain number of questions correctly. If the student will take
the civics exam, list it as a district-wide assessment and include a statement of any needed accommodations.
Not applicable, the student is not in a grade in which they will take the high school civics exam.
It is appropriate to administer the high school civics test to the student.
It is not appropriate to administer the high school civics test to the student.
District-wide assessment(s) the Are accommodations needed? If yes, describe the accommodations
student will take (yes/no) needed
Alternate District-wide Assessment If the IEP team determines the student will take an alternate assessment,
the IEP must describe why the student cannot participate in the regular assessment, why the particular alternate
district-wide assessment is appropriate and contain a statement of any needed accommodations.
Alternate Describe why the Describe why the Are accommodations If yes, describe the
district-wide student cannot particular needed? (yes/no) accommodations
assessment(s) the participate in the alternate needed
student will take district-wide district-wide
assessment assessment is
appropriate.
Dynamic Learning Kamika is not Kamika will yes Human Read Aloud,
Maps (DLM) currently meeting receive this Administered on a
4th grade assessment at her Touchscreen
standards instructional
level
I-1 (2) Revised 10/13/06

WORKSHEET FOR DETERMINING

EDUCATIONAL ENVIRONMENT CODES
Worksheet EE-1 (Rev. 7/10)

School District _____Edgemont____________________________________
Name of Student _____Kamika Kanzia____________________________________
EnvironmentCode

ForStudentsAge6through21

A (insidetheregularclassroomwithnondisabledpeers80%ormoreofthetime)
B (insidetheregularclassroomwithnondisabledpeers40to79%oftime)
C (insidetheregularclassroomwithnondisabledpeerslessthan40%ofthetime)
D (publicseparatedayschool) I (hospital)
E (privateseparatedayschool) J (homebound)
F (publicresidentialfacility) S (correctionalfacilities)
G (privateresidentialfacility) T (parentallyplacedprivate)

ForStudentsAge3through5
RegularEarlyChildhoodSetting(Programincludesatleast50%nondisabledchildren)
R1 (in regular early childhood at least 10 hours per week & majority of hours of special
educationandrelatedservicesaredeliveredinECprogram)
R2 (in regular early childhood at least 10 hours per week & majority of hours of special
educationandrelatedservicesaredeliveredinotherlocation)
R3 (in regular early childhood less than 10 hours per week & majority of hours of special
educationandrelatedservicesaredeliveredinECprogram)
R4 (in regular early childhood less than 10 hours per week & majority of hours of special
educationandrelatedservicesaredeliveredinotherlocation)
SpecialEducationEarlyChildhoodSetting(Programincludeslessthan50%nondisabledchildren)
B1 (specialeducationclassroom) B2(separateschool)
I-1 (2) Revised 10/13/06

B3(residentialfacility)
Neither Regular Early Childhood nor Special Education Early Childhood Setting
B4(home) B5(serviceproviderlocation)
I-1 (2) Revised 10/13/06

Behavior Intervention Plan
Proactive Strategies:
Staff should keep demands and language short, clear, and should be consistent among staff. Staff should use
visuals, such as a visual task completion chart to make expectations clear. Kamika should be reinforced for
positive behaviors using a token system.
Desired Behaviors to Increase, Maintain and/or Teach:

Kamika will use functional communication to inform staff if she needs an item or a break. She will utilize tools
from the Zones of Regulation instead of engaging in aggression.
Positive Interventions, Accommodations, and/or Strategies:

-Staff will teach tools for each of the 4 zones in the Zones of Regulation
-Staff models I need a break during structured and unstructured activities
-Immediately reinforce Kamika when she utilizes a tool from the Zones of Regulation or when she completes
the required task
Consequences/Interactions which serve to Increase Desired Behavior:

Kamika will utilize a tool rather than engaging in challenging behaviors.
Implementation Considerations
Staff will model functional language; as well as utilize visuals to offer choice and set clear expectations (visual
task completion chart). Staff in the special education room will work to encourage generalization across
settings. These will be implemented during the duration of the IEP and be monitored by the special education
teacher and IEP team.
Progress monitoring will take place as behaviors occur and weekly for collaboration among staff and the team
will meet to evaluate progress at Kamikas annual IEP meeting.

I-1 (2) Revised 10/13/06

SummaryofIEPWriting

I chose Kamikaduetoherplacementinaself-containedspecialeducationclassroom.Basedonthementionofa
self-contained classroom, I could infer that Kamika would require minutes in all academic areas as well as
emotional,social,orbehavioral(ESB),communication,grossmotor,functionalskills,andsocialskills.Kamikas
case study did include some description of hercurrentlevel.Byincludingthisinformationinmypresentlevel,I
was able to create goals that would advance those skills. In addition, I included communication, gross motor,
functional,social,andemotional/social/behavioralgoalsforKamikatofilloutallofherminutes.

