STATE SELPA IEP TEMPLATE - DOC

							                                 RIVERSIDE COUNTY SPECIAL EDUCATION LOCAL PLAN AREA (SELPA)                                                                 Page ____ of____
                                                                      SPECIAL FACTORS
           The use and distribution of this form is limited to employees of public school agencies within the Riverside County Special Education Local Plan Area (SELPA)

Name:                                                                            Birthdate:             /       /                IEP Meeting Date:                  /      /
Does the student require assistive technology devices and/or services?               No       Yes (explain)
Does the student require low incidence services, equipment and/or materials to meet educational goals? No           Yes (explain)
Considerations if the student is blind or visually impaired:
Considerations if the student is deaf or hard of hearing:
Considerations if the student has an orthopedic impairment:
Physical Education:          Requirement met        General        Specially Designed:
Special Transportation:         None\General Ed          Special Ed     Rationale:           Specify Type:
If the child is an English Learner, consider the language needs of the child as those needs relate to the IEP:
Does student’s behavior impede learning of self or others?              No      Yes (describe):
     If yes, specify positive behavior interventions, strategies, and supports:
     Positive Behavior Support Plan (PBSP) attached            Positive Behavior Intervention Plan (PBIP) attached Goal(s) #
                                PARTICIPATION IN STATE/DISTRICT WIDE ASSESSMENT PROGRAMS
ENGLISH LANGUAGE ARTS (ELA)
      CST without testing accommodations        CST with testing accommodations         or                                 CST with testing modifications
      CMA without testing accommodations        CMA with testing accommodations
      To participate in CAPA                    Outside of Testing Grade Range
MATH
      CST without testing accommodations        CST with testing accommodations         or                                  CST with testing modifications
      CMA without testing accommodations        CMA with testing accommodations
      To participate in CAPA                    Outside of Testing Grade Range
ALGEBRA 1         AND/OR      GEOMETRY
      CST without testing accommodations        CST with testing accommodations         or                                  CST with testing modifications
      CMA without testing accommodations        CMA with testing accommodations                                             Outside of Testing Grade Range
SCIENCE
      CST without testing accommodations        CST with testing accommodations         or                                  CST with testing modifications
      CMA without testing accommodations        CMA with testing accommodations
      To participate in CAPA                    Outside of Testing Grade Range
HISTORY/SOCIAL SCIENCE
      CST without testing accommodations        CST with testing accommodations        or                                   CST with testing modifications
      To participate in CAPA                    Outside of Testing Grade Range
WRITING
      CST without testing accommodations        CST with testing accommodations         or                                  CST with testing modifications
      CMA without testing accommodations        CMA with testing accommodations
      To participate in CAPA                    Outside of Testing Grade Range
CAHSEE
      Without testing accommodations/modifications       With testing accommodations                                        With testing modifications
      To participate in CAPA                             Outside of Testing Grade Range
CALIFORNIA ALTERNATE PERFORMANCE ASSESSMENT (CAPA) :                Level 1 2 3 4 5
  The student will not participate in the CST or CMA because . Participation in the CAPA is appropriate because
PHYSICAL FITNESS TEST(Grades 5, 7, 9)       Without Accommodations /Modifications      With Accommodations:
                                            With Modifications:                        Excused :
CELDT (For English Learners Only)       Specify subtest(s) for each accommodation or modification (listening, reading, writing, speaking)
   Without Accommodations/Modifications    With Accommodations:            With Modifications:           CELDT Alternative:
DESIRED RESULTS DEVELOPMENTAL PROFILE (DRDP) (For Preschoolers Only):                                          DRDP Access
Adaptations:              -                  -                   -                                                               -                            -
    Other State-Wide/ District-Wide Assessments (Accommodations/Modifications):
    Other Alternate State-Wide/ District-Wide Assessment(s)    Appropriate because:




R07/12                                                                     Form 4 (E)