Based on the description in the case study, Kamika isatalevelsignificantlybelowhersame-agepeers.Manyof
the goals I created related to kindergarten to second grade Common Core Essential Elements. With this
information, I was able to build on her skills when creating goals. For example, Kamika can recognize11sight
words (pre-primer level and functional safety words). Recognizing sight words is an imporant skills asKamika
continues to age. Due to this, I created a reading goal for recognizing 50 sight words including, but notlimited
to, pre-primer and functional sight words. As Kamika continues her academic career and begins independent
living skills, these sight words will help ensure her safety. Iusedtheinformationinthecasestudytocreateher
written language and math goal as well. Due to Kamikas described speech impairment and limp, I also
includedacommunicationandgrossmotorgoaltomeettheseneeds.
I felt it was also important to include a Behavior Intervention PlanbasedonKamikasviolentoutburstswhen

completing tasks in the classroom. As a Behavior Analyst, I would avoid using time-outs and work to teach
Kamika a more appropriate behavior (as included in her ESB goal) to replace these outburstsandincreaseher
independence with regulation. I also included an ESB goal to focus on utilizing tools for self-regulation and a
functional goal to increase her task completion to help with the outbursts that weredescribedwhenpresented
with a new activity and while engaged in work activities. I feel that these goals will help teach Kamika
alternativebehaviorsthatarepositiveandwillreplacethenegativeoutbursts.
Overall, while writing this IEP, I utilized the prior knowledge that I learned from my current school district. I
realize that many districts complete IEPformsdifferentlyand,ifIweretochangedistricts,wouldneedtoadapt
to their standard of completion. I would be more than happy to work with Kamika based on the information I
receivedinthecasestudy.

I-1 (2) Revised 10/13/06

Waldera Kimikaiep

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INVITATION TO A MEETING OF THE

INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM

Edgemont SCHOOL DISTRICT

Dear _Mr. and Mrs. Kanzia_________________________ Date __05/05/17____________

EVALUATION AND REEVALUATION

INDIVIDUALIZED EDUCATION PROGRAM (IEP) (if student is eligible)

PLACEMENT (if student is eligible)

________Anna Baker___________________ _________Jeryn Waldera___________________

______Theresa May __________________ ________Kelsey Fellrath, SLP________________

_______Ben Tell, OT _________________ _______Corey Oman, Adaptive Phy ED________

In addition to district staff, you may also contact _________________________________ at

I-1 (2) Revised 10/13/06

Edgemont SCHOOL DISTRICT

Parent or Legal Guardian Telephone (area code/number)

District of Residence Current District of Placement

Date of Meeting: 05/14/17 (month/day/year)

PURPOSE OF MEETING (check all that apply):

INDIVIDUALIZED EDUCATION PROGRAM (IEP) (if student is eligible)

PLACEMENT (must be determined when the IEP is developed or reviewed/revised)

I-1 (2) Revised 10/13/06

IEP Team Participants Attending or Participating by Alternate Means in the Meeting:

Student (if appropriate): Special education teacher/title: Special education teacher/title:

LEA Representative/title: Other: Other:

Other: Other: Other:

I-1 (2) Revised 10/13/06

B. Current Academic Achievement and Functional Performance

I-1 (2) Revised 10/13/06

1. Does the students behavior impede his/her learning or that of others?

2. Is the student an English Learner (EL)?

I-1 (2) Revised 10/13/06

D. Concerns of the Parent(s)/Family

I-1 (2) Revised 10/13/06

F. Summary of Disability-Related Needs

I-1 (2) Revised 10/13/06

I-1 (2) Revised 10/13/06

I-1 (2) Revised 10/13/06

I-1 (2) Revised 10/13/06

I-1 (2) Revised 10/13/06

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IX. MEASURABLE ANNUAL GOALS

I-1 (2) Revised 10/13/06

A. Supplementary Aids and Services

B. Special Education / Specially Designed Instruction

I-1 (2) Revised 10/13/06

C. Related Services Needed to Benefit from Special Education

Medical Services for Diagnosis and Evaluation

Occupational Therapy 30 minutes Special Education Duration 5, 6, 7 5, 6, 7

Rehabilitation Counseling Services

School Health Services

School Nurse Services

School Social Work Services

I-1 (2) Revised 10/13/06

Transportation Daily to and from All School Duration 1-7 1-7

D. Program Modifications or Supports for School Personnel

I-1 (2) Revised 10/13/06

Regular Physical Education

I-1 (2) Revised 10/13/06

IEP teams are responsible for deciding whether students withdisabilitieswillparticipateingeneraleducation

I-1 (2) Revised 10/13/06

I-1 (2) Revised 10/13/06

Dear _Mr. and Mrs. Kanzia___________ Date 05/05/17

Anna Baker_______ _Jeryn Waldera_______________

Theresa May Kelsey Fellrath, SLP____

_Ben Tell, OT _______ _Corey Oman, Adaptive Phy ED______

Name of Student_Kamika Kanzia______________________

Name of Student _Kamika Kanzia________________________